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

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.