Single-center Experience on Nonlung Solid Organ Transplantation From SARS-CoV-2–positive Donors

Abstract

Early in the coronavirus disease 2019 (COVID-19) pandemic, limited testing availability and knowledge about disease transmission raised concern about the safety of using organ donors with positive severe acute respiratory distress coronavirus 2 (SARS-CoV-2) testing.¹ Recent registry reports suggest the safety of this approach, but granular data on such transplants remain limited.^2-5 We report our single-center experience of 36 nonlung solid organ transplant (SOT) allografts from polymerase chain reaction (PCR) SARS-CoV-2⁺ donors.

We conducted a retrospective review of all nonlung SOT recipients at our center who underwent transplantation between July 2020 and July 2022 from deceased donors with SARS-CoV-2⁺ PCR testing within 28 d of donation (institutional review board no. 805160) (Figure 1). Donor SARS-CoV-2 PCR testing was obtained from nasopharyngeal (NP) swabs, tracheal aspirates, or bronchoalveolar lavage (BAL). The lowest cycle threshold (Ct) value was reported when available. Data analysis was performed by Stata 14.2 for Mac (College Station, TX). We report continuous variables as medians with associated range or interquartile range and discrete variables as percentages.

Thirty-six transplanted allografts from 29 deceased donors with SARS-CoV-2⁺ PCR within 28 d of donation were identified. None of the recipients developed donor-derived COVID-19. Twenty of 29 donors (69%) had a SARS-CoV-2⁺ test within 72 h of donation, 11 (38%) were symptomatic within 28 d of donation, and 4 (14%) had died from COVID-19 (Table 1). Of the 20 donors who were SARS-CoV-2⁺ within 72 h of donation, 6 donors had NP⁺ and BAL⁺, 5 had NP⁺ and BAL^–, and 1 donor had NP^– but BAL⁺ SARS-CoV-2 test. Eight donors had NP SARS-CoV-2⁺ test without lower respiratory tract testing. Ct values were available for 16 of 20 donors; the median Ct value was 33 (range, 18.0–38.2).

TABLE 1. - Donor and recipient characteristics

Donor characteristics (N = 29)
Age, y, median (IQR)	33 (27–47)
Cause of death, n (%)
Trauma	4 (14)
Anoxia	16 (55)
Cerebrovascular accident	5 (17)
COVID-19	4 (14)
Symptomatic COVID-19 within 28 d, a n (%)	11 (38)
SARS-CoV-2 PCR+ within 72 h, b n (%)	20 (69)
SARS-CoV-2 PCR+ type c
NP+, BAL+, n (%)	6 (30)
NP+, BAL–, n (%)	5 (25)
NP+, no BAL, n (%)	8 (40)
NP–, BAL+, n (%)	1 (5)
Cycle threshold value, median (range) (N = 16)	33.0 (18.0–38.4)
Recipient characteristics (N = 34)
Age, y, median (IQR)	57 (42–62)
Organ, n (%)
Kidney	17 (50)
cPRA, median (range)	0 (0–86)
KAS, median (range)	9.60 (5.39–14.14)
Liver	8 (24)
MELD, d median (range)	31 (17–40)
Heart	7 (20)
Status, median (range)	2 (1–3)
Heart-kidney	1 (3)
Status	2
Liver-kidney	1 (3)
MELD	29
Induction agent, N (%)
Antithymocyte globulin	20 (59)
Basiliximab	1 (3)
Steroid	13 (38)
Pretransplant vaccine, e n (%)	26 (76)
Doses of COVID-19 vaccine, median (range)	2 (1–5)
Prior SARS-CoV-2 infection, n (%)	7 (21)

^aSymptomatic COVID-19 was defined as symptoms compatible with COVID-19 within 28 d of procurement.

^bPositive SARS-CoV-2 PCR test within 72 h of procurement.

^cDonors who were PCR+ within 72 h of donation underwent all listed combinations of NP or BAL SARS-CoV-2 testing.

^dAllocation MELD score.

^eReceipt of at least 1 dose of any COVID-19 vaccine before transplant.

BAL, bronchoalveolar lavage; COVID-19, coronavirus disease 2019; cPRA, calculated panel-reactive antibody; IQR, interquartile range; KAS, kidney allocation score; MELD, model for end-stage liver disease score; NP, nasopharyngeal; PCR, polymerase chain reaction; SARS-CoV-2, severe acute respiratory coronavirus 2.

Thirty-four transplant recipients including 17 kidney (50%), 8 liver (24%), 7 heart (20%), 1 heart-kidney (3%), and 1 liver-kidney (3%) recipients were identified (Table 1). Twenty-six recipients (76%) received at least 1 dose of any COVID-19 vaccine before transplant. Seven recipients (21%) had COVID-19 before transplant; median time from COVID-19 to transplant was 31 d (range, 6–637). The first 3 recipients from donors with SARS-CoV-2⁺ PCRs within 72 h of donation received prophylactic remdesivir for 3 d per our protocol although this practice was later discontinued.

Overall mortality related to COVID-19 has reduced considerably owing to improved therapeutics and vaccination.⁶ As COVID-19 is now endemic, we suggest that SARS-CoV-2⁺ allografts be considered in the same way centers consider other respiratory viral infections in donors for nonlung SOT, such as influenza and respiratory syncytial virus, for which risk of transmission is low and vaccination and/or antivirals are available.

FIGURE 1.: Organ acceptance criteria for all non-lung solid organs from donors with a history of COVID-19 at our center. COVID-19, coronavirus disease 2019; PCR, polymerase chain reaction; SARS-CoV-2, severe acute respiratory distress coronavirus 2.

To date, this is one of the largest single-center series of SARS-CoV-2⁺ donor allografts transplanted into nonlung SOT recipients and is consistent with other studies demonstrating a lack of transmission in this setting.^2-5,7 We have extended prior work by including donors with SARS-CoV-2⁺ PCRs within 72 h of donation, adding granularity to a growing body of evidence supporting the safety of using acutely SARS-CoV-2⁺ allografts for nonlung SOT recipients.