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Letters to the Editor

Long-term and Short-term Outcomes of Solid Organ Transplantation From Donors With a Positive SARS-CoV-2 Test

Dhand, Abhay MD1,2; Gass, Alan MD3; John, Devon MD2; Kai, Masashi MD2; Wolf, David MD1,2; Bodin, Roxana MD1,2; Okumura, Kenji MD2; Veillette, Gregory MD2; Nog, Rajat MD1,2; Ohira, Suguru MD2; Diflo, Thomas MD2; Wolfe, Kevin PhD2; Spielvogel, David MD2; Lansman, Steven MD2; Nishida, Seigo MD, PhD2

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doi: 10.1097/TP.0000000000004196
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Utilization of organs from donors with coronavirus disease 2019 (COVID-19) is increasing,1-3 but long-term outcome data regarding these transplants are limited. To date, no cases of transmission of SARS-CoV-2 have been reported from a positive donor to a negative recipient in nonlung transplantation.4 To address this knowledge gap, we present our data regarding donor and recipient characteristics, long-term, and short-term outcomes of solid organ transplantation when using organs from a donor with a positive SARS-CoV-2 polymerase chain reaction (PCR) test from upper respiratory tract and/or lower respiratory tract (COVID+ donor) at the time of organ recovery. All adult recipients who underwent transplantation of organs from COVID+ donors with at least 30-d follow-up between the period of March 2021 and February 2022 were included in the analysis. The study was approved by our Institutional Review Board. Donor, recipient characteristics, and outcomes are summarized in Table 1. Organs from 12 COVID+ donors were transplanted into 14 recipients (5 livers, 3 hearts, and 6 kidneys). Donors had a mean age of 34 (range: 13–65) y and were hospitalized for a mean 6 (range: 1–18) d before organ recovery. The first positive SARS-CoV-2 PCR test was on mean 12 (range: 1–80) d and last positive test was on mean 2 (range: 1–3) d before organ recovery. During the terminal hospitalization of donors, 3 (25%) had new onset symptoms suggestive of COVID-19, 1 (8%) had resolved symptoms, 2 (17%) were asymptomatic, and 6 (50%) had unknown symptoms. Cycle threshold (Ct) values were available for 9 (75%) of the donors with a Ct value of the last positive PCR test ranging from 22 to 42. None of the donors had critical COVID-19, and all had good function of the transplanted organ along with no other identified indirect complication related to COVID-19. The recipients were followed for mean 165 (range: 30–367) d posttransplant. Recipients had no clinical or molecular evidence of transmission of SARS-CoV-2 from the donor, regardless of their vaccination status. Clinical graft-rejection before discharge was noted in 1 (8%) liver recipient, which improved with increase in immunosuppression. Delayed renal-graft function (DGF), as defined by need for hemodialysis within 1 wk of transplant, was seen in 1 (17%) kidney transplant recipient. Excellent graft function was noted in all 13 of 13 (100%) recipients during 1-mo follow-up and in 7 of 7 (100%) recipients with >6-mo of follow-up (Table 1). These short-term and long-term outcomes regarding graft outcomes were comparable to recipients of COVID-negative donors in our institution during the study period (kidney DGF rate, 30%; liver rejection rate, 11%).

TABLE 1. - Patient characteristics and outcomes of solid organ transplantation from donors with a positive SARS-CoV-2 test
Donors D 1 D 2 D 3 D 4 D 5 D 6 D 7 D 8 D 9 D 10 D 11 D 12
Age (y) 29 34 32 39 65 28 50 13 20 37 32 31
Cause of death Anoxia Cardiac arrest Head trauma Anoxia Anoxia Head trauma Stroke Anoxia Anoxia Anoxic brain injury Intracranial bleed Anoxia
LOS (d) 18 5 4 7 6 3 9 2 7 8 4 1
KDPI n/a n/a n/a n/a n/a n/a 43 23 n/a 50 33 75
Terminal Creatinine, mg/dL 0.9 2.9 1.1 0.8 3.0 0.8 1.0 0.9 0.5 0.3 0.7 1.2
AST/ALT, µ/L 48/58 48/63 n/a 15/27 24/40 9/11 n/a n/a n/a n/a n/a n/a
LVEF (%) 50 n/a 70 n/a n/a n/a n/a n/a 66 n/a n/a n/a
Site of positive PCR URT, LRT URT URT URT URT URT URT, LRT URT, LRT URT, LRT URT, LRT URT URT, LRT
Last positive test to transplant (d) 1 1 1 2 3 2 3 3 3 3 1 1
Ct value 38.5, 40.5 33.0 38.5 n/a n/a 42.0 39.0 n/a 22.0 24.0 28.0 26.0
Symptoms New 1 d Resolved Unknown Unknown Unknown Unknown New Unknown New Unknown None None
Recipients R 1 R 2 R 3 R 4 R 5 R 6 R 7 R 8 R 9 R 10 R 11 R 12 R 13 R 14
Organ Heart Liver Liver Heart Liver Liver Liver Kidney Kidney Heart Kidney Kidney Kidney Kidney
Follow-up (d) 367 367 320 318 230 193 153 77 58 56 52 51 40 30
Age (y) 67 54 36 65 35 59 46 61 21 57 42 58 50 61
Vaccination No 2 doses 1 dose No No 2 doses 1 dose 3 doses 3 doses No 2 doses 3 doses 3 doses 2 doses
Prior COVID No No No No Yes No No No No Yes No No No No
Waitlist status Status 1 (ECMO) MELD 18 MELD 30 Status 2 (IABP) MELD 22 MELD 27 MELD 33 WL 4 y WL 3 y Status 2 WL 3 y WL 5 y WL 5 y WL 3 y
CIT (min) 32 284 282 84 337 306 188 906 1166 152 975 975 1051 751
Induction Steroid Steroid Steroids Steroids Steroids Steroids Steroids ATG ATG ATG + Eculizumab ATG ATG ATG ATG
Maintenance S+TAC+MMF S+TAC+MMF S+TAC S+TAC+MMF S+TAC S+TAC S+TAC S+TAC S+TAC+MMF S+TAC S+TAC+MMF S+TAC+MMF S+TAC+MMF S+TAC+MMF
Treatment C-I C-I C-I n/a C-I C-I C-I n/a T-C T-C T-C T-C T-C T-C
LOS (d) 50 11 12 n/a 7 10 16 13 4 n/a 5 12 6 5
Organ rejection before discharge No No No No No No Clinical, steroids + MMF No No No No No No No
DGF n/a n/a n/a n/a n/a n/a n/a Yes No n/a No No No No
Current organ function LVEF 75% LFTs normal LFTs normal n/a LFTs normal LFTs normal LFTs normal eGFR > 60 eGFR > 60 LVEF 60% eGFR 60 eGFR > 60 eGFR > 60 eGFR = 59
Other outcomes COVID 11 mo post-HT COVID 11 mo post-LT None Died of unrelated causes None None None None None Still hospitalized None None None None
ALT, alanine aminotransferase; AST, aspartate aminotransferase; ATG, antithymocyte globulin; C-I, casirivimab-imdevimab; CIT, cold ischemia time; COVID, coronavirus disease; Ct, cycle threshold; DGF, delayed graft function; ECMO, extracorporeal membrane oxygenation; eGFR, estimated glomerular filtration rate; HT, heart transplantation; IABP, intraaortic balloon pump; KDPI, kidney donor profile index; LFT, liver function test; LOS, length of stay; LRT, lower respiratory tract; LT, liver transplantation; LVEF, left ventricular ejection fraction; MELD, model for end-stage liver disease; MMF, mycophenolate mofetil; n/a, not applicable; PCR, polymerase chain reaction; S, steroid; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; TAC, tacrolimus; T-C, tixagevimab-cilgavimab; URT, upper respiratory tract; WL, waitlist.

A positive COVID test can signify a potentially false positive test to various stages of COVID-19 in the donor.4 A careful review of clinical, radiological evidence, and Ct values from the PCR test by a dedicated group of transplant team can help determine the risk of infectivity of the donor1 and then the donor organ is matched with a carefully selected recipient. Two recipients developed COVID-19 11 mo after the initial transplantation, thus highlighting the need for continuous counseling regarding safe practices, need for complete vaccination of the recipient and all household contacts, and/or use of pre-exposure prophylaxis in selected high-risk recipients.5

REFERENCES

1. Gupta G, Azhar A, Gungor A, et al. Early data on utilization and discard of organs from COVID-19-infected donors: a US National Registry analysis. Transplantation. 2022;106:e266–e268.
2. Kute VB, Fleetwood VA, Meshram HS, et al. Use of organs from SARS-CoV-2 infected donors: is it safe? A contemporary review. Curr Transplant Rep. 2021;8:281–292.
3. Eichenberger EM, Kaul DR, Wolfe CR. The pandemic provides a pathway: what we know and what we need to know about using COVID positive donors. Transpl Infect Dis. 2021;23:e13727.
4. Organ Procurement Transplantation Network Ad Hoc Disease Transmission Advisory Committee. Summary of current evidence and information—donor SARS-CoV-2 testing and organ recovery from donors and a history of COVID-19. 2022. Available at https://optn.transplant.hrsa.gov/media/4424/sars-cov-2-summary-of-evidence.pdf. Accessed March 20, 2022.
5. Chapman JR, Wigmore SJ. Simple vaccination is not enough for the transplant recipient. Transplantation. 2022;106:447–448.
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