Coronavirus disease 2019 (COVID-19) has caused many units to suspend or reduce transplantation. As transplantation activity resumes, guidelines on screening have developed, with active COVID-19 generally a contraindication for transplantation.1 We report a case of a kidney transplant recipient who likely was infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at the time of transplant.
A 37-year-old man was admitted for a preemptive living donor kidney transplant. Both donor and recipient were reviewed in a COVID-secure outpatient clinic 14 days pretransplant. Neither reported COVID-19 symptoms or confirmed or suspected contact with anyone with COVID-19. SARS-CoV-2 nasopharyngeal swabs 14 and 3 days pretransplant were negative. Both patients were instructed to self-isolate until admission.
The transplant proceeded with no intraoperative complications. Postoperatively he was admitted to a COVID-secure ward specifically for elective surgical patients who had self-isolated and negative SARS-CoV-2 tests within 3 days preadmission. He had immediate graft function, with good urine output and a 136 µmol/L fall in creatinine on postoperative day 1. Routine SARS-CoV-2 nasopharyngeal swabs were taken on admission and postoperative day 3. The first result was negative, but he tested positive on day 3. He remained asymptomatic, blood tests revealed no evidence of severe disease, and a chest radiograph was unremarkable. The immunosuppressive regime of tacrolimus, mycophenolate mofetil, and prednisolone was unchanged as his creatinine was static at 160 µmol/L, causing concerns about rejection. On postoperative day 7, his creatinine increased to 191 µmol/L. A kidney biopsy was performed, showing significant lymphocytic infiltrate causing subtle tubilitis. With the rising creatinine, this was considered significant for Banff’s borderline rejection. He was treated with 3 doses of methylprednisolone and the tacrolimus dose was increased. He remained asymptomatic and was discharged on postoperative day 11. His inflammatory markers were never significantly raised, with a normal white cell count throughout and a peak C-reactive protein 27 mg/L on postoperative day 5. COVID-19-targeted therapies were considered at multidisciplinary meetings, but as he was asymptomatic throughout, these were not commenced. At 3 weeks, he remains asymptomatic, his creatinine is 160 µmol/L, and repeat SARS-CoV-2 nasopharyngeal swabs remain positive. A SARS-CoV-2 antibody test 10 days after his first positive swab was negative.
His COVID-19 was likely pretransplant community acquired. Unknown to the team at the time of surgery, he was noncompliant with self-isolation guidelines. Five days preadmission, without using masks or distancing, he met his sister who subsequently developed symptoms and tested positive for SARS-CoV-2. Noncompliance with self-isolation may expose patients and staff to SARS-CoV-2. There are also exposure risks to other patients via the anesthetic ventilation equipment and theater environment.2 His follow-up was modified to minimize the risk of spread to other immunosuppressed transplant patients.
There is limited evidence to guide the management of COVID-19 in acute posttransplant patients. The balance of immunosuppression and stopping mycophenolate mofetil in the context of active COVID-19 and possible rejection was considered at multidisciplinary meetings. A refractory rejection would have posed the dilemma of using antithymocyte globulin although its use in simultaneous pancreas-kidney transplant recipients with recent COVID-19 has been reported.3 Finally, the sensitivity of SARS-CoV-2 tests should be considered, with factors including time from exposure, specimen source, and collection technique influencing results.4 The time between exposure and test positivity remains unclear, and a negative test may not necessarily rule out COVID-19, although the estimated median incubation period is 5 days.5 Following this experience, we have introduced additional counseling by clinical nurse specialists and transplant surgeons regarding the need for strict self-isolation to all patients at pretransplant appointments.
1. National Health Service Blood and Transplant. SARS-CoV-2 assessment and screening in organ donors and recipients. In: Organ Donation and Trasplantation. 2020. National Health Service Blood and Transplant
2. Obara S. Anesthesiologist behavior and anesthesia machine use in the operating room during the COVID-19 pandemic: awareness and changes to cope with the risk of infection transmission. J Anesth. [Epub ahead of print. August 27, 2020]. doi:10.1007/s00540-020-02846-z
3. Barros N, Sharfuddin AA, Powelson J, et al. Rabbit anti-thymocyte globulin administration to treat rejection in simultaneous pancreas and kidney transplant recipients with recent COVID-19 infection. Clin Transplant. 2021;35:e14149.
4. Sethuraman N, Jeremiah SS, Ryo A. Interpreting diagnostic tests for SARS-CoV-2. JAMA. 2020;323:2249–2251.
5. Lauer SA, Grantz KH, Bi Q, et al. The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med. 2020;172:577–582.