SARS‐CoV‐2 RNA positive pediatric organ donors: A case report

Abstract

Background

Preliminary evidence suggests that non‐lung organ donation from resolved, asymptomatic or mildly symptomatic SARS‐CoV‐2 infected adults may be safe. However, several biological aspects of SARS‐CoV‐2 infection differ in children and the risk for transmission and outcomes of recipients from pediatric donors with SARS‐CoV‐2 infection are not well described.

Methods

We report two unvaccinated asymptomatic pediatric non‐lung organ deceased donors who tested positive for SARS‐CoV‐2 RNA by RT‐PCR. Donor One unexpectedly had SARS‐CoV‐2 RNA detected in nasopharyngeal swab and plasma specimens at autopsy despite several negative tests (upper and lower respiratory tract) in the days prior to organ recovery. Donor Two had SARS‐CoV‐ 2 RNA detected in multiple nasopharyngeal swabs but not lower respiratory tract specimens (endotracheal aspirate and bronchoalveolar lavage) during routine surveillance prior to organ recovery and was managed with remdesivir and monoclonal antibodies prior to organ recovery.

Results

Two hearts, two livers and four kidneys were successfully transplanted into seven recipients. No donor to recipient transmission of SARS‐CoV‐2 was observed and graft function of all organs has remained excellent for up to 7 months of followup.

Conclusions

Due to the persistent gap between organ availability and the number of children waiting for transplants, deceased pediatric patients with non‐disseminated SARS‐CoV‐2 infection, isolated to upper and/or lower respiratory tract, should be considered as potential non‐lung organ donors.

Abbreviations

COVID‐19

coronavirus disease 2019

CT

computed tomography

RNA

ribonucleic acid

RT‐PCR

reverse transcriptase polymerase chain reaction

SARS‐CoV‐2

severe acute respiratory syndrome coronavirus 2

1. INTRODUCTION

Limited evidence is available to assess the risk for transmission of SARS‐CoV‐2 from infected donors to recipients of non‐lung organs. To date, several case series in adults suggest that the risk of transmission of SARS‐CoV‐2 from resolved, asymptomatic or mildly symptomatic adult donors of non‐lung organs is remarkably low, with no reported cases of transmission to date. ¹ , ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ The risk of transmission of SARS‐CoV‐2 from asymptomatic or mildly symptomatic deceased pediatric donors has not previously been reported.

Deceased pediatric organ donation is relatively rare compared to deceased adult organ donation. ¹⁹ The gap between organ availability and the number of patients on transplant waiting lists remains quite wide and children continue to die waiting for an organ. ¹⁹ Now that SARS‐CoV‐2 infection is prevalent, eliminating organ donor eligibility based on SARS‐CoV‐2 status will have a detrimental impact on pediatric organ donation and transplantation. In the United States, over 12 million children, or 19% of cumulated cases, tested positive for SARS‐CoV‐2 RNA (rate of 17 139 cases per 100 000 children) from the onset of the pandemic in March, 2020 through April 22, 2022. ²⁰ From the states reporting, children accounted for <5% of all COVID‐19 hospitalizations, and 0.02% of total child cases of COVID‐19 resulted in childhood death. ²⁰ Additionally, a number of children are hospitalized for other medical reasons and are incidentally found to have asymptomatic or minimally symptomatic SARS‐CoV‐2 infection on routine admission screening. Since children are less likely to become seriously ill or be hospitalized with acute infections from SARS‐CoV‐2 compared to adults, the risk of injury to non‐lung organs from SARS‐CoV‐2 induced inflammation may be reduced, potentially leading to higher quality organs than those from adults. Although rare cases of multisystem inflammatory syndrome in children (MIS‐C) associated with SARS‐CoV‐2 infection are well described, most children with MIS‐C recover with normal organ function. ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷

Here we report, to our knowledge, the first cases where two asymptomatic SARS‐CoV‐2 RNA positive pediatric deceased donors resulted in seven successful organ transplants without evidence of transmission of SARS‐CoV‐2. (Table 1) This case report was determined exempt status following review by the Seattle Children's Hospital IRB (Institutional Review Board).

TABLE 1.

Pediatric SARS‐CoV‐2 RNA Positive Donor Characteristics

	Donor one	Donor two
Donor Characteristics
Donor age (years)	1.3	13
Cause of death	Anoxic brain injury	Traumatic brain injury
Hospital length of stay (days)	10	5
Deceased per neurologic criteria (“brain death”)	Yes	Yes
SARS‐CoV‐2 treatment prior to donation	None	Remdesivir (loading dose and one daily dose), monoclonal antibodies (casirivimab/imdevimab)
SARS‐CoV‐2 test: RT‐ PCR
Source, result (days from test to donation), cycle threshold	NP, negative (−9)	NP, negative (− 4)
	NP, negative (−5)	NP, positive (−3), Ct 34.1
	ETA, negative (−5)	ETA, negative (−3)
	NP, negative (−1)	NP, positive (−2), Ct 30.5
	NP, positive (+1), Ct NA	BAL, negative (−2)
	NP, positive (+1), Ct NA	NP, positive (−1), Ct 32
	Plasma, positive (+1), Ct NA	NP, positive (0), Ct 37.1
		ETA, negative (0)
SARS‐CoV‐2 Serology
Spike protein IgG	Unknown, not tested	Reactive, 1902.3 AU/ml
Nucleocapsid protein IgG	Unknown, not tested	Reactive
Diagnostic imaging (days from test to donation)
Chest computed tomography	Bilateral posterior upper and lower lobe consolidations, consistent with atelectasis; small bilateral pleural effusions; no ground glass opacities (−4)	Bibasilar atelectasis, right greater than left (−3)
Chest x‐ray	Central and subsegmental atelectasis; no focal consolidations; small blunting of right costophrenic angle consistent with pleural effusion (−2) Mild diffuse hazy opacity, likely edema; retrocardiac opacity, may be superimposed atelectasis (−1)	Clear lung fields (−4) Large left pneumothorax with left lung atelectasis (−2) No discernible pneumothorax status post placement of a left thoracostomy tube (−2) Small residual left apical pneumothorax (−1)
Abdomen and pelvic computed tomography	No liver, spleen, gallbladder, biliary tree, pancreas, adrenal kidney abnormalities; moderate amount of free fluid in abdomen and pelvis (−4)	Normal appearance of liver, pancreas and kidneys; single renal arteries supplying the left and right kidney; patent portal and renal veins; trace pelvic ascites and small amount of ascites interposed between gallbladder and liver; sludge vs. vicarious excretion of contrast within nondistended gallbladder (−3)
Echocardiogram	Normal right and left ventricular size and systolic function, ejection fraction 58%, left ventricular shortening fraction 40%, normal coronary arteries (−1)	Normal right and left ventricular size and systolic function, ejection fraction 74%, left ventricular shortening fraction 42%, normal coronaries, normal valves (−2)
Laboratory data (days from test to organ recovery)
B‐type natriuretic peptide (BNP) (pg/ml)	44 (−9), 113 (−5)	Unknown
Troponin I (ng/ml)	9.51 (−9), 0.26 (0)	0.095 (−2), 0.06 (−1), 0.03 (−1)
Blood urea nitrogen (BUN) (mg/dl)	12 (−9), 5 (0)	10 (−5), 13 (0)
Creatinine (mg/dl)	0.5 (−9), 0.2 (0)	0.6 (−5), 0.5 (0)
Aspartate transaminase (AST) (IU/L)	1087 (−9), 230 (0)	35 (−5), 24 (0)
Alanine transaminase (ALT) (IU/L)	602 (−9), 29 (0)	34 (−5), 51 (0)
Total Bilirubin, unconjugated bilirubin (mg/dl)	0.1, 0 (−9), 0.5, 0 (0)	0.2 (−5), 0.3 (0)
Prothrombin time (s), international normalized ratio (INR)	16.6, 1.4 (−9), 16.6, 1.4 (0)	14.7, 1.1 (−5), 18.9, 1.6 (0)
White blood cell count (K/mm3)	12.1, N16%, L63%, B9% (−9) 20.6, N46%, L 40% (0)	20.3 (−5), 16.21 (0)
Platelet (K/mm3)	387 (−9), 296 (0)	382 (−5), 255 (0)
Hemoglobin (g/dl), hematocrit (%)	12.8, 42.6 (−9); 10.4, 29.8 (0)	13.9, 41 (−5), 10.4 (0)
Erythrocyte sedimentation rate (mm/hr)	N/A	8 (−4)
C reactive protein (mg/dl)	<0.4 (−9), 22 (−5)	2.5 (−4)
Procalcitonin (ng/ml)	N/A	0.92 (−2)
Ferritin (ng/ml)	N/A	68 (−2)
Lactate dehydrogenase (IU/L)	7437 (−5), 12 091 (0)	816 (−2)
Fibrinogen (mg/dl)	190 (−9), 664 (−5)	243 (−5), 479 (0)
D‐dimer (mcg/ml)	15.1 (−9)	2.11 (−4), 1.69 (0)

Abbreviations: AU, arbitrary units; BAL, bronchoalveolar lavage; dL, deciliters; ETA, endotracheal aspirate; g, grams; hr, hour; IU, international units; IgG, immunoglobulin G; K, 1000; L, liter; mcg, micrograms; mg, milligrams; mL, milliliter; mm, millimeter; ng, nanograms; NA, not available; NP, nasopharyngeal; pg, picograms; s, seconds; SARS‐CoV‐2, severe acute respiratory syndrome coronavirus 2.

These bold values are significant to highlight the positive SARS‐CoV‐2 tests.

2. CLINICAL CASES

2.1. Donor One

A previously healthy 16 month old presented with severe anoxic brain injury and multi‐organ system dysfunction following cardiopulmonary arrest at home secondary to presumed narcotic overdose. Approximately 2 weeks prior to admission, the patient was evaluated by the primary care provider for 2 months of chronic nasal congestion in the absence of cough or fever. At that time, clinical exam revealed no pathology and SARS‐CoV‐2 PCR test was not obtained. A course of amoxicillin was prescribed for presumed sinusitis, after which symptoms reportedly resolved. On admission, the patient had no acute respiratory or viral symptoms, including fever, nasal congestion, cough, vomiting, diarrhea, or rash. The patient was ineligible for SARS‐CoV‐2 vaccination due to age and routine admission screening SARS‐CoV‐2 PCR nasopharyngeal test was negative.

Four days after the initial brain injury, the patient was declared deceased based on neurologic criteria. Parental authorization for organ donation was obtained, and routine organ donor medical management ensued, including surveillance for infections, empiric antibiotics, pulse corticosteroids, and ongoing organ support. Routine organ donation surveillance revealed three negative nasopharyngeal and one negative endotracheal aspirate SARS‐CoV‐2 RT‐PCR tests (9, 5 and 1 day and 5 days prior to organ recovery, respectively). White blood cell count and C‐reactive protein (CRP) were normal on admission, however increased to 22 000 cells/mm³ (day of organ recovery) and 22 mg/dl (5 days prior to organ recovery), respectively, with no identifiable source of acute viral or bacterial infection. Lactate dehydrogenase remained elevated throughout the hospital course (7437 IU/L on admission and 12 091 IU/L on day of organ recovery). A chest computed tomography (CT) 5 days prior to organ recovery revealed no ground glass opacities or focal consolidations consistent with pneumonia. Two echocardiograms were performed (4 days and 1 day prior to organ recovery) and revealed no evidence of myocarditis or coronary dilation with normal right ventricular (RV) and left ventricular (LV) size and function (LV ejection fraction 63% and shortening fraction 38%).

On hospital day 10, the donor's heart, liver, and en‐bloc kidneys were transplanted into three recipients. (Table 2) Routine testing by the medical examiner at autopsy conducted 1 day after donation and transplant demonstrated three positive SARS‐CoV‐2 RT‐PCR tests (two nasopharyngeal and one plasma). Positive tests were prior to presence of Omicron variant in the community. The transplant centers were notified of the findings 4 days post‐transplant, as soon as the organ procurement agency received the results. No SARS‐CoV‐2 transmission to the recipients was identified by 5 months post‐transplant.

TABLE 2.

Characteristics of organ recipients from pediatric SARS‐CoV‐2 positive donors

	Donor one			Donor two
	Recipient 1	Recipient 2	Recipient 3	Recipient 4	Recipient 5	Recipient 6	Recipient 7
Demographics and clinical characteristics
Age (years)	2	2	48	15	57	41	50
Gender	Female	Male	Male	Female	Female	Female	Male
Diagnosis	Tricuspid atresia with heart failure	Alagille Syndrome	Renal sclerosis, unspecified	Anthracycline induced cardiomyopathy	Primary Biliary Cholangitis	Polycystic kidney disease	Polycystic kidney disease
Organ transplanted	Heart	Liver	En‐bloc kidneys	Heart	Liver	Right kidney	Left kidney
Pre‐transplant SARS‐CoV‐2 characteristics
SARS‐CoV‐2 vaccination status	Ineligible due to age	Ineligible due to age	Completed two dose vaccination 6 months prior to transplant	Unvaccinated	Completed one dose vaccination 6 months prior to transplant	Completed 2 dose vaccination Unknown date	Completed 2 dose vaccination Unknown date
SARS‐CoV‐2 serology	Unknown, not tested	Unknown, not tested	Unknown, not tested	IgG reactive 11 months pre‐transplant	Unknown, not tested	Unknown, not tested	Unknown, not tested
SARS‐CoV‐2 RNA testing (source, result, day pre‐ transplant)	NP, negative (−1)	NP, negative (0)	NP, negative (−1)	NP, negative (0)	Unknown	NP, negative (0)	NP, negative (0)
Post‐transplant SARS‐CoV‐2 characteristics
SARS‐CoV‐2 serology (post‐ transplant day)	IgG spike‐ reactive (+5) IgG nucleocapsid ‐ non‐reactive (+5) IgM serologies nonreactive (+5)	Negative (0)	Unknown, not tested	Unknown, not tested	Unknown, not tested	Unknown, not tested	Unknown, not tested
SARS‐CoV‐2 RNA testing (source, result, post‐ transplant day)	NP, negative (+4, +7, +9, +11, +13) Plasma, negative (+12)	Not tested	NP, negative (+4, +13, +29)	NP, negative (+2, +4, +6, +8)	NP, negative (+4, +20)	NP, negative (+5)	NP, negative (+4)
Post‐transplant medical management and outcomes
Immunosuppression regimen modified	Yes Thymoglobulin reduced to 4 doses	No	No	No	No Mycophenolic acid held (nausea)	No	No
Antiviral therapies (day post‐transplant)	No	No	Casirivimab/imdevimab, +3	Casirivimab/imdevimab, +3	Casirivimab/imdevimab, +3	No	No
Hospital length of stay (days)	18	11	4	14	25	2	2
Delayed graft function	No	No	No	No	No	No	No
Graft function at last follow up	Excellent	Excellent	Excellent	Excellent	Excellent	Excellent	Excellent
Transplant recipient status	Alive at 5 months post‐transplant	Alive at 5 months post‐transplant	Alive at 5 months post‐transplant	Alive at 7 months post‐transplant	Alive at 7 months post‐transplant	Alive at 7 months post‐transplant	Alive at 7 months post‐transplant

Abbreviations: dL, deciliters; g, grams; hr, hour; IU, international units; IgG, immunoglobulin G; K, 1000; L, liter; mcg, micrograms; mg, milligrams; mL, milliliter; mm, millimeter; ng, nanograms; NP, nasopharyngeal; pg, picograms; s, seconds; SARS‐CoV‐2, severe acute respiratory syndrome coronavirus 2.

2.2. Donor Two

A previously healthy 13 year old presented with status epilepticus and irreversible brain injury due to subarachnoid and subdural hemorrhages, a non‐occlusive thrombus in the right internal carotid artery, and pontine and midbrain ischemia, presumed to result from traumatic brain injury. The patient had no respiratory or viral symptoms (fever, nasal congestion, cough, vomiting, or diarrhea) and had a negative SARS‐CoV‐2 PCR nasopharyngeal screening test on admission. The patient was not vaccinated against SARS‐CoV‐2. Two days after the initial brain injury, the patient was declared deceased based on neurologic criteria. Parental authorization for organ donation was obtained, and routine organ donor medical management ensued, including surveillance for infections, empiric antibiotics, pulse corticosteroids, and ongoing organ support.

Routine organ donation surveillance revealed three positive SARS‐CoV‐2 PCR nasopharyngeal tests (Abbott Alinity m SARS‐CoV‐2 Real‐Time RT‐PCR assay) with high Cycle thresholds, proxy measure for low viral loads, at 3, 2, and 1 day prior to organ recovery. These were all positive prior to Omicron variant presence in the community. SARS‐CoV‐2 PCR tests from endotracheal aspirate and bronchoalveolar lavage, 4 and 3 days prior to organ recovery, respectively, were negative. No blood PCR for SARS‐CoV‐2 was performed. Chest CT 3 days prior to organ recovery demonstrated no ground glass opacities or focal consolidations. Echocardiogram 2 days prior to organ recovery revealed no evidence of myocarditis or coronary dilation with normal RV and LV size and function (LV ejection fraction 74% and shortening fraction 42%). SARS‐CoV‐2 serologies 3 days prior to organ recovery (hospital day 2) were positive for IgG nucleocapsid and spike proteins, indicating naturally‐acquired infection at least 10–14 days prior to admission. Although risk for viral transmission with non‐lung organs was deemed to be low based on preliminary adult data, the donor was managed with remdesivir (loading dose and one daily dose) and monoclonal antibodies (casirivimab/imdevimab) as a strategy to potentially further decrease transmission risk.

On hospital day 5, the donor's heart, liver, and both kidneys were transplanted into four recipients. (Table 2) Approximately 7 months after transplant, all recipients were doing well with adequate graft function and no reported donor to recipient SARS‐CoV‐2 transmission based on laboratory screening or symptoms.

3. DISCUSSION

Recent SARS‐CoV‐2 infection (<21 days prior) is currently considered a relative contraindication to organ donation among adults because of the theoretical risk of SARS‐CoV‐2 transmission. ²⁸ , ²⁹ , ³⁰ However, available evidence suggests that the risk of transmission of SARS‐CoV‐2 from resolved, asymptomatic or mildly symptomatic adult donors of non‐lung organs to recipients is extremely low or even non‐existent. ¹ , ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ To date, no genotypically‐confirmed cases of transmission through non‐lung organ donation have been reported. Pediatric specific organ donation guidelines regarding SARS‐CoV‐2 infection do not exist. In this case report, multiple organs, including two hearts, two livers, and four kidneys, were recovered from two asymptomatic SARS‐CoV‐2 RNA positive (nasopharyngeal and plasma) pediatric deceased donors and successfully transplanted into seven recipients, including three SARS‐CoV2 unvaccinated children, without transmission of virus with follow‐up to at least 5 months following transplant.

In this case report, the potential risk for transmission of SARS‐CoV‐2 from Donor One may have been higher than from Donor Two, as the clinical data suggested a very recently acquired nosocomial infection, and infection onset is typically associated with peak viral load. Donor One was viremic at autopsy. The significance of detecting viral RNA in the blood remains unclear since bloodborne transmission has not been described. ³¹ Two recent case reports of stem cell transplant donors with positive nasopharyngeal SARS‐CoV‐2 PCR tests did not result in transmission to highly immunosuppressed recipients. ³² , ³³

Whether treatment of the donor or recipient with antiviral therapy and/or monoclonal antibodies reduces the risk of transmission remains uncertain. Donor Two tested positive for SARS‐CoV‐2 RNA (nasopharyngeal) on donor evaluation and was pre‐emptively managed with remdesivir and monoclonal antibodies (casirivimab/imdevimab) prior to organ recovery. Donor One unexpectedly tested positive for SARS‐CoV‐2 RNA at autopsy, and therefore did not receive any pre‐donation antiviral therapies. Three recipients received monoclonal antibodies (casirivimab/imdevimab) on post‐transplant day 3 and one heart recipient had the post‐transplant immunosuppression treatment modified (thymoglobulin reduced from five to four doses). Otherwise, there were no modifications or additional antiviral therapies provided to the recipients. No evidence of donor to recipient transmission was identified in either case. Currently, there are no guidelines regarding donor or recipient medical management in relation to SARS‐CoV‐2 infection, including the use of antiviral therapies, monoclonal antibody treatments, or modification of the immunosuppressive regimens in transplant recipients from SARS‐CoV‐2 positive donors.

This case report also highlights several considerations unique to pediatric recipients versus adults. Whether vaccination status of donors and recipients impacts the risk of transmission of SARS‐CoV‐2 is unknown. Many adult transplant centers require SARS‐CoV‐2 vaccination for potential adult recipients, whereas it is only strongly encouraged in pediatric patients. Unlike older children and adults, pediatric recipients under the age of 5 years are not yet eligible for vaccination (at the time this report was written) and substantial vaccine hesitancy among parents persists. As of April 22, 2022, only 28.3% and 58.9% of vaccine eligible children (age 5–11 years, age 12–17 years, respectively) were fully vaccinated in the United States. ³⁴ In this case report, neither pediatric donor was vaccinated and three of seven recipients were unvaccinated. The unvaccinated heart recipient of Donor One tested positive for IgG antibodies to SARS‐CoV‐2 spike proteins and negative for IgG antibodies to SARS‐CoV‐2 nucleocapsid on post‐transplant day 4, potentially indicating transfer of vaccine‐mediated antibodies through plasma, blood transfusion, post‐transplant intravenous immunoglobulins (IVIG), or remote infection (as antibodies to spike proteins potentially persist longer than antibodies to nucleocapsid proteins). ³⁵ Whether SARS‐CoV‐2 antibodies in recipients serve as a protective factor remains unknown. The results of SARS‐CoV‐2 serology may complement use of RNA testing for assessing status of infection (e.g., recent versus remote).

In addition to the risk of viral transmission, the impact of SARS‐CoV‐2 infection on donor organ quality should also be considered. Extrapulmonary organ function (heart, liver, kidney) is likely not significantly impacted in pediatric donors with acute mild or asymptomatic SARS‐CoV‐2 infection, as was seen in this case report. Of the 991 193 reported COVID19 deaths in the United States, 1167 (0.001%) were people age 18 years and under. ³⁶ Worldwide, of the 3.7 million deaths from COVID19, 0.4% have occurred in people <20 years old. ³⁷ However, patients who present with multi‐organ dysfunction in the setting of severe acute infections with SARS‐CoV‐2 or post‐infectious MIS‐C are not good candidates for organ donation, unless they have completely recovered and are at least 21 days following onset of symptoms.

As new variants of SARS‐CoV‐2 become more prevalent, such as Omicron, the number of children and adults who are admitted to hospitals for other disease processes and are asymptomatic or have mild disease with SARS‐CoV‐2 continues to rise. ³⁸ , ³⁹ If the practice of eliminating asymptomatic or mildly symptomatic SARS‐CoV‐2 positive donors continues, the high incidence of SARS‐CoV‐2 infection in the community has the potential to further reduce pediatric organ availability, which could result in significantly longer wait times for pediatric organs and potentially increase waitlist mortality. From 1988 through March, 2022, children aged 17 years and younger comprised approximately 13% (33 140/253974) of deceased donors, resulting in a smaller donor pool for young children on the waiting list. ¹⁹ Pre‐exisiting disparities based on ethnicity and race that already exist in organ donation and transplantation could be further exaggerated. ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ Pre‐pandemic deceased pediatric organ donation is already less common than deceased adult organ donation in the United States due to a multitude of factors, including lower childhood mortality rates.

While there is emerging evidence that the risk of SARS‐CoV‐2 transmission from deceased asymptomatic or mildly symptomatic adult non‐lung donors to recipients is remarkably low, developing protocols for testing and assessing SARS‐CoV‐2 disease severity in potential donors is crucial to mitigate risk. As new variants of SARS‐CoV‐2 arise, careful assessment of varying tissue tropism of the virus also may be important in calculating potential risk and benefit. ⁴⁶ Establishing SARS‐CoV‐2 RNA positive donor management and peri‐transplant recipient treatment guidelines are necessary steps to ensure the benefits of transplantation outweigh both the potential risks of transmission and prolonged wait times on the donor registry. As data regarding the risk of transmission are still emerging, transplant teams should maintain full transparency, and when possible, obtain informed consent from potential recipients, similar to the current approach with potential transmission of other blood borne viral infections, such as hepatitis C. Finally, vaccination of individuals awaiting transplantation and their family members should be encouraged, and infection control precautions, including adequate personal protective gear, need to be utilized to prevent potential transmission to health care workers during donor management and organ recovery and transplantation. ²⁷ , ³³

4. CONCLUSIONS

Based on the lack of transmission of SARS‐CoV‐2 to recipients of non‐lung organs from asymptomatic adult donors, and the pediatric organ donation cases reported here, pediatric donors with non‐disseminated SARS‐CoV‐2 infection should be considered as potential non‐lung organ donors. Careful balance of the risk for transmission and the risk of prolonged waitlist times should be considered and discussed with the family and transplant team. Furthermore, as newer preventive and therapeutic options against SARS‐CoV‐2 become available, the risk–benefit analysis may further favor accepting organs from SARS‐CoV‐2 positive donors. Prospective registries to better understand transmission risk of SARS‐CoV‐2 from pediatric donors should be implemented.

AUTHOR CONTRIBUTIONS

Dr. Jonna Clark contributed to research design, data collection, writing and editing manuscript, and IRB approval. Dr. Ajit Limaye contributed to research design, writing and editing the manuscript. Dr. Erin Albers, Candy Wells, BSN MM, Beth Johnson, APRN CPNP, Meg Rogers BSN, and Holly Thompson, APRN CPNP‐AC, assisted with data collection and editing and writing the manuscript. Dr. Jesselle Albert, Dr. Emily Berkman, Dr. Janet Englund, Dr. Reid Farris, Dr. Mithya Lewis‐Newby, Dr. John McGuire, Dr. Thor Wagner, Dr. Ofer Yanay, and Dr. Danielle Zerr contributed to writing and editing the manuscript. All authors reviewed and approved the final manuscript.

DISCLOSURES

Dr. Jonna Clark serves as a Medical Advisor to the local organ procurement organization, LifeCenter Northwest. Dr. Ajit Limaye serves as an Infectious Disease consultant for the local organ procurement organization, LifeCenter Northwest. Dr. Janet Englund receives research support from AstraZeneca, GlaxoSmith Kline, Merck, and Pfizer, and is a consultant for AstraZeneca, Sanofi Pasteur, and Meissa Vaccines. No other authors disclose financial interests, activities, relationships, or affiliations that could be construed as real or potential conflicts of interest related to the manuscript or the related investigation.

Clark JD, Albers EL, Albert JE, et al. SARS‐CoV‐2 RNA positive pediatric organ donors: A case report. Pediatric Transplantation. 2022;00:e14452. doi: 10.1111/petr.14452

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. This is a case report/case series. Authors choose not to share these data due to privacy or ethical considerations.