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CME / ABIM MOC / CE

Does COVID-19 Affect Donor Kidney Outcomes?

  • Authors: News Author: Nancy A. Melville; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 7/21/2023
  • Valid for credit through: 7/21/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
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Target Audience and Goal Statement

This activity is intended for nephrologists, diabetologists/endocrinologists, critical care clinicians, infectious disease clinicians, internists, nurses, physician assistants, and other members of the healthcare team for patients awaiting kidney transplant.

The goal of this activity is for members of the healthcare team to be better able to describe national patterns in kidney use and kidney transplant outcomes among adult recipients of kidneys from deceased donors with active or resolved COVID-19, based on a large, retrospective cohort study using national US transplant registry data.

Upon completion of this activity, participants will:

  • Assess national patterns in kidney use and kidney transplant outcomes among adult recipients of kidneys from deceased donors with active or resolved COVID-19, based on a large, retrospective cohort study using national US transplant registry data
  • Determine the clinical and public health implications of national patterns in kidney use and kidney transplant outcomes among adult recipients of kidneys from deceased donors with active or resolved COVID-19, based on a large, retrospective cohort study using national US transplant registry data
  • Outline implications for the healthcare team


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News Author

  • Nancy A. Melville

    Freelance writer, Medscape

    Disclosures

    Nancy A. Melville has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC
     

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

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This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Does COVID-19 Affect Donor Kidney Outcomes?

Authors: News Author: Nancy A. Melville; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/21/2023

Valid for credit through: 7/21/2024, 11:59 PM EST

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Clinical Context

In the US, kidney transplant is the most common type of solid organ transplant. During the COVID-19 pandemic, solid organ transplant rates globally decreased immediately and substantially, particularly for kidney transplant.

Early in the pandemic, COVID-19-positive patients were not considered eligible for kidney transplant donation, causing high nonuse rate of kidneys from SARS-CoV-2 nucleic acid amplification test-positive donors. Uncertainty regarding potential SARS-CoV-2 transmission risk and relative risk-benefit profile of such organs likely also influenced decision-making.

Study Synopsis and Perspective

Patients receiving kidneys transplanted from donors with either resolved or active COVID-19 show no greater risk for 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.[1]

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,” Dr 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,” Dr 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 men, and 66.9% were White; among the recipients, the mean age was 54.3, 60.9% were men, 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), whereas the rate of nonuse was also higher, although to a lesser degree, among kidneys from donors with resolved COVID-19 (AOR, 1.31).

However, an analysis of kidney use stratified by year shows that 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 nonuse of 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 the course of 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, body mass index, 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.[2]

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, Dr 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. Dr Alhamad reports receiving personal fees from CareDx, Natera, Eurofins, Sanofi, Veloxis, and the National Institutes of Health outside of the study.

Study Highlights

  • This retrospective cohort study used US transplant registry data from 35,851 deceased donors (71,334 kidneys) and 45,912 adult KT recipients from March 1, 2020, to March 30, 2023.
  • Mean donor age was 42.5±15.3 years, 62.3% were men, and 66.9% were White. 
  • Mean recipient age was 54.3±13.2 years, 60.9% were men, and 33.4% were Black.
  • Active COVID-19 was defined as positive donor SARS-CoV-2 nucleic acid amplification test (NAT) results 7 or fewer days before procurement, and resolved COVID-19 as positive NAT more than 7 days before procurement.
  • Primary outcomes were kidney nonuse, all-cause kidney graft failure, and all-cause patient death.
  • Likelihood of nonuse of kidneys from active or resolved COVID-19-positive donors decreased over time. 
  • Compared with kidneys from COVID-19-negative donors, likelihood of nonuse was higher overall in those from active COVID-19-positive donors (AOR, 1.55; 95% CI, 1.38-1.76) and those from resolved COVID-19-positive donors (AOR, 1.31; 95% CI, 1.16-1.48). 
  • Compared with kidneys from COVID-19-negative donors, likelihood of nonuse was higher from 2020 to 2022 for kidneys from active COVID-19-positive donors (2020: AOR, 11.26 [95% CI, 2.29-55.38]; 2021: AOR, 2.09 [95% CI, 1.58-2.79]; 2022: AOR, 1.47 [95% CI, 1.28-1.70]).
  • Kidneys from resolved COVID-19-positive donors had a higher likelihood of nonuse in 2020 (AOR, 3.87; 95% CI, 1.26-11.90) and 2021 (AOR, 1.94; 95% CI, 1.54-2.45), but not in 2022 (AOR, 1.09; 95% CI, 0.94-1.28). 
  • In 2023, kidneys from neither active nor resolved COVID-19-positive donors were associated with higher odds of nonuse. 
  • Risk for graft failure or death was not higher in patients receiving kidneys from active COVID-19-positive donors or resolved COVID-19-positive donors, after adjustment for factors including age, sex, body mass index, diabetes, and transplant characteristics.
  • Donor COVID-19 positivity was not associated with longer transplant hospitalization length of stay, higher risk for acute rejection (in the first 6 months after kidney transplant), or higher risk for delayed graft function.
  • The investigators concluded that the likelihood of nonuse of kidneys from active or resolved COVID-19-positive donors decreased over time, with no higher likelihood of nonuse for kidneys from COVID-19-positive donors in 2023, and that donor COVID-19 positivity was not associated with worse transplant outcomes within 2 years after transplant.
  • The findings suggest that use of kidneys from donors with active or resolved COVID-19 is safe, with excellent outcomes during medium-term follow-up, which may be useful information for kidney transplant professionals and patients.
  • Further research is needed to determine longer-term transplant outcomes, but the investigators suggest that if the donor has good kidney function at the time of procurement with no proteinuria, risk for kidney disease is minimal in long-term follow-up.
  • Disqualifying the more than 40% of US individuals with evidence of a past COVID-19 diagnosis as of May 2022 as potential kidney donors based on past or current COVID-19 diagnosis would substantially limit opportunities for organ use and kidney transplant, with significant public health consequences.
  • As patients are more likely to die or withdraw from the waiting list while awaiting kidney transplant (30.5%) than to undergo transplant, maximizing the use of all potentially transplantable organs is a lifesaving priority.
  • The findings support recent American Society of Transplantation guidelines recommendations that SARS-CoV-2 positive donors who died of COVD-19-attributable complications should be considered for nonlung transplant acceptance, acknowledging limited long-term outcome data availability.
  • Study limitations include retrospective design precluding causal inferences; potential selection bias creating residual confounding; and follow-up limited to 2 years, preventing determination of risk for graft loss or death beyond that time.

Clinical Implications

  • Likelihood of nonuse of kidneys from active or resolved COVID-19-positive donors decreased over time, and donor COVID-19 positivity was not associated with worse transplant outcomes within 2 years after transplant.
  • The findings suggest that use of kidneys from donors with active or resolved COVID-19 is safe.
  • Implications for the healthcare team: Maximizing the use of all potentially transplantable organs is a lifesaving priority.

 

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