Kidney transplants from COVID-19-positive donors appear safe

JAMA Network Open published a study yesterday on the safety of donors with COVID-19 donating a kidney, showing that the use of kidneys from donors with either active or resolved COVID-19 infections yields excellent outcomes.

Now that the COVID-19 pandemic has entered a phase wherein many Americans have experienced infections, questions about the medium-term prognosis of organ donation remain to be answered.

The study was based on national US transplant registry data from 35,851 deceased donors (71,334 kidneys) and 45,912 adult patients who received kidney transplants from March 1, 2020, to March 30, 2023.

At the beginning of the pandemic, COVID-19positive organs from deceased donors were not recommended for use, and overall, the number of organs transplanted in the United States fell, alongside a 15% reduction in global transplant rates. From August 8, 2020, to September 29, 2021, only 150 SARS-CoV-2positive deceased donors were assessed for organ donation, the authors said.

All kidneys in the study were subjected to nucleic acid amplification tests (NAT) to determine if the organ donor had an active infection (within 7 days of kidney procurement) or a resolved infection (at least 1 week prior). The primary outcomes studied were kidney nonuse, all-cause kidney graft failure, and all-cause recipient death. Secondary outcomes included acute rejection (within 6 months of the transplant), transplant hospitalization length of stay, and delayed graft function.

The deceased donors had an average age of 42.5, 62.3% were men, and 66.9% were white. Recipients had an average age of 54.3, 60.9% were men, and 33.4% were Black.

Though kidneys from deceased donors with an active or resolved infection were less likely to be used than those without COVID-19, that trend decreased overtime, and by 2023, kidneys from donors with active infections or resolved infections were being used.

From 2020 to 2022, kidneys from active COVID-19positive donors (2020: adjusted odds ratio [AOR], 11.26; 95% confidence interval [CI], 2.29 to 55.38; 2021: AOR, 2.09 [95% CI, 1.58 to 2.79]; 2022: AOR, 1.47 [95% CI, 1.28 to 1.70]) had a higher likelihood of nonuse compared with kidneys from donors without COVID-19. That means kidneys from active COVID-19positive donors had 56% higher odds of nonuse, and donors with resolved COVID-19 had 31% higher odds of nonuse.

According to the authors, patients receiving kidneys from active COVID-19positive donors had no greater risk for graft failure (adjusted hazard ratio [AHR], 1.03; 95% CI, 0.78 to 1.37), patient death (AHR, 1.17; 95% CI, 0.84 to 1.66). And results were similar with resolved COVID-19positive donors (graft failure: AHR, 1.10; 95% CI, 0.88 to 1.39; patient death: AHR, 0.95; 95% CI, 0.70 to 1.28).

Receiving a kidney from a COVID-19positive donor was not associated with any longer hospital stay nor with a higher risk of acute rejection.

Our findings support the use of these valuable organs.

In January of 2023, the American Society of Transplantation updated guidance stating that donors who are SARS-CoV-2positive on NAT and who died of COVD-19attributable complications should be considered for non-lung transplant acceptance.

"Our findings support the use of these valuable organs and may encourage organ procurement organizations to consider recovering more kidneys from COVID-19positive donors and promote further acceptance among transplant professionals," the authors concluded.

"Given that more than 40% of individuals in the US had evidence of a past COVID-19 diagnosis as of May 2022, excluding potential kidney donors based on past or current COVID-19 diagnosis would substantially limit opportunities for organ use and [kidney transplant], which is not a benign consequence."

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Kidney transplants from COVID-19-positive donors appear safe