Is it safe to perform abdominal transplantation from SARS-CoV-2 polymerase chain reaction positive donors?

To the Editor:

We read “Kidney transplantation from a SARS‐CoV‐2‐positive donor for the recipients with immunity after COVID‐19” by Puodziukaite et al. with great interest. This was a case report about the transplantation of two kidneys from a donor with active coronavirus disease 2019 (COVID‐19).

COVID‐19 pandemic has created new challenges for health care systems around the world and also has directly affected solid organ transplantation (SOT) including donation. The ongoing pandemic has not decreased the need for SOT, and a global concern has been safe transplantation during this time. During a pandemic, the potential organ donation pool should be affected, which raises the question of how to approach a possible donor with history of COVID‐19. One report mentioned the possibility of donor‐derived severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection in lung transplantation that may affect all types of transplant recipients. On the other hand, successful heart and liver transplant from SARS‐CoV‐2 polymerase chain reaction (PCR)‐positive donor has been reported. This suggests there should potentially be a concern in lung transplantation, but still this is unclear in other transplants whether we can use these donors safely. We report successful kidney transplantation from nasopharyngeal (NP) swab PCR‐positive donor to two PCR‐negative recipients, and additional two recipients (one kidney and one liver) whose donor had active history of COVID‐19, but SARS‐CoV‐2 PCR achieved negativity at the time of procurement. We did not modify induction or maintenance immunosuppressive medication or add any SARS‐CoV‐2‐specific treatment despite of the donor PCR positivity. During surgery, SARS‐CoV‐2 infection precaution methods including wearing N95 masks and using negative pressure surgery rooms were implemented.

The donor was a 19‐year‐old male with no known history of SARS‐CoV‐2 infection. The cause of death was determined to be due to a gun shot. There was no documented evidence of respiratory symptoms. Chest x‐ray at the time of procurement was normal, and no chest CT was available. This donor had positive PCR result of NP swab for SARS‐CoV‐2 (Labcorp) with cycle threshold (Ct) value of 40.2. As the donor did not have any active symptoms consistent with COVID‐19 and Ct value was high, we proceeded with transplantation. Both kidneys were transplanted into two different recipients. Recipients’ information is summarized in Table 1. Patients had close follow‐up to 12 weeks after transplant with no evidence of symptomatic COVID‐19. Nine days after transplant, we did follow NP swab PCR and both of them were negative. Allograft function and overall clinical status has been optimal during follow‐up.

TABLE 1

Recipient characteristics

Case number	Age/Gender	Type of transplant	Primary disease for end‐stage kidney disease	Positive donor SARS‐CoV‐2NP swab immediately prior to transplant	SARS‐CoV‐2NP swab follow‐up after transplant	Follow‐up period (days)	Prior recipient vaccination	Induction immunosuppression	Graft outcome at last follow‐up	Upper respiratory like symptoms at follow‐up
1	33/Female	Kidney	Lupus nephritis	Yes	Negative/9 days after transplant	84	No	Thymoglobulin/basiliximab/methylprednisolon	Cr 0.8 mg/dl BUN 17 mg/dl	None
2	21/Female	Kidney	Bilateral renal hypoplasia	Yes	Negative/9 days after transplant	84	1 Week prior to transplant (first dose‐Pfizer)	Thymoglobulin/basiliximab/methylprednisolon	Cr 0.69 mg/dl BUN 6 mg/dl	None
3	50/Female	Kidney	Atrophic kidneys	No	Negative/7 days after transplant	58	No	Thymoglobulin/basiliximab/methylprednisolon	Cr 0.8 mg/dl BUN 13 mg/dl	None
4	22/Male	Liver	Autoimmune hepatitis	No	Negative/13 days after transplant	35	Yes (two doses‐Pfizer)	Methylprednisolone/antithymocyte/rituximab	Normal liver function test	None

Abbreviations: BUN, blood urea nitrogen; Cr, creatinine; NP, nasopharyngeal; SARS‐CoV‐2, severe acute respiratory syndrome coronavirus 2.

Similar to Puodziukaite et al., we safely performed abdominal transplantations from a donor with positive PCR of NP swab for SARS‐CoV‐2. During a pandemic, to expand the donor pool, we may need to reassess utilization of organs from PCR‐positive donors for kidney transplantation, especially when there are no signs of active infection with high Ct value. To validate the safety of PCR‐positive donor in abdominal transplantation, a larger sample sized study should be needed.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

AUTHOR CONTRIBUTIONS

Paola Frattaroli, Shweta Anjan, and Yoichiro Natori designed the study. All authors were responsible for data interpretation and writing.