Successful heart and kidney transplantation from a deceased donor with PCR positive COVID-19.

bronchoalveolar lavage

coronavirus disease 2019

Cycle threshold

end‐stage renal disease

nonischemic cardiomyopathy

nasopharyngeal

polymerase chain reaction

severe acute respiratory syndrome coronavirus 2

solid organ transplant

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic has had profound effects on organ transplantation partly due to concern for infection transmission. Risk of mortality for waitlisted candidates must be weighed against risk of transmission to the recipient and transplant team.

We report our clinical experience of transplanting three patients with organs from a deceased donor who was reverse transcriptase polymerase chain reaction positive (PCR+) for SARS‐CoV‐2 within 72 h of procurement. All recipients were informed of the donor's infection status and consented to proceed. None of the recipients had prior coronavirus disease 2019 (COVID‐19). As detailed in Table 1, the heart recipient was Status 2 and at high risk of waitlist mortality, one kidney recipient had completed COVID‐19 vaccination series with positive anti‐spike antibody (serology was not available at time of transplant), and the second kidney recipient was a retransplant with high panel reactive antibodies. The donor had recent symptomatic COVID‐19 and nasopharyngeal (NP) swab PCR+ with cycle threshold (Ct) values of 29.45 and 31.0. As these Ct values may be associated with infectious virus, we kept the recipients in air‐borne and contact isolation and treated with perioperative remdesivir; both were discontinued with negative SARS‐CoV‐2 PCR on post‐operative day 3. However, such testing would probably be negative in the setting of donor‐derived transmission for a nonlung organ. Serum PCR was unavailable. SARS‐CoV‐2 serology was negative for both unvaccinated individuals. Standard immunosuppression protocols were followed. All recipients remained asymptomatic and did not develop COVID‐19. There was no infection transmission to the transplant team. All recipients are currently alive with well‐functioning grafts.

TABLE 1

Donor and Recipient Details

Donor	Donor testing for SARS‐CoV‐2	Date of transplant	Organ/recipient	Recipient testing for SARS‐CoV‐2	SARS‐CoV‐2 therapy	Immunosuppression	Follow‐up
25‐Year‐old male found down, anoxia. Recently diagnosed with COVID‐19 on 2/6/21 when he presented with respiratory symptoms; clinical resolution occurred in about a week.	2/6/2021—positive test (unknown type) 3/6/2021—NP swab neg 3/10/2021—NP swab PCR+ (Ct value 29.45 and 31.0) 3/10/2021—BAL PCR neg	3/12/2021	Heart (status 2) 21‐year‐old male with Danon disease cardiomyopathy	‐POD 0—Nasal PCR a neg ‐POD 3 and 7—Nasal PCR b neg ‐POD 7—SARS‐CoV‐2 S antibody c neg	Remdesivir POD 0–3. 200 mg intravenous once in the pre‐operative period followed by 100 mg once daily for two additional doses.	No induction (had received rituximab and eculizumab 5 months prior) Prednisone Mycofenolate mofetil Tacrolimus	Alive with functioning graft at 81 days from transplant. (Received casirivimab/ imdevimab as an outpatient.)
		3/13/2021	Left kidney 37‐year‐old female with ESRD due to lupus nephritis. Received 2nd COVID‐19 vaccine (Moderna) 2 weeks prior to transplant	‐POD 0—Nasal PCR a neg ‐POD 3 and 7—Nasal PCR b neg ‐POD 0‐ SARS‐CoV‐2 S antibody c positive		Thymoglobulin induction Prednisone Mycofenolate mofetil Tacrolimus	Alive with functioning graft at 80 days from transplant
		3/13/2021	Right kidney 28‐year‐old male with ESRD due to renal dysplasia, previous kidney transplant in 2000 complicated by graft failure in 2011; PRA 89%	‐POD 0—Nasal PCR a neg ‐POD 3 and 7—Nasal PCR b neg ‐POD 7‐ SARS‐CoV‐2 S antibody c neg		Thymoglobulin induction Prednisone Mycofenolate mofetil Tacrolimus	Alive with functioning graft at 80 days from transplant

Abbreviations: BAL, bronchoalveolar lavage; Ct, cycle threshold; ESRD, end stage renal disease; Nasal swab, mid nasal turbinate; NP, nasopharyngeal; PCR, polymerase chain reaction, real‐ time PCR; POD, post‐operative day; PRA, panel reactive antibody.

Rapid assay‐ Roche Cobas LIAT, utilizing quantitative PCR.

In‐house NAAT/RT‐PCR nucleic acid amplification.

Elecsys Anti‐SARS‐CoV‐2 S protein assay.

‐POD 0—Nasal PCR neg

‐POD 3 and 7—Nasal PCR neg

‐POD 7—SARS‐CoV‐2 S antibody neg

‐POD 0—Nasal PCR neg

‐POD 3 and 7—Nasal PCR neg

‐POD 0‐ SARS‐CoV‐2 S antibody positive

‐POD 0—Nasal PCR neg

‐POD 3 and 7—Nasal PCR neg

‐POD 7‐ SARS‐CoV‐2 S antibody neg

There are scant reports of heart transplant from donor with PCR+ COVID‐19 in the published literature in which PCR+ organ transplant was intentionally carried out in recipients without a history of COVID‐19 with informed consent. There are several recent reports demonstrating safety of utilizing organ donors intentionally with prior COVID‐19 either with negative PCR at procurement; or PCR+ organs transplanted into recipients with recent COVID‐19. , ,

Ct values are a surrogate marker of virus viability; the donor had a single positive test with low Ct values corresponding to high viral load and infectivity. Due to variability of Ct values among testing platforms, serial testing values is recommended rather than the single test result available to us. Lack of transmission to abdominal organs in recent cases of donor‐derived COVID‐19 in lung transplant, suggests low transmission risk and remdesivir may not have been needed. It is important to further assess mitigation strategies to reduce risk of disease transmission such as waitlisted candidate vaccination and potential use of prophylactic monoclonal antibodies/antivirals.

Our case series adds to current sparse data regarding successful transplantation from donors with PCR+ COVID‐19 in the non‐lung transplant setting, though more experience is needed to determine the risk and benefits of this approach. Developing a generalizable protocol for donor assessment, risk of disease transmission, recipient surveillance, and potential prophylaxis with informed consent is needed to successfully utilize such donors.

CONFLICT OF INTEREST

Saima Aslam receives grant funding from the Cystic Fibrosis Foundation; Consultant for Merck, Gilead, BioMx. None of the other authors had personal or financial conflicts of interest to report.

AUTHOR CONTRIBUTIONS

RS, SA, MS, MT, JD, GS, and VP were responsible for acquisition, analysis and interpretation of the data. RS and SA drafted the paper and created the table. The paper was reviewed and revised by RS, SA, MS, MT, JD, GS, and VP. All authors approved the manuscript.