Successful Kidney Transplantation from a Deceased Donor with Severe COVID-19: Undetectable SARS-CoV-2 in Donor Kidney and Aorta by Sensitive Molecular Testing

ABSTRACT

Purpose: Kidney transplantation (KT) from coronavirus disease 2019 (COVID-19) positive donors has been avoided due to concerns for donor-derived transmission and possibility of the kidney being a viral reservoir. There is no long-term safety data, and sensitive molecular testing for SARS-CoV-2 in donor kidney is not routinely performed. We report a case of successful KT from a deceased donor who died from severe COVID-19 respiratory illness whose donor kidney and aorta were probed for virus using in situ hybridization (ISH) and quantitative reverse transcriptionpolymerase chain reaction (qRT-PCR). Method(s) A 30-year-old female was admitted to the hospital with severe COVID-19 pneumonia with a positive RT-PCR test for SARS-CoV-2 on nasopharyngeal swab. With clinical worsening, she was placed on extracorporeal membrane oxygenation, but developed hypoxic brain injury and progressed to brain death. Renal function was stable during her hospital course with serum creatinine concentration of 0.7 mg/dL. SARS-CoV-2 RT-PCR on bronchoalveolar lavage and nasopharyngeal samples tested again three days prior to donation was negative. A 55-year-old male recipient with an end-stage renal disease secondary to hypertension was transplanted with the left kidney from the above donor. The donor kidney was studied using pre-implantation surgical biopsy tissues to investigate the presence of SARS-CoV-2 RNA. Aorta tissue with the kidney was also studied given high expression of angiotensin-converting enzyme 2 receptors in vasculature. Result(s) ISH analyses did not show any positive signal for SARS-CoV-2 RNA in the donor kidney sample compared to a SARS-CoV-2 positive lung control. All samples tested by qRT-PCR were also negative for SARS-CoV-2. We found no evidence of SARS-CoV-2 mRNA in the donor kidney and aorta. The recipient has been free of COVID-19 related signs or symptoms and tested negative for SARSCoV- 2 by nasopharyngeal swab RT-PCR on days 20, 30, and 90 following KT. After an initial period of delayed graft function requiring hemodialysis, the recipient now has excellent renal recovery over 6 months following the transplant, and the most recent creatinine is 1.3 mg/dL. Conclusion(s) Taken together with recent observations of successful KT outcomes from mild or asymptomatic COVID-19 donors, we believe that the transmission risk of SARS-CoV-2 through KT is likely to be very low. Use of deceased donors who died after severe COVID-19 can be considered for KT. Larger scale studies are needed to confirm our findings.