Non‐contagious, second COVID‐19 infection: Implications for organ donation eligibility

1.

Dear Editor:

As of May 19, 2020, the Korea Centers for Disease Control and Prevention (KCDC) has found evidence suggesting COVID‐19 patients testing positive for a second infection are incapable of infecting others. ¹ 96% of these cases were positive for neutralizing antibodies, responsible for dead virus particles unable to grow in culture. An implication yet to be discussed in the literature, such non‐contagious patients with a second infection (termed “re‐positive” by the KCDC) should be considered as potential organ donors. While peer review ought to precede actionable policy amendment, preliminary dialogue surrounding this possible donor source may expedite guideline modification if these findings are indeed corroborated.

Recent studies indicate the nominal transmissibility risk of COVID‐19 with transplant of extrapulmonary organs, specifically hearts and livers. In fact, Hong et al ² report no transmission from a living donor liver transplant using a mildly symptomatic COVID‐19‐positive donor. Building off this data, and now taking into account KCDC evidence pointing to the presence of neutralizing antibodies with a second infection, blanket guidelines barring organs from potential donors with COVID‐19 may require revision. With the pandemic progressing, the prospective donor source of re‐positive patients could come to constitute a consequential percentage of transplantable organs.

Patient‐focused hypotheticals are central to this discussion, for example, is symptomatic COVID‐19 infection in recipients of re‐positive organs worth the risk. Initial research is relatively ambiguous. Outcomes are generally good in some studies demonstrating similar COVID‐19 clinical manifestations compared to the general population. ³ Data of 13 consecutive recipients with COVID‐19 exhibited no higher mortality rate relative to overall transplant mortality. ⁴ Other research reveals significant complications and mortality, not necessarily attributable to immunosuppression but perhaps due to highly associated comorbidities. ⁵ We must consider the cost‐benefit for patients by thoughtfully weighing the speculated risk for worsened COVID‐19 symptomatology with immunosuppression and/or associated comorbidities (in the seemingly unlikely event of infection from re‐positive organs) against the certain, fatal risk of foregoing transplant.

From resource deficits to a depleted donor pool, a catch‐22 in the wake of social restrictions, transplant physicians are increasingly unable to provide for waiting candidates amid the ongoing COVID‐19 pandemic. We cannot stand idly by as the gap between organ supply and demand widens while possibly excluding more donors than necessary. We owe transplant candidates swift action to align policy with the most topical information, necessitating OPO access to timely antibody testing to ideally facilitate the determination of re‐positivity. A potential limitation, distinguishing between positive antibodies (following an initial infection) and neutralizing antibodies (present with a second infection) would be required, and no gold standard assay exists. Though re‐positive donors may be COVID‐19 PCR‐positive, the connotation of contagiousness ought to be reconsidered with a second infection. Trailblazing centers willing to utilize re‐positive organs should be preferentially allocated evolving COVID‐19 medications in cautious anticipation of symptomatic infection. Potential transplant candidates must not be limited to COVID‐19 patients but should include others in dire need of organs, for example, heart candidates above Status 3 and liver candidates with a MELD score > 30.

CONFLICT OF INTEREST

The authors of this manuscript have no conflicts of interest to disclose as described by Clinical Transplantation.

Goss MB, Moreno NF, Galván NTN, Rana A. Non‐contagious, second COVID‐19 infection: Implications for organ donation eligibility. Clin Transplant. 2020;34:e14039. 10.1111/ctr.14039