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Letters to the Editor

Early Data on Utilization and Discard of Organs From COVID-19–infected Donors: A US National Registry Analysis

Gupta, Gaurav MD1; Azhar, Ambreen MD, MS1; Gungor, Ahmet PhD2; Molnar, Miklos Z. MD, PhD3; Morales, Megan K. MD1; Tanriover, Bekir MD, MPH, MBA2

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doi: 10.1097/TP.0000000000004091

To the Editor:

Expansion of the donor pool remains a major unmet need for solid organ transplants. Early data suggest that at least some severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid test–positive (NAT+) organs could be transplanted safely although there is substantial controversy about this topic.1-5 In theory, respiratory viruses are less likely to carry risk of viremia and infection of abdominal organs, although no commercial test is currently available to assess SARS-CoV-2 viremia. In this retrospective analysis of the US Organ Procurement and Transplantation Network database, we report the initial experience with SARS-CoV-2 NAT+ (coronavirus disease 2019 [COVID-19] NAT+) deceased donor organs, with a focus on kidney transplants, from August 8, 2020, to September 29, 2021.

During this time period, 17 143 COVID-19 NAT-negative (NAT) deceased donors and 150 COVID-19 NAT+ deceased donors were assessed for organ donation (Figure 1). When compared with COVID-19 NAT donors, there was a higher (P < 0.001 for all) nonrecovery rate for COVID-19 NAT+ hearts (35% versus 87%), lungs (71% versus 99%), livers (24% versus 53%), and pancreas (89% versus 98%), although this was not the case for kidneys (4.5% versus 1.6%).

F1
FIGURE 1.:
Relative proportional disposition of recovered organs between August 8, 2020, and September 29, 2021. COVID-19 NAT-negative (–) organs: N = 17 143; COVID-19 NAT-positive (+) organs: N = 150. COVID-19, coronavirus disease 2019; NAT, nucleic acid test.

Of total 385 recovered organs from 150 COVID-19 NAT+ donors, 276 (72%) organs were transplanted into 262 recipients. Donor details for these 150 donors are reported in Table 1. There was an increasing trend toward organ recovery across 3 pandemic periods (July 22, 2020–December 2020 [13; 9%]; January 2021–June 2021 [56; 37%]; and July 2021–September 2021 [81; 54%]). Most donors had a last reported COVID-19 NAT+ ≤7 d before procurement (94; 62.7%; Table S1, SDC, https://links.lww.com/TP/C375). Table S2 (SDC, https://links.lww.com/TP/C375) describes the utilization of all COVID-19 NAT+ organs. Although only a minority of pancreata, hearts, lungs, and livers were procured, they were almost all transplanted postprocurement. In contrast, there was a high discard rate for kidneys postprocurement (102/295; 34.6%) compared with COVID-19 NAT kidneys (6767/32717; 20.6%). Presumably superior quality COVID-19 NAT+ kidneys were discarded (mean kidney donor profile index, 67% versus 76%; P = 0.04) with the most common reason (~70%) for discards being “exhaustion of the waitlist” (Table 1). The organ discard rate did not differ substantially based upon the time (≤7 d [27.6%] versus 8–28 d [26.7%] or ≥28 d [30.8%]) of positive COVID-19 NAT before donation.

TABLE 1. - COVID-19 NAT-positive deceased donor characteristics
Donor parameter Value
N 150
Positive COVID-19 NAT result, n (%) 150 (100)
COVID-19 NAT site, n (%)
 Lower respiratory 13 (8)
 Upper respiratory 136 (91)
 Rectal 1 (1)
Time between donor recovery date and COVID-19 NAT date (d), median (IQR) 4 (1–31)
Positive COVID-19 antibody result, n (%) a 20 (69)
Age (y), mean (SD) 43 (14)
Sex (male), n (%) 98 (65)
Weight (kg), mean (SD) 95 (29)
BMI (kg/m2), mean (SD) 32 (9.5)
Caucasian race, n (%) 91 (61)
Cause of death, n (%)
 Anoxia 48 (32)
 Stroke 33 (22)
 Other 69 (46)
Reported pulmonary infection, n (%) 74 (49)
Chest x-ray, n (%)
 Normal 13 (10)
 Abnormal left 9 (7)
 Abnormal right 9 (7)
 Abnormal both 96 (76)
Kidney-specific donor measures
Terminal creatinine (mg/dL), median (IQR) 0.89 (0.53–1.5)
Kidney donor profile index, mean (SD) 48 (27)
Right kidney reason for discard, n (%)
 Donor’s medical history 1 (2.5)
 Biopsy finding 3 (7.5)
 Poor organ function 2 (5)
 No recipient located; list exhausted 27 (67.5)
 Unknown 7 (17.5)
Left kidney reason for discard, n (%)
 Biopsy finding 3 (8)
 Poor organ function 1 (3)
 No recipient located; list exhausted 27 (73)
 Unknown 6 (16)
Double kidneys reason for discard, n (%)
 No recipient located; list exhausted 4 (80)
 Unknown 1 (20)
aNot available for all donors.
BMI, body mass index; COVID-19, coronavirus disease 2019; IQR, interquartile range; NAT, nucleic acid test.

Limited outcome data (Table S3, SDC, https://links.lww.com/TP/C375) were available on 262 transplant recipients with median posttransplant follow-up of 75 d (range, 23–243 d). Three (of 180; 1.6%) kidney allograft losses were reported, of which, 2 were because of allograft thrombosis on the day of transplant. Five deaths (2 kidneys [1%]; 3 livers [5.6%]) were reported, of which, 1 was because of respiratory failure and 1 because of sepsis. Table S4 (SDC, https://links.lww.com/TP/C375) shows the characteristics of 180 “kidney-only” transplant recipients. Most patients received induction rabbit antithymocyte globulin (62.8%) followed by triple maintenance immunosuppression (tacrolimus/mycophenolate/steroids; ~67%–80%). Of the 149 patients of whom data were available, the average length of stay was relatively short (median = 4 d) with a delayed graft function rate of 24%.

These data provide early reassuring evidence on the utilization of non–lung SARS-CoV-2 NAT+ solid organ transplants. Many of these donors were selected despite positive NAT ≤7 d before procurement and abnormal lung imaging. Despite this, a substantially lower procurement rate for non–kidney transplantable organs and a high discard rate for kidneys (driven primarily by absence of recipient availability) were noted. For “kidney-only” transplant patients, immunosuppression regimens were largely unaltered compared with the “standard-of-care.” These data are limited by the absence of detailed donor characteristics, for example, computer tomographic imaging of lungs, vaccination status of donors and recipients, use of pretransplant (donor) or posttransplant (recipient) COVID-19 therapies, and longer-term follow-up of recipients with the availability of transmission data. Finally, it is unclear as to how many COVID-19–positive potential donors were never approached for organ donation.

REFERENCES

1. Frattaroli P, Anjan S, Coro A, et al. Is it safe to perform abdominal transplantation from SARS-CoV-2 polymerase chain reaction positive donors? Transpl Infect Dis. 2021;23:e13688.
2. Kates OS, Fisher CE, Rakita RM, et al. Use of SARS-CoV-2-infected deceased organ donors: should we always “just say no?”. Am J Transplant. 2020;20:1787–1794.
3. Koval CE, Poggio ED, Lin YC, et al. Early success transplanting kidneys from donors with new SARS-CoV-2 RNA positivity: a report of 10 cases. Am J Transplant. 2021;21:3743–3749.
4. Manzia TM, Gazia C, Lenci I, et al. Liver transplantation performed in a SARS-CoV-2 positive hospitalized recipient using a SARS-CoV-2 infected donor. Am J Transplant. 2021;21:2600–2604.
5. Shah MB, Lynch RJ, El-Haddad H, et al. Utilization of deceased donors during a pandemic: argument against using SARS-CoV-2-positive donors. Am J Transplant. 2020;20:1795–1799.

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