Successful Kidney Transplantation for Children Within 3 Weeks of COVID-19 Infection.

Abstract

Listen

Translate article

The COVID-19 pandemic has caused significant disruption to kidney transplantation programs. Current guidelines from the Transplantation Society of Australia and New Zealand recommend a temporary hold on listing status until 7 wk after COVID-19 infection and avoiding transplantation until the reverse transcription polymerase chain reaction (RT-PCR) test is negative.1 This advice is based on prospective United Kingdom data captured among mostly unvaccinated adults with prior circulating strains.2 However, the applicability of this recommendation to children, who are at lower risk of severe COVID-19 and in whom the donor pool is typically restricted by age and human leukocyte antigen (HLA) matching, is uncertain. Despite these important differences, only 1 case of an RT-PCR–positive child receiving a kidney transplant has been reported thus far,3 with advice generally to avoid transplantation in children who are RT-PCR positive and have evidence of recent COVID-19 infection.1,4,5 To understand the current practice in Australia and New Zealand, we conducted a survey of all pediatric kidney transplant units and identified 2 cases of children transplanted within 1 mo of symptomatic COVID-19 infection, one with a positive RT-PCR at the time of transplantation. Here, we report those cases and consider their implications in relation to current advice regarding furloughing or deactivation of children awaiting a kidney transplant. Case 1 is a 3-y-old girl with kidney failure secondary to nephronophthisis, who had been on peritoneal dialysis for 8 mo. She received a kidney transplant from a 6-y-old donor after brain death with good kidney function and class II HLA matching. The recipient had symptomatic COVID-19 3 wk before the offer, diagnosed on RT-PCR. She had 24 h of fever and malaise initially but had since fully recovered. At the time of transplantation, she underwent a rapid antigen test which was negative, but her RT-PCR (BioFire Diagnostics Respiratory 2.1 Panel) was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The E gene target was not detected on the RT-PCR platform and the N2 gene target was detected at a cycle threshold (Ct) of 43.7, consistent with past infection. A repeat RT-PCR on day 5 posttransplantation was negative for SARS-CoV-2. She received our standard protocol with basiliximab induction and tacrolimus, mycophenolate mofetil, and prednisolone as ongoing immunosuppression. Following transplantation, kidney function rapidly normalized, and the patient was discharged home on postoperative day 11 with normal graft function and no evidence of COVID-19 reactivation or perioperative complications. Case 2 is a 15-y-old boy with kidney failure secondary to postinfectious glomerulonephritis, on hemodialysis, who received a deceased-donor kidney transplant from a donor who was RT-PCR positive at the time of transplant. The donor had been mildly symptomatic of COVID-19 3 wk before their death from a suspected cardiac arrythmia. Their RT-PCR (Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV) was still positive on the day of their death, with a Ct of 35 for the E gene and 37 for the N2 gene. The recipient had a positive rapid antigen test for COVID-19 with mild symptoms 2 wk before transplantation but was RT-PCR negative on admission. Transplantation occurred uneventfully, and the recipient received standard immunosuppression with basiliximab induction, methylprednisolone, tacrolimus, and mycophenolate mofetil. There were no complications from COVID-19, and the patient was discharged from hospital 13 d after transplantation with normal graft function. Case 1 had not received any COVID-19 vaccinations (not currently approved for children <5 y in Australia) but was at an age where complications are rare, even among the immunocompromised. Case 2 was fully immunized, having received 2 doses of the Pfizer-BioNTech BNT162b2 mRNA vaccine 3 wk apart, but of older age and received a kidney from a donor who was RT-PCR positive. Both recipients were from minority groups among the Australian population and thus carried uncommon HLA alleles for which well-matched, young donors are less frequent. In both cases, the treating teams decided to proceed with transplantation after receiving informed consent from the families about the potential risks, benefits, and unknowns of the clinical scenario. Neither patient received specific treatment for COVID-19 following consideration of the limited licensed options for children and the evidence of clinical and microbiological resolution of infection at the time of transplant. With the increasing prevalence of COVID-19 in the Australian community, there is a need to balance patient safety with resource utilization and the known benefits of transplantation. Our report supports a personalized approach to deceased-donor transplantation in COVID-19–positive recipients and a reconsideration of the applicability of current guidelines to children.