Prior COVID-19 and Organ Donation

February 23, 2021

As the pandemic persists, questions about prior donor Covid-19 infection, duration, viral mutations, vaccine efficacy have arisen. The Strikeforce would like to summarize the current understanding re: prior SARS-CoV-2 infection and potential organ donation. There are two major issues to address: 1) safety for healthy people in organ acquisition (recovery team/healthcare providers and live donors) and 2) the impact of prior Covid-19 disease upon organ quality.

First, we continue to advise that individuals with active (PCR+) Covid-19 infection not be pursued as organ donors. The risk of SARS-CoV-2 transmission through deceased donor, non-pulmonary, organs is very low. However, during the activity of the donation procedure, it is likely/probable that a high inoculum exposure will occur to the retrieval team, especially if the donor airway is entered. The inoculum size is virtually impossible to estimate in the deceased donation setting. Even under vaccination protection of recovery teams, the risks associated from viral variants and the potential for large inoculum exposures, adds sufficient uncertainty that we continue advise against using Covid+ (PCR) deceased donors. For live organ donors, the literature suggests that operating upon an individual with active infection (even asymptomatic) places that person at substantial risk for respiratory decompensation, ICU/intubation and death. A live donor should not be placed in a risky position. We continue to advise pre-donation distancing precautions/isolation and a negative PCR prior to surgical live organ donation.

When is the appropriate time to consider using organs from an individual with a past history of Covid-19 infection? The Strikeforce recommends that the ASTS membership again focus upon the two separate issues: 1) risk to the recovery team and/or live donor and 2) the impact of Covid-19 upon donor organ quality.

SARS-CoV-2 is almost exclusively spread through airway secretions/aerosols and the PCR test is known to have false negative results. The CDC notes that the healthy person with “mild/moderate” disease is not contagious after 10 days and the more severely ill will likely “remain infectious no longer than 20 days after symptom onset”. Therefore, in the case that protection of the healthcare provider/team is the end goal, the SF recommends that a PCR negative donor with a past Covid-19 diagnosis greater than a month earlier (an abundance of caution) should be considered safe to perform donation. As it is possible that individuals can be reinfected after initial Covid-19 infection, we feel that it remains prudent that all potential organ donors test PCR negative, irrespective of a history of prior disease. We realize that long-term non-infectious fragments are detectable in some patients, but donor dynamics, changing viral variants and uncertain durability of immunoprotection, all make for uncertainty. Erring on the side of safety is the SF recommendation.

Live donor: While there is no definitive information regarding risks to live organ donors with prior Covid-19 disease, we are inclined to recommend that one wait a month from initial symptoms/positive PCR, assess the donor pulmonary status and repeat the PCR. If the live donor is asymptomatic and the PCR negative, it is probably “safe” to proceed. Donor safety is a key factor that must be maintained. The changing viral variants and potential escape from immunosurveillance strongly reinforces the need for an undetectable PCR prior to proceeding with live donation.

Covid-19 can be associated with significant organ damage. Any donor with prior Covid-19 needs thorough assessment prior to retrieving lungs for transplantation. However, extrapulmonary organ damage is also well recognized. Kidney damage (proteinuria and hematuria) has been described in up to 30% of hospitalized for Covid (Nat Rev Nephrol 16, 747–764 (2020). and significant myocarditis has been noticed in people recently recovered from Covid-19, even those with mild disease (JAMA Cardiol. 2020;5(11):1265-1273). Rare liver damage has been described. The recognition that extrapulmonary organ damage is not rare, behooves the transplant team to rigorously assess the suitability of organs from individuals with prior Covid-19 disease. The extent of reversibility/repair of organ damage is not clear at present, but it is presumed that significant recovery will occur after viral inflammatory response has abated. However, the time-frame and the necessary pathways remain poorly understood and stress the importance of organ quality assessment from donors with prior Covid-19.

The SF recognizes the desirability of vaccination of live donors, but the priority distribution is a societal issue and in the public health domain. We recommend engagement in community discussion, but donation practice should continue using existing knowledge and policy. The use of Covid antibody testing has also been popularized as a measure for donor suitability and safety. At present we cannot endorse its routine use. Uncertainty remains as to the relevance between immune response antibodies without direct neutralization potential to infection (nucleocapsid vs spike protein) and the degree of protective immune response afforded by antibody detection. While there is sound logic that prior exposure results in some degree of immunoprotection, the degree is uncertain (especially with the changing viral variants).