Kidney transplantation from SARS-CoV-2–positive deceased donor

Abstract

To the Editor: To expand the available donor pool, many organ procurement organizations and transplant programs have begun to consider severe acute respiratory syndrome coronavirus (SARS-CoV-2) nucleic acid test positive candidates.1Organ Procurement and Transplantation Network: Summary of Current Evidence and Information– Donor SARS-CoV-2 Testing & Organ Recovery from Donors with a History of COVID-19. 2021.Google Scholar It is becoming increasingly clear that not all donors with a positive nucleic acid amplification test for SARS-CoV-2 are contagious, and some of these organs can be transplanted with careful selection.2Kute VB Fleetwood VA Meshram HS Guenette A Lentine KL. Use of organs from SARS-CoV-2 infected donors: is it safe? a contemporary review.Curr Transplant Rep. 2021; : 1-12Google Scholar,3Koval CE Poggio ED Lin YC Kerr H Eltemamy M Wee A. Early success transplanting kidneys from donors with new SARS-CoV-2 RNA positivity: a report of 10 cases.Am J Transplant. 2021; 21: 3743-3749Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Data from 31 kidney transplants from living donors with resolved COVID-19 in India showed the safety of this approach.4Kute VB Godara S Guleria S et al.Is it safe to be transplanted from living donors who recovered from COVID-19? Experience of 31 kidney transplants in a multicenter cohort study from India.Transplantation. 2021; 105: 842-850Crossref PubMed Scopus (36) Google Scholar However, it is unknown whether kidneys from donors with active COVID-19 can also be safely transplanted.3Koval CE Poggio ED Lin YC Kerr H Eltemamy M Wee A. Early success transplanting kidneys from donors with new SARS-CoV-2 RNA positivity: a report of 10 cases.Am J Transplant. 2021; 21: 3743-3749Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar,5Ali H Mohamed M Molnar MZ Krishnan N. Is it safe to receive kidneys from deceased kidney donors tested positive for COVID-19 infection?.Ren Fail. 2021; 43: 1060-1062Crossref PubMed Scopus (5) Google Scholar Beyond the “active” infection designation, it is clinically possible to risk stratify donors with COVID-19 based on additional parameters such as clinical history and radiologic or laboratory findings. Here we present a case and 210-day outcome of a successful kidney transplantation from otherwise medically suitable SARS-CoV-2 PCR–positive deceased donors. The donor was a 48-year-old man who had been admitted to the intensive care unit (ICU) with worsening SARS-CoV-2 pneumonia. Urinalyses showed minimal or no proteinuria. On hospital days 20 and 28, he tested negative for COVID-19 by nasopharyngeal (NP) swab PCR; however, PCR testing was again positive on day 29 with a cycle threshold (Ct) of 38. The donor received remdesivir treatment during the hospital stay. The donor primary cause of death was COVID-19 pneumonia secondary to severe worsening hypoxemic respiratory failure. Only kidneys were recovered for transplantation. The mate kidney of this offer was not placed. The recipient was a 48-year-old Hispanic man with a history of end-stage kidney disease (ESKD) from presumed hypertensive nephrosclerosis (Table 1). He had no personal history of COVID-19 and had received a second shot of COVID-19 vaccination (BNT162b2 vaccine) 14 days before this preemptive kidney transplantation. Despite a long cold ischemia time, he never required dialysis after transplantation but had slow graft function and was discharged on post-operative day (POD) 4 on belatacept, mycophenolate mofetil, and prednisone for maintenance immunosuppression. He reported a low-grade fever (#POD7) but denied any cough, shortness of breath, or gastrointestinal symptoms. He tested negative for SARS-CoV-2 via nasal swab PCR. He underwent a kidney graft biopsy for prolonged slow graft function. The biopsy showed moderate acute tubular injury, glomerular basement membrane thickening, and mesangial expansion, no rejection. Serum creatinine continued to trend down, and by POD#210, he had excellent stable graft function with a serum creatinine of 1.39 mg/dl and no proteinuria (Table 1).TABLE 1Donor, recipient, and transplant characteristicsCaseDonor characteristicsHistory of COVID before admissionNoReason for hospital/ICU admissionCOVID pneumoniaSARS-CoV−2 PCR result #1PositiveTime since symptoms (days)0 dayTime before transplantation (days)31 daysSourceNP swabCycle thresholdNo dataSARS-CoV−2 PCR result #2NegativeTime since symptoms (days)20 daysTime before transplantation (days)11 daysSourceNP swabCycle thresholdNo dataSARS-CoV−2 PCR result #3NegativeTime since symptoms (days)28 daysTime before transplantation (days)3 daysSourceNP swabCycle thresholdNo dataSARS-CoV−2 result #4PositiveTime since symptoms (days)29 daysTime before transplantation (days)2 daysSourceNP swabCycle threshold38Age, years48GenderMaleRace/EthnicityWhite/HispanicKDPI65%DCDYesKidney sideLeftCause of deathAnoxiaHistory of hypertensionNoHistory of diabetesYes, >10 yearsPeak serum creatinine1.38 mg/dlTerminal serum creatinine0.25 mg/dlBiopsyLeft kidney biopsy revealed 75 glomeruli, minimal inflammation, no arterial sclerosis, no interstitial fibrosis/tubular atrophyRecipient characteristicsAnti-spike IgG index before transplant (reference range; ≥1.1 is considered positive)>20SARS-CoV−2 PCR before transplantationNegativeTime since vaccination completed14 daysHistory of COVID infectionNoAge50 yearsGenderMaleRace/EthnicityWhite/HispanicCause of ESKDHypertensive Nephrosclerosis (not biopsy proven)Dialysis vintagePreemptive transplantcPRA0%Transplantation related dataCold ischemia time37 hours 37 minutesDelayed Graft FunctionNoHLA mismatches2/6 (0 DR)CrossmatchB and T cell negativeType and dose of inductionrATG 4.5 mg/kgTransplantation outcomeLength of hospital stay4 daysSerum creatinine at POD#711.5 mg/dlSerum creatinine at POD#147.22 mg/dlSerum creatinine at POD#302.28 mg/dlSerum creatinine at POD#451.66 mg/dlSerum creatinine at POD#901.63 mg/dlSerum creatinine at POD#2101.39 mg/dlSARS-Cov−2 PCR after transplantationNegative (POD#11)Anti-spike IgG index after transplant (reference range; ≥1.1 is considered positive)>20 (at POD#19)Post-transplant hospitalizations in the first monthNone Open table in a new tab We report a successful kidney transplant from SARS-CoV-2 nucleic acid test positive deceased donors who were admitted with COVID pneumonia and tested PCR positive 29 days after admission and 2 days before donation. This case demonstrates these transplants can be performed safely without viral transmission to the recipient. Currently, there is a lack of bigger cohort data of these transplants which would be able to assess long-term outcome and potential unexpected complication of these transplants such as the potential higher risk of thromboembolic complication and worse graft function in long-term as described after SARS-CoV-2 infection. The development of registry of organ transplantation from SARS-CoV-2 NAT positivity donors is highly warranted to answer these questions. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

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