Donor organ evaluation in the era of coronavirus disease 2019: A case of nosocomial infection

A 45-year-old man with a history of substance abuse presented with altered mental status secondarily to a fall. Computed tomography (CT) of the head suggested anoxic brain injury with no hemorrhage. Chest CT angiography was consistent with a right lower lobe pulmonary artery segmental embolus. On Day 2, he was found to have a large, acute left middle cerebral artery ischemic infarct. Subsequently, on Day 7, he developed sub-falcine herniation. He remained afebrile, but his white blood cell count increased from 7,600 to 17,800 cells/mm³ of blood with no bacterial infection on respiratory and blood cultures. During organ-donation work-up, a repeat chest CT (on Day 8) showed resolution of his pulmonary embolus, but new scattered, bilateral ground-glass opacifications were noted, which prompted bronchoalveolar lavage and nasal swab specimens for coronavirus disease 2019 (COVID-19) testing. These were positive 24 hours later, and the patient was declined as an organ donor. This case raises several points regarding the assessment of donors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Given the frequent absence of donor history, the extent of community spread, concern for the risk of nosocomial acquisition, and concomitant hazard to medical personnel, donor screening should be mandatory. The International Society for Heart and Lung Transplantation currently recommends that all donors should be tested for SARS-CoV-2 infection if testing is available.¹ Early screening may be prudent, particularly when medical history is sparse or absent. Admission to a facility or units known to have cases of COVID-19 increases concern for nosocomial transmission. In this case, the patient may have arrived with pre-existing asymptomatic COVID-19 infection but may also have acquired the infection after arrival at the donor hospital.^{2 , 3} In such cases, even if an initial screening test is negative, a repeat test should be performed before the recovery of organs. For organ procurement organizations, tests may need to be sent out if the donor hospital is unable to provide in-house testing, resulting in significant delays in allocation. Although reverse transcriptase polymerase chain reaction (RT-PCR) sensitivity varies widely by sampling site, concurrent evaluation of chest CT seems to greatly increase sensitivity for the disease.⁴ In this candidate donor, the final chest CT demonstrated the development of bilateral ground-glass opacities that were consistent with COVID-19, which was confirmed by respiratory RT-PCR. The chest CT was convincing evidence to defer making a decision to accept the organ until the RT-PCR result was available. Multimodality RT-PCR testing should also be considered as the virus may be present in mucosal areas such as the gut. However, availability of such testing may be limited. Although the disease primarily affects the lungs, it is not clear whether other organs may be safely transplanted. From a cardiac standpoint, the angiotensin-converting enzyme 2 receptor is required for SARS-CoV-2 entry and is expressed on cardiac myocytes. There has been evidence of fulminant myocarditis in COVID-19, and troponin elevation has been associated with increased mortality. Because the outcomes of transplanting organs from a COVID-19–positive donor and the extent of cardiac involvement in COVID-19 are currently unknown, it is our practice at the time of publication to decline organs from donors with positive RT-PCR testing, even for an isolated cardiac transplant. Other considerations include a significant risk of transmission to the procurement team, the lack of resource-effective surveillance strategies for donor transmission, absence of proven treatments for this potentially lethal condition, and potential for turning the recipient into a vector for viral transmission. Owing to the many uncertainties and rapidly evolving data regarding SARS-CoV-2, it is vital to develop donor testing protocols for COVID-19 during this pandemic.