Patients receiving kidneys transplanted from donors with either resolved or active COVID-19 show no greater risk of poor outcomes or death, shows new research, which also indicates that the reluctance to use those kidneys early in the pandemic appears to be waning.

“This cohort study found that the likelihood of nonuse of COVID-19–positive donor kidneys decreased over time and, for kidneys procured in 2023, donor COVID-19 positivity was no longer associated with higher odds of nonuse,” write the authors in their study, published today in JAMA Network Open.

Senior author Tarek Alhamad, MD, noted that there are nevertheless still some holdouts.

“Despite…having zero cases of COVID-19 transmission through kidney transplantation, kidney transplant providers continue to discard these highly valuable organs,” Alhamad, of the Division of Nephrology, Washington University, St. Louis, Missouri, told Medscape Medical News.

“Our study shows no increased risk of rejection and no increased risk of kidney failure with the use of kidneys from COVID-19–positive donors,” Alhamad emphasized.

Data From US Transplant Registry

The new findings are from a retrospective cohort study of national US transplant registry data, involving 35,851 deceased donors and 71,334 kidneys, as well as 45,912 adult patients who received kidney transplants from March 2020 to March 2023.

Among the donors, the mean age was 42.5 years, 62.3% were male and 66.9% were White, and among the recipients, the mean age was 54.3, 60.9% were male and 33.4% were Black.

Overall, kidneys from donors with active COVID-19 had a significantly higher likelihood of not being used vs kidneys from COVID-19–negative donors (adjusted odds ratio [AOR], 1.55), while the rate of non-use was also higher, though to a lesser degree, among kidneys from donors with resolved COVID-19 (AOR, 1.31).

However, an analysis of kidney utilization stratified by year shows the lower rates of use largely concentrated early on: in 2020, the nonuse of kidneys from donors with active COVID-19 donors was as much as 11 times higher compared with kidneys from donors without COVID-19 (AOR, 11.26), but the rate of nonuse from active COVID-19 donors declined significantly by 2021 (AOR, 2.09), and dropped further by 2022 (AOR, 1.47).

Kidneys from donors with resolved COVID-19 also had a higher likelihood of nonuse in 2020 (AOR, 3.87) and 2021 (AOR, 1.94), but by 2022, the difference was no longer significant (AOR, 1.09).

By 2023, the rate of nonuse of kidneys was not significantly higher from donors with either active COVID-19 (AOR, 1.07) or resolved COVID-19 (AOR, 1.18).

Outcomes No Worse With Kidneys From Donors With COVID-19

In terms of outcomes associated with those donors over 2 years of follow-up, the risk for graft failure or death was found to be no higher among patients receiving kidneys from active COVID-19–positive donors compared with those from COVID-19-negative donors (graft failure: AHR, 1.03; patient death: AHR, 1.17). Nor were outcomes any different for resolved COVID-19–positive donors (graft failure: AHR, 1.10; patient death: AHR, 0.95), after adjustment for factors including age, sex, BMI, diabetes, transplant characteristics, and other factors.

Furthermore, “Transplant of kidneys from donors with resolved or active COVID-19 was not associated with increased risk of all-cause graft loss, all-cause death, acute rejection, delayed graft function, or longer hospitalization over more than 2 years of follow-up compared with kidneys from COVID-19–negative donors,” the authors write.

The findings are especially important considering the high and ever-increasing proportion of individuals who have had a previous COVID-19 diagnosis.

“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,” the authors note.

Previous studies that stoked concerns about use of organs from patients with COVID-19 included a recent autopsy study showing persistent SARS-CoV-2 organ and brain infection in patients who had received a COVID-19 diagnosis as early as 230 days before their death.

And other studies recommended against the transplantation of organs from donors with active COVID-19 as a result of direct evidence of transmission in the case of lung transplant and laboratory evidence of plausible transmission from other organs, the authors note.

However, other evidence that emerged early in the pandemic suggested that proceeding with transplant of solid organs retrieved from living and deceased donors after confirmation of resolution of COVID-19 is likely safe.

The current results support those findings, and longer-term safety is also likely, Alhamad stressed. “We think that if the donor has good kidney function at the time of procurement with no proteinuria, there is a minimal risk of kidney disease in the long-term follow up.”

The results are echoed in recent national guidelines from the American Society of Transplantation, which indicate that donors who are SARS-CoV-2 positive and who died of COVD-19–attributable complications should be considered for nonlung transplant acceptance, acknowledging limited long-term outcome data availability.

The study was supported by grant from the Foundation for Barnes-Jewish Hospital. Alhamad reports receiving personal fees from CareDx, Natera, Eurofins, Sanofi, Veloxis, and the NIH outside of the study.

JAMA Network Open. Published May 30, 2023. Full text

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