Kidney transplantation from SARS-CoV-2–positive deceased donor

To the Editor:

To expand the available donor pool, many organ procurement organizations and transplant programs have begun to consider severe acute respiratory syndrome coronavirus (SARS-CoV-2) nucleic acid test positive candidates.¹ It is becoming increasingly clear that not all donors with a positive nucleic acid amplification test for SARS-CoV-2 are contagious, and some of these organs can be transplanted with careful selection.^{2 , 3} Data from 31 kidney transplants from living donors with resolved COVID-19 in India showed the safety of this approach.⁴ However, it is unknown whether kidneys from donors with active COVID-19 can also be safely transplanted.^{3 , 5} Beyond the “active” infection designation, it is clinically possible to risk stratify donors with COVID-19 based on additional parameters such as clinical history and radiologic or laboratory findings. Here we present a case and 210-day outcome of a successful kidney transplantation from otherwise medically suitable SARS-CoV-2 PCR–positive deceased donors.

The donor was a 48-year-old man who had been admitted to the intensive care unit (ICU) with worsening SARS-CoV-2 pneumonia. Urinalyses showed minimal or no proteinuria. On hospital days 20 and 28, he tested negative for COVID-19 by nasopharyngeal (NP) swab PCR; however, PCR testing was again positive on day 29 with a cycle threshold (Ct) of 38. The donor received remdesivir treatment during the hospital stay. The donor primary cause of death was COVID-19 pneumonia secondary to severe worsening hypoxemic respiratory failure. Only kidneys were recovered for transplantation. The mate kidney of this offer was not placed.

The recipient was a 48-year-old Hispanic man with a history of end-stage kidney disease (ESKD) from presumed hypertensive nephrosclerosis ( Table 1). He had no personal history of COVID-19 and had received a second shot of COVID-19 vaccination (BNT162b2 vaccine) 14 days before this preemptive kidney transplantation. Despite a long cold ischemia time, he never required dialysis after transplantation but had slow graft function and was discharged on post-operative day (POD) 4 on belatacept, mycophenolate mofetil, and prednisone for maintenance immunosuppression. He reported a low-grade fever (#POD7) but denied any cough, shortness of breath, or gastrointestinal symptoms. He tested negative for SARS-CoV-2 via nasal swab PCR. He underwent a kidney graft biopsy for prolonged slow graft function. The biopsy showed moderate acute tubular injury, glomerular basement membrane thickening, and mesangial expansion, no rejection. Serum creatinine continued to trend down, and by POD#210, he had excellent stable graft function with a serum creatinine of 1.39 mg/dl and no proteinuria (Table 1).

TABLE 1.

Donor, recipient, and transplant characteristics

	Case
Donor characteristics
History of COVID before admission	No
Reason for hospital/ICU admission	COVID pneumonia
SARS-CoV−2 PCR result #1	Positive
Time since symptoms (days)	0 day
Time before transplantation (days)	31 days
Source	NP swab
Cycle threshold	No data
SARS-CoV−2 PCR result #2	Negative
Time since symptoms (days)	20 days
Time before transplantation (days)	11 days
Source	NP swab
Cycle threshold	No data
SARS-CoV−2 PCR result #3	Negative
Time since symptoms (days)	28 days
Time before transplantation (days)	3 days
Source	NP swab
Cycle threshold	No data
SARS-CoV−2 result #4	Positive
Time since symptoms (days)	29 days
Time before transplantation (days)	2 days
Source	NP swab
Cycle threshold	38
Age, years	48
Gender	Male
Race/Ethnicity	White/Hispanic
KDPI	65%
DCD	Yes
Kidney side	Left
Cause of death	Anoxia
History of hypertension	No
History of diabetes	Yes, >10 years
Peak serum creatinine	1.38 mg/dl
Terminal serum creatinine	0.25 mg/dl
Biopsy	Left kidney biopsy revealed 75 glomeruli, minimal inflammation, no arterial sclerosis, no interstitial fibrosis/tubular atrophy
Recipient characteristics
Anti-spike IgG index before transplant (reference range; ≥1.1 is considered positive)	>20
SARS-CoV−2 PCR before transplantation	Negative
Time since vaccination completed	14 days
History of COVID infection	No
Age	50 years
Gender	Male
Race/Ethnicity	White/Hispanic
Cause of ESKD	Hypertensive Nephrosclerosis (not biopsy proven)
Dialysis vintage	Preemptive transplant
cPRA	0%
Transplantation related data
Cold ischemia time	37 hours 37 minutes
Delayed Graft Function	No
HLA mismatches	2/6 (0 DR)
Crossmatch	B and T cell negative
Type and dose of induction	rATG 4.5 mg/kg
Transplantation outcome
Length of hospital stay	4 days
Serum creatinine at POD#7	11.5 mg/dl
Serum creatinine at POD#14	7.22 mg/dl
Serum creatinine at POD#30	2.28 mg/dl
Serum creatinine at POD#45	1.66 mg/dl
Serum creatinine at POD#90	1.63 mg/dl
Serum creatinine at POD#210	1.39 mg/dl
SARS-Cov−2 PCR after transplantation	Negative (POD#11)
Anti-spike IgG index after transplant (reference range; ≥1.1 is considered positive)	>20 (at POD#19)
Post-transplant hospitalizations in the first month	None

We report a successful kidney transplant from SARS-CoV-2 nucleic acid test positive deceased donors who were admitted with COVID pneumonia and tested PCR positive 29 days after admission and 2 days before donation. This case demonstrates these transplants can be performed safely without viral transmission to the recipient. Currently, there is a lack of bigger cohort data of these transplants which would be able to assess long-term outcome and potential unexpected complication of these transplants such as the potential higher risk of thromboembolic complication and worse graft function in long-term as described after SARS-CoV-2 infection. The development of registry of organ transplantation from SARS-CoV-2 NAT positivity donors is highly warranted to answer these questions.