COVID in the Donor Organ: What’s the Risk?

Three U.S. lung transplant recipients contracted COVID-19 from their new organs, including one patient who died and two patients who transmitted the virus to others, researchers found.

From March 2020 to March 2021, nine SARS-CoV-2 infected donors donated organs to 19 recipients. Three individuals who received bilateral lungs acquired infections from the donors but the remaining 16 recipients of extra-pulmonary organs did not, reported Rebecca Free, MD, MPH, of the CDC in Atlanta, and colleagues.

The study looked at 125 cases of potential organ donor-derived infection. All-cause mortality was substantially higher among the 25 recipients with COVID-19 within 45 days of transplant versus the 100 recipients without COVID infections (36% vs 6%).

“These findings suggest a higher risk of donor-derived SARS-CoV-2 infection among lung recipients than recipients of extrapulmonary organs,” the authors wrote in Open Forum Infectious Diseases. “While donor-derived SARS-CoV-2 infection is uncommon, it can result in recipient morbidity and mortality.”

The first potential SARS-CoV-2 transmission in the U.S. through transplantation was reported in March 2020, the authors stated. In October 2021, the American Society of Transplantation recommended nucleic acid amplification testing (NAAT) of both upper and lower respiratory tract testing in the case of lung donors, and Free and colleagues found that less than half of organ procurement organizations actually obtained donors’ lower respiratory tract specimen testing results prior to transplantation.

In the case of the three patients who received donor lungs from a SARS-CoV-2 positive donor, the donor tested negative on a pre-transplant upper respiratory tract specimen, but archived post-transplant lower respiratory tract specimens tested positive.

For their study, the researchers examined data reported to the Organ Procurement and Transplantation Network, including laboratory and epidemiologic assessments, as well as recent solid organ transplant recipient outcomes.

During the study period, about 42,740 organs were transplanted, including 2,736 lungs. Three living donors and 37 deceased donors were referred for investigation of “potential donor-derived SARS-CoV-2 transmission events.” While cause of death for deceased donors was determined to be non-infectious, the three living donors had “unknown” SARS-CoV-2 status at the time of transplantation.

Overall, 140 organs from these 40 donors (including 62 kidneys, 33 livers, 22 lungs, 15 hearts, and eight pancreases) were transplanted into 125 recipients. Nine donors had evidence of SARS-CoV-2 infection within 72 hours of organ procurement, the authors said, and nine were not tested prior to organ procurement — mostly early in the pandemic. They added that in cases where lungs were procured, only 35% of donors had lower respiratory tract testing.

Of the 25 organ recipients who had evidence of COVID infection after transplant, 11 had received a lung transplant, and nine ultimately died (six of the lung recipients). Median time from transplantation to positive test was 7 days. Fourteen recipients with COVID experienced fever, and 15 required mechanical ventilation. Three-quarters were treated with “therapeutic agents” (mostly remdesivir [Veklury], steroids, or convalescent plasma).

Besides the three lung cases of donor-derived infection, one other donor also tested positive for SARS-CoV-2 post-transplant and was linked with two positive recipients who tested positive for SARS-CoV-2 at 7 to 11 days after transplant — a kidney recipient who experienced symptoms and a liver recipient who was asymptomatic. But “a retrospective serologic test of the donor’s serum and a NAAT of lung tissue were SARS-CoV-2 negative, indicating a low probability of donor-derived SARS-CoV-2 infection,” the authors noted.

Limitations to the data included that most donors were not tested for SARS-CoV-2 prior to organ procurement during the early stages of the pandemic, that the results are limited by the performance and sensitivity of NAAT tests and specimen types. Finally, “retrospectively identifying the correct source of transmission was challenging,” according to the authors.