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Shortage of organ donors is an ongoing limiting factor in lung transplantation (LT). Despite increasing prevalence of asymptomatic COVID-19 infection, positive COVID-19 testing from a potential donor remains a contraindication at many LT centers.
In this report, we present the outcomes of LT utilizing an algorithm based on donor clinical presentation, and COVID-19 real-time reverse transcription polymerase chain reaction (RT-PCR) with cycle threshold (Ct) values evaluation. The Ct value threshold for organ acceptance was >35. A total of 8 COVID-positive donors were included. No donor-to-recipient transmissions of COVID-19 were observed. Short-term outcomes were comparable to those reported in pre-COVID literature. Survival-to-date is 100% with median POD of 161 days. Our findings support the safety and efficacy of utilizing our algorithm including Ct value threshold for selection of donors with incidental COVID-19 positive testing.
Following 3 donor derived COVID-19 transmissions to LT recipients from donors with initial negative nasopharyngeal (NP) testing that retrospectively tested positive in lower respiratory tract (LRT) samples, the Organ Procurement and Transplantation Network (OPTN) required LRT SARS-CoV-2 testing for all potential lung donors. In its current iteration, the OPTN guidance on SARS-CoV-2 screening and donor organ acceptance identifies COVID-19 positive donors as low risk if the test was performed between 21 and 90 days after disease onset in the setting of resolved COVID-19.
For donors who test positive with no known history of infection, it is recommended that organs be considered for non-lung recipients only. However, these guidelines can decrease the number of organ acceptance without considering quality of the lungs and our evolving knowledge of COVID-19 risk of transmission and severe disease. Therefore, we present our center's experience utilizing an algorithm based on donor clinical presentation, and COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) with cycle threshold (Ct) values (Figure 1).
This is a single-center case series evaluating LT outcomes utilizing donors with incidental positive SARS-CoV-2 RT-PCR with Ct >35 via NP or LRT testing at any point during hospitalization between October 2021 and August 2022. SARS-CoV-2 RT-PCR testing per organ acceptance algorithm was ordered by the organ procurement organization as requested by our center and performed at the donor hospital facility. The primary outcome was COVID-19 transmission based on positive COVID-19 testing within 30 days of transplant. Secondary outcomes were primary graft dysfunction (PGD) grading at 72 hours, incidence of acute cellular rejection (ACR), 30-day survival, and 90-day survival. All LT recipients had received vaccination against COVID-19 prior to listing and signed informed consent to the use of lungs from donors with COVID-19 RT-PCR Ct values >35.
As of October 30, 2022, there have been a total of 8 COVID-positive donors meeting criteria. Donor and recipient clinical characteristics are described in Table 1. All donors were male. Donor median age was 24.5 years (y) (range 17-32y) and median BMI was 27.9 (range 20.7-31.1). No donors had history of diabetes or smoking greater than 20 packs/y. The median donor sequence number (DSN), which represents the number of recipients to whom the organ had been offered prior to acceptance for transplantation, was 7.5 (range 1-75). All offers prior to acceptance (7 out of 8) had been declined due to NP COVID-19 positive testing. Median Ct value of SARS-CoV-2 RT-PCR testing was 36.4 (range 35.7-37.5), with 7 (87.5%) detected from NP sampling. Median number of days between positive donor testing and transplantation was 4 (range 3-5). Median number of chest imaging tests, including chest X-rays and at least 1 computed tomography, was 12 during donor admission. All images were reviewed by transplant surgeons and pulmonologist prior to acceptance. Cause of deaths included drug intoxication (2), motor vehicle accident (2), suicide (2), head trauma (1), and cardiovascular (1). All 8 LT recipients underwent bilateral lung transplants. The median age of LT recipients in years was 44.5 (range 34.5-50.3) and median lung allocation score (LAS) was 46 (range 37-85). There was no donor-derived COVID-19 transmission to recipients based on LRT SARS-CoV-2 RT-PCR testing post-transplant. At 72 hours, 3 (37.5%) developed Grade 1 PGD, 1 (12.5%) Grade 3 PGD, and 4 (50%) had no evidence of PGD. One recipient (12.5%) developed Grade A1 rejection. All recipients are alive to date, corresponding to 30-day survival of 100% for 8 recipients and 90-day survival of 100% for 7 thus far (Table 2).
Table 1Donor and Recipient Characteristics
Cause of death
P/F ratio at offer
Time to transplant (d)
Offers prior to acceptance
Ground-glass and patchy alveolar opacities are present within RUL and bilateral lobes
Patchy infiltrate in LUL. Ground-glass infiltrate in LLL
Mild dependent aspiration and atelectasis.
Dependent atelectasis is present at RLL
Minimal ground-glass density in RUL. Minimal atelectasis in LLL
Consolidation in RLL. A small dependent left basilar consolidation is also present.
Minimal bilateral effusion, no opacities
Consolidation in RLL, scattered small consolidation LLL
Abbreviations: Ct, cycle threshold; IPF, idiopathic pulmonary fibrosis; LAS, lung allocation score; LLL, left lower lobe; LRT, lower respiratory tract; LUL, left upper lobe; MVA, motor vehicle accident; NP, nasopharyngeal; NSIP, nonspecific interstitial pneumonia; PF, Pulmonary fibrosis; PH, pulmonary hypertension; RLL, right lower lobe; RUL, right upper lobe.
There is currently no consensus for determining the safety of utilization of donors for LT with incidental positive COVID-19 testing. Only 2 LTs have been described at a single center, where donor eligibility required initial positive NP testing to be >20 days from procurement and a negative LRT testing.
However, it does not include evaluation of the cycle threshold (Ct) value. In fact, Ct values are presently not recommended for assessment of infectivity by the Centers for Disease Control and Prevention and the Food and Drug Administration due to test variability.
Ct values represent the number of amplification cycles needed on a RT-PCR sample to breach the threshold for positivity. They have been inversely correlated to viral load and mortality and used clinically to reduce isolation period for COVID-19 infected individuals.
Our experience based on an evaluation of the RT-PCR Ct values contributes to the available evidence of safety of utilizing donors with incidental positive COVID-19 testing. Across our 8 cases, all donors had Ct values greater than 35, a threshold that has been shown to correlate with inability to detect culturable virus.
Based on our algorithm, only 8 potential donors were evaluated. We believe that performing LRT COVID-19 RT-PCR to rule out infection in appropriate donors, such as those with incidental positive NP COVID-19 positive RT-PCR with a Ct greater than 30, normal P/F ratio and benign chest imaging, could potentially increase the donor pool even further. While most (7 of 8) tested positive by NP RT-PCR alone with negative LRT testing, it should be noted that 1 donor had negative NP testing and subsequent LRT positivity with Ct value above 35. We thus did not make a distinction between NP or LRT source if Ct value threshold >35 was met and did not decline donors due to lack of prior COVID testing data if initial RT-PCR positivity was within 20 days of procurement. We observed that the donors’ causes of death are attributed to circumstances that often pose a practical challenge to ensuring adequate time from initial positive testing to organ procurement as proposed under current OPTN guidelines. Ct may therefore represent a surrogate for consideration for donor organ risk stratification in case of incidental COVID-19 positive RT-PCR, as proposed in Figure 1. Since positive RT-PCR by LRT with negative NP testing was represented by only 1 donor during the study period, the donor selection algorithm we put forth in Figure 1 utilizes positive NP RT-PCR alone (Ct value >35) as initial criteria.
Our study has limitations. First, our experience is small with only 8 LTs. Second, donor clinical information was limited to data obtained by organ procurement organizations . However, there were no cases of COVID-19 donor transmission and no mortality to date. Moreover, we noted similar rate of PGD to what is reported in literature.
These results should be interpreted cautiously but they support a reassessment of current recommendations for donor lung acceptance to maximize donor utilization as incidental COVID-19 positive testing is expected to increase.
The authors of this publication have no conflicts of interest or financial considerations to disclose.
J.H., A.Y., L.Z., and R.R. contributed to the analysis and drafted the manuscript. All other authors revised the manuscript and approved the final version. R.R., P.Z., P.D. and D.J.M. contributed to the planning of the study.