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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 15  |  Issue : 4  |  Page : 364-367

Live kidney donor with a history of COVID-19 infection: When to go for transplant? - A case report


Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India

Date of Submission24-Feb-2021
Date of Decision06-May-2021
Date of Acceptance08-May-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Dr. Hari Shankar Meshram
Nephrology and Transplantation Institute of Kidney Diseases and Research Centre, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_19_21

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  Abstract 

Transplant in COVID era is a challenging task given a paucity of data and limited experience worldwide. A 35-year-old male patient with chronic kidney disease on dialysis for the past 9 months underwent successful living-related donor transplant with his father (aged 64 years) as donor at our center. In this case, donor was diagnosed with reverse-transcription polymerase chain reaction (RT-PCR)-confirmed COVID-19 during evaluation, and he was managed with supportive care and comprehensive social distancing at home. Donor was asymptomatic throughout this period. Interval from positive to negative RT-PCR for nasopharyngeal swab test was 37 days. Interval from negative RT-PCR to kidney transplant was 33 days. Later, recipient and donor were discharged with negative RT-PCR posttransplant. At 71 days of follow-up, both recipient and donor have stable kidney function with normal urinalysis. Hence, prospective donor with a history of COVID-19 infection can be taken for transplant after thorough pretransplant evaluation and having two negative RT-PCR reports after infection, normal imaging, and additional preprocedural negative RT-PCR testing.

Keywords: COVID-19, kidney transplant, live donor, novel coronavirus 2019


How to cite this article:
Meshram HS, Kute VB, Patel H, Dave RM, Gupta VR, Navadiya VV, Patel DD, Chauhan S, Desai S, Dave R. Live kidney donor with a history of COVID-19 infection: When to go for transplant? - A case report. Indian J Transplant 2021;15:364-7

How to cite this URL:
Meshram HS, Kute VB, Patel H, Dave RM, Gupta VR, Navadiya VV, Patel DD, Chauhan S, Desai S, Dave R. Live kidney donor with a history of COVID-19 infection: When to go for transplant? - A case report. Indian J Transplant [serial online] 2021 [cited 2022 Aug 10];15:364-7. Available from: https://www.ijtonline.in/text.asp?2021/15/4/364/334428




  Introduction Top


Novel coronavirus 2019 is responsible for ongoing pandemic of acute respiratory illness, known as coronavirus disease (COVID-19) since March 2020[1] As on December 22, 2020, India has reported a 10,075,116 detected cases of COVID-19, the second highest in the world, with 292,518 active cases and 146,111 deaths. Earlier, the Government of India had implemented nationwide lockdown in a phased manner from March 24 to July 31, 2020.[2] The transplant activity was suspended during this period in India due to scarcity of data and lack of guidelines. Resumption of kidney transplant in the wake of pandemic is a challenging task as data and consensus guidelines are lacking for different scenarios. With ongoing pandemic, the numbers are expected to rise. Studies have shown that transplantation can improve survival in patients undergoing hemodialysis. The mortality risk for all patients on dialysis is higher than that of patients who were on the transplant waiting list across different age groups.[3],[4],[5] Recently, various international societies have issued their guidelines on evaluation for transplant in the present times. The caveat of available guidelines is that there are no data available about how long transplant should be delayed in such cases due to scarcity of information regarding renal complications in cured patients with normal renal function and transmission of the virus through organ donation. Till date, no organ donor-derived infections or blood-borne transmissions have been reported.[6],[7] There is also debate regarding change in immunosuppressive regimen in such scenarios. At our center, we follow the National Organ and Tissue Transplant Organization (NOTTO) guidelines for the evaluation and management of kidney-transplant recipients and donors.


  Case Report Top


Pretransplant

A 35-year-old nondiabetic male from Ahmedabad diagnosed as crescentic glomerulonephritis. He was subjected to cyclophosphamide and plasma exchange. The patient did not respond and was put on maintenance hemodialysis through left brachiocephalic arteriovenous fistula for 9 months. The patient visited IKDRC-ITS Hospital in January 2020 for kidney transplant with his father, aged 64 years, as potential donor. Recipient and donor were evaluated [Table 1] and posted for kidney transplant in March. However, transplantation was delayed due to COVID-19 pandemic as the living donor transplant program was halted from March 10, 2020, to July 23, 2020.
Table 1: Pre transplant evaluation of recipient and donor

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When the transplant program resumed, the recipient and the donor were re-evaluated as per the NOTTO guidelines[8] for transplant. During re-evaluation, the recipient was negative for COVID-19 serially was being followed up regularly.

The donor was diagnosed as COVID-19 through positive reverse-transcription polymerase chain reaction (RT-PCR) pretransplant evaluation. As donor was asymptomatic, only supportive treatment was given. The recipient and the donor followed comprehensive social distancing and hand hygiene along with their respective caregivers for 17 days at home. The duration between positive to negative RT-PCR testing was 37 days. The duration between negative RT-PCR testing and kidney transplant was 33 days. The total duration between positive RT-PCR testing and kidney transplant was 70 days. The computed tomography (CT) thorax of the donor was normal along with serological markers of COVID-19 infection [Table 2]. Then, they were posted for transplant surgery after discussing possible risk and benefit and taking written informed consent. Additional pretransplant RT-PCR was negative for both donor and recipient. Donor–recipient human leukocyte antigen (HLA) match was 3/6 (A, B, DR−) and cross-match was negative.
Table 2: Symptoms, radiological and laboratory findings of kidney donor with coronavirus disease-2019

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Peritransplant course

Laparoscopic left-sided donor nephrectomy was done, and allograft was transplanted in the right iliac fossa of recipient by open incision at 33 days after the first negative RT-PCR. The procedure was uneventful. Injection basiliximab 20 mg was used as an induction agent along with methylprednisolone 500 mg. Standard immunosuppression (tacrolimus and mycophenolate sodium) was started 2 days before transplant. On-table urine output was 1 l. Recipient was shifted to the transplant unit in stable condition.

Posttransplant course

Donor was discharged on postoperative day 2 in stable condition with normal kidney function. Later, the recipient was discharged on day 5 after transplant with serum creatinine of 1.31 on standard triple immunosuppression (prednisolone, tacrolimus, and mycophenolate) with negative RT-PCR test posttransplant. There was no change in the routine induction or immunosuppression protocol. Recipient was given three doses of methyl prednisone 500 mg for 3 days followed by 20 mg oral steroids which was tapered to 10 mg at 2nd month follow-up. Dose for mycophenolate was 360 mg total dissolved solids and for calcineurin inhibitors was 0.08 mg/kg.

Both donor and recipient are on regular follow-up. At 71 days after transplant, donor is stable with normal kidney function and urinalysis [Table 2]. The recipient is on triple immunosuppression with stable graft function (serum creatinine - 1.21) and urinalysis.


  Discussion Top


We have performed living donor kidney transplantation with as father donor who recovered from PCR-confirmed COVID-19 rather than continuing dialysis, which is associated with higher mortality risk in resource-limited country like India. In this scenario, a live-related donor had a history of COVID-19 infection. Here, the recipient was on hemodialysis for 9 months, and there was due to no potential donor available in rest of the family; we considered proceeding for transplant at 33 days after the first negative sample postinfection with normal imaging and additional negative RT-PCR for nasopharyngeal swab after discussing risks and benefit with recipient and donor analysis. Aspartate transaminase recommends organ donation from a live donor with a history of COVID-19 infection only after resolution of clinical symptoms from negative RT-PCR test within 21–90 days of initial COVID infection.[9] The NICE guidelines for live donors with COVID-19 infection recommend deferring transplant for 28 days and 14 days of comprehensive social distancing and hand hygiene measures. Donation should start only after donor is clinically cured and with negative nasopharyngeal swab test result for RT-PCR and another negative test not more than 3 days before donation.[10] The NOTTO guidelines in India suggest practicing social distancing for 14 days before surgery for both living donor and recipient and to defer transplant for 3–6 months as data on long-term outcomes of cured patients are awaited. The NOTTO guidelines suggest accepting donor with a previous diagnosis of COVID-19 with documented two negative COVID-19 tests and complete symptom resolution for 28 days and another negative test at the time of donation in case of life-saving transplant.[8] Testing antibodies might not be very helpful in this context, as it does not differentiate between the current and past infection. In various international guidelines, there is no routine change in the immunosuppression regimen in the context of recovered COVID-19 donor or recipient and immunological risk is only assessed based on routine HLA, donor-specific antibodies, and cross-matches.[11] After 71 days posttransplant surgery, both recipient and donor are stable without any complication. This is an important addition to the literature regarding kidney transplant in COVID-19 era given the concerns regarding COVID-19-related morbidity and mortality in transplant recipient and potential risk of donor-derived infection.


  Conclusion Top


With resumption of the transplant program in various countries, new issues related to transplant likely to come up. In this case, we found that it is safe to proceed for living donation after 28 days after symptoms resolve following COVID-19 infection with two negative RT-PCR tests with additional negative RT-PCR test and normal imaging result before transplant. When large-scale data and long-term results become available, we can build further consensus on the issue.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-42.  Back to cited text no. 1
    
2.
Available from: https://www.mygov.in/corona-data/COVID19-statewise -status/. [Last accessed on 2020 Dec 15].  Back to cited text no. 2
    
3.
Kaballo MA, Canney M, O'Kelly P, Williams Y, O'Seaghdha CM, Conlon PJ. A comparative analysis of survival of patients on dialysis and after kidney transplantation. Clin Kidney J 2018;11:389-93.  Back to cited text no. 3
    
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Bouaoun L, Villar E, Ecochard R, Couchoud C. Excess risk of death increases with time from first dialysis for patients on the waiting list: Implications for renal allograft allocation policy. Nephron Clin Pract 2013;124:99-105.  Back to cited text no. 4
    
5.
Heldal K, Hartmann A, Grootendorst DC, de Jager DJ, Leivestad T, Foss A, et al. Benefit of kidney transplantation beyond 70 years of age. Nephrol Dial Transplant 2010;25:1680-7. doi: 10.1093/ndt/gfp681. Epub 2009 Dec 27.   Back to cited text no. 5
    
6.
American Society of Transplant Surgeons. Organ Retrieval for Transplantation in the COVID-19 era. Available from: https://asts.org/advocacy/COVID-19-resources/asts-COVID-19-strike-force/asts-COVID-19-strike-force-organ-retrieval-guidance#.Xqb1BGhKiUl. [Last acessed on 2020 Dec 15].  Back to cited text no. 6
    
7.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 7
    
8.
Kute V, Guleria S, Prakash J, Shroff S, Prasad N, Agarwal SK, et al. NOTTO Transplant Specific Guidelines with Reference to COVID-19. Indian J Nephrol 2020;30:215-20.  Back to cited text no. 8
  [Full text]  
9.
American Society of Transplantation. Recommendations and Guidance for Organ Donor Testing. AST COVID-19 Information. Available from: https://www.myast.org/COVID-19-information. [Last accessed on 2020 Dec 15].  Back to cited text no. 9
    
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11.
Kute VB, Ray DS, Yadav DK, Pathak V, Bhalla AK, Godara S, et al. A multicenter cohort study from India of 75 kidney transplants in recipients recovered after COVID-19 [published online ahead of print, 2021 Mar 10]. Transplantation 2021;10.1097/TP.0000000000003740.  Back to cited text no. 11
    



 
 
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  [Table 1], [Table 2]



 

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