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Successful kidney transplantation from a deceased donor with severe COVID-19 respiratory illness with undetectable SARS-CoV-2 in donor kidney and aorta

Year: 2022

Type: article

Abstract: To the Editor: Kidney transplantation (KT) from coronavirus disease 2019 (COVID-19) donors were avoided due to concerns for donor-derived transmission.1Kates OS Fisher CE Rakita RM Reyes JD Limaye AP. Use of SARS-CoV-2-infected deceased organ donors: should we always "just say no?".Am J Transplant. 2020; 20 (doi:10.1111/ajt.16000): 1787-1794Crossref PubMed Scopus (0) Google Scholar,2Shah MB Lynch RJ El-Haddad H Doby B Brockmeier D Goldberg DS. Utilization of deceased donors during a pandemic: argument against using SARS-CoV-2-positive donors.Am J Transplant. 2020; 20 (doi:10.1111/ajt.15969): 1795-1799Crossref PubMed Scopus (43) Google Scholar There have been no data on the long-term safety, and sensitive molecular testing for SARS-CoV-2 in donor kidney is not routinely performed. We report a successful KT from a deceased donor who died with severe COVID-19 respiratory failure with a detailed investigation of the donor kidney and aorta tissue for SARS-CoV-2. A 30-year-old female was admitted to a hospital due to severe COVID-19 pneumonia with a positive nasopharyngeal RT-PCR for SARS-CoV-2. With clinical worsening, she was placed on extracorporeal membrane oxygenation, but developed hypoxic brain injury and progressed to brain death. Renal function was stable during her hospital course with a serum creatinine concentration of 0.7 mg/dl. SARS-CoV-2 PCR for bronchoalveolar lavage and nasopharyngeal swab re-tested 3 days prior to donation was negative. A 55-year-old male recipient with an end-stage renal disease secondary to hypertension underwent a transplant with the left kidney from this donor. The donor kidney was studied using pre-implantation surgical biopsy samples to investigate the presence of SARS-CoV-2 RNA using in situ hybridization (ISH) and quantitative RT-PCR (qRT-PCR). Aorta tissue dissected with the kidney during the organ procurement was also studied given high expression of angiotensin-converting enzyme 2 receptors in vasculature. Kidney hematoxylin and eosin staining showed acute tubular injury without any glomerular damage or inflammation (Figure 1A). ISH analyses lacked a positive signal for SARS-CoV-2 RNA in the donor kidney sample (Figure 1B) compared to the SARS-CoV-2 positive lung control (Figure 1C). All samples for qRT-PCR were negative for SARS-CoV-2. We found no evidence of SARS-CoV-2 in donor tissues. The recipient has tested negative for SARS-CoV-2 by nasopharyngeal swab RT-PCR on days 20, 30, and 90 following transplantation, and there have been no signs or symptoms of COVID-19. After an initial period of delayed graft function requiring hemodialysis, the recipient now has excellent renal recovery over 9 months following the transplant, and the most recent creatinine is 1.3 mg/dl. Evidence supporting the use of deceased donors who died due to catastrophic COVID-19-related respiratory illness is limited, and these cases do not fit in any categories of the most up-to-date guideline for COVID-19 donors.3Summary of current evidence and information–donor SARS-CoV-2 testing & organ recovery from donors with a history of COVID-19. https://optn.transplant.hrsa.gov/media/kkhnlwah/sars-cov-2-summary-of-evidence.pdf. Published September 22, 2021. Accessed December 20, 2021.Google Scholar As such, the decision of whether to accept nonlung organs from those donors has been decided on a case-by-case basis. Based on recent observations of successful KT outcomes from mild or asymptomatic SARS-CoV-2 positive donors,4Koval 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 (doi:10.1111/ajt.16765): 3743-3749Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar and a short-term safety report of KT from a donor similar to this case,5Meshram HS Kute VB Patel H Desai S Chauhan S Dave RB. A case report of successful kidney transplantation from a deceased donor with terminal COVID-19-related lung damage: ongoing dilemma between discarding and accepting organs in COVID-19 era!.Transpl Infect Dis. 2021; 23 (doi:10.1111/tid.13683)Crossref Scopus (10) Google Scholar the transmission risk of SARS-CoV-2 through KT is likely very low. In conclusion, the use of deceased donors who died after severe COVID-19 can be individually considered for KT, and these organs should not be routinely discarded. We acknowledge that our case may not be representative of many possible COVID-19 donors since the donor was negative for SARS-CoV-2 PCR at the time of transplantation. Larger scale studies are warranted to confirm our findings, and long-term graft outcomes from COVID-19 donors should be studied. We thank all the JH kidney transplant and COVID-19 research team members. These studies were supported through the generosity of the collective community of donors to the Johns Hopkins University School of Medicine for COVID research (J.L.M.), HHSN272201400007C (A.P.), and T32 AI007417 (J.R.).

Source: American Journal of Transplantation

DOI: 10.1111/ajt.16956