Solid non‐lung organs from COVID‐19 donors in seropositive or naive recipients: Where do we stand?

Field: Medicine (Health Sciences)

To the Editor We read with great interest the Eichenberger et al.’s editorial1 and as suggested by the authors, we would like to share the data from our liver transplant (LT) center in Turin, Italy. In our view, an accurate definition of coronavirus disease-19 (COVID-19) donor, as recently updated by organ procurement and transplantation network (OPTN)2 is deemed to be crucial in order to standardize the worldwide experience and to balance the risk of SARS-CoV-2 donor transmission with the threat of dying from the underlying chronic disease. According to the literature, individuals who are convalescent from COVID-19 have a significantly lower risk of infection because they are very likely to be protected by natural immunity.3 Therefore, non-lung organs from COVID-19 donors can be transplanted into informed recipients with ongoing or resolved SARS-CoV-2 infection,1, 3 who might otherwise have limited opportunities for transplant due to disease acuity. Nevertheless, transplant community must keep on thinking outside the box to face the increased shortage of donor organs. For this reason, between November 2020 and April 2021, before the beginning of our anti-SARS-CoV-2 vaccination program, all patients on our LT waiting list, were screened for immunoglobulin G (IgG) anti-SARS-CoV-2 (LIAISON SARS-CoV-2 S1/S2 IgG test, Saluggia, Italy; positive value ≥15 AU/ml). Thirty-six out of 124 (29%) patients tested IgG positive (median value, 34 AU/ml; interquartile range 25th–75th, 22–92 AU/ml): 10 out of 36 (28%) had a previous history of COVID-19, whereas 26 out of 36 (72%) had a previous asymptomatic COVID-19. Four of our 26 IgG positive recipients with previous asymptomatic COVID-19 received a liver graft from four brain-dead donors affected by COVID-19: one donor with severe COVID-19 characterized by pneumonia and oxygen requirement, one donor with resolved COVID-19, and the other two donors with SARS-CoV-2 RNA positive in bronchoalveolar lavage at procurement, without evidence of infection or history of COVID-19. None of the recipients were treated with peritransplant antiviral drugs or monoclonal antibody and none of them developed COVID-19 after LT, as detailed in Table 1. In the same table, we reported the 45 published cases of transplants which were performed from 21 COVID-19 donors (classification according to OPTN: two mild, seven resolved, four severe, and eight not classifiable) into 10 vaccinated recipients (eight kidneys and two livers) and 35 naive/asymptomatic recipients (19 kidneys, seven hearts, and nine livers). None of these 45 subjects developed COVID-19 after transplant. One heart recipient4 was preemptively treated with remdesivir (once in the preoperative period followed by two additional doses) plus Casirivimab-Imdevimab and two patients (one naive heart recipient and one vaccinated liver recipient)5 were treated with Casirivimab-Imdevimab on day 1 after transplant. In conclusion, even though more solid data are needed, we agree with Eichenberger that the use of non-lung grafts from well-categorized COVID-19 donors might represent a precious source not only in previous symptomatic COVID-19, but also in patients with documented evidence of humoral immunity resulting either from asymptomatic infection, from vaccination or from long-acting monoclonal antibody infusion. None. The authors declare no conflict of interest.