When all is said and done, there will have been many forgotten victims of COVID-19. With the SARS-CoV-2 virus showing up in more and more human organs, will potential recipients be among them?
When all is said and done, there will have been many forgotten victims of COVID-19. With the SARS-CoV-2 virus showing up in more and more human organs, will potential recipients be among them? And what precautions are being taken to ensure that recipients are not receiving virus-infected organs at a time when they are perilously immunocompromised?
Organ donations “decreased dramatically” during the first wave of the pandemic, said Dr. Atul Humar, a physician, senior scientist, and director of the Toronto General Hospital Research Institute (TGHRI).
“People who traditionally might become donors, people with heart attacks and strokes, I think that more of them were not wanting to come to the hospital with their heart attacks and strokes because they were afraid of COVID. So more people were probably dying at home is the sense that I got,” Humar told BioSpace.
In order for an individual’s organs to be eligible for donation, they would need to be on ventilated support in a hospital to keep oxygen and blood flowing through their organs.
Other factors Humar referenced included intensive care units (ICUs) being overwhelmed with COVID-19 patients, fewer referrals with the all-hands-on-deck pandemic situation, and the potential for transmission of the virus from both deceased and living donors.
The situation improved as the scientific community learned more about COVID-19, and safeguards were put in place. Humar explained that the lynchpin of Toronto General Hospital’s transplant program is polymerase chain reaction (PCR) testing.
“On the deceased donor side, we’ve put in these very robust donor screening protocols. So we screen every single deceased donor by history from the family, by imaging, and then we do two separate PCR assays on all donors for COVID to confirm that they’re COVID-negative. That’s actually worked really well. We’ve been able to carry out deceased donor transplants without really a single transmission of COVID in our jurisdiction,” said Humar.
SARS-CoV-2, however, is a novel coronavirus that just keeps on throwing curveballs, particularly for more elective procedures. A study published January 21st in JAMA Ophthalmology identified the presence of viral genomic and subgenomic RNA from the virus n the corneal tissue of deceased patients, which the authors stated: “would seem to have clinical relevance for a corneal transplant.”
In this particular study, researchers from the University Medical Center Hamburg-Eppendorf in Hamburg, Germany, found SARS-CoV-2 genomic RNA, but not the live virus, in the corneas of six of 11 patients who had succumbed to COVID-19 between March 20 and May 14. Could these findings have an impact on corneal transplants?
Corneal transplants, or keratoplasty, where the clear front layer of the eye, critical for seeing clearly, is replaced, are relatively common and can give the gift of vision and alleviate pain associated with diseases of the cornea. The procedure does come with a risk of rejection, and if corneas are accepted from donors who die positive for COVID-19, it seems it may also come with a risk of infection.
While researchers were not able to confirm infectivity or presence of viral structural proteins in the eyes, those patients whose corneas were positive for the virus did, however, test positive on other parts of the eye, and five had postmortem evidence of the virus in their bloodstream.
“It’s hard to know what to make of that because they’re detecting RNA. They’re not necessarily detecting replicating viruses, although they also detected some subgenomic RNA. Really, for transmission to occur from donor to recipient, you need replicating the virus,” said Humar. “The bottom line is, in donors with active COVID, it’s not wise to use any of the organs for transplantation. Because I think there is a potential risk of transmission.”
Humar added, “I think the issue is really about whether there’s replication versus detection of RNA, right? There have been studies that show that some people, especially immunocompromised people, shed replication-competent virus for a long period of time. So they shed virus that’s able to replicate for a long period of time.”
Current guidance on the National Institutes of Health (NIH) National Institute on Aging website states: “Currently, organ donation from donors known to have COVID-19 is not recommended, but this guidance may change as more becomes known about the condition.”
While the German study focused only on eyes, this is certainly not the only organ where the effects of COVID-19 may live on after death. In fact, the damage inflicted by the virus is likely to eliminate multiple organs from willing donors.
In a study published in April 2020 in the journal Kidney International, researchers analyzed the kidneys of 26 patients who had died from COVID-19. Kidney injury was found in nine of the 26.
This study, and others like it, reveal that lungs are not the only organ that will be in short supply in the coming years at organ transplantation centers. Even more alarming is how long this could last. Preliminary analysis from a British NHS-funded “Coverscan Study” found that of 70% the first 200 patients to be screened had impairments in one or more organs, including the heart, lungs, liver, and pancreas four months after being diagnosed with COVID-19.
“This is of interest because we need to know if [the impairments] continue or improve – or if there is a subgroup of people who could get worse,” said Amitava Banerjee, a cardiologist and associate professor of clinical science at University College London.
Dr. Humar shared that there have been instances where organs could not be used from donors who have perished from another cause after recovering from COVID-19.
“We have used organs from many of those donors, but there is some variability. Especially if some people had lung damage from previous COVID and we’re not able to use the lungs. So there is certainly a longer-term impact. We’re not sure where that’s going to go for now, but it’s something that we have to see and keep an eye on.”
Humar added, however, that all signs currently point to the ability of most organs to recover completely
“What we know is that the vast majority of people who recover from COVID actually do not have long-term organ damage that precludes them from being an organ donor in the event that they die from something else, or they do a living donation,” he said.
Another complicating factor for potential transplant recipients is their inherent vulnerability to contracting COVID-19 following the life-saving procedure.
“What we’ve also seen is that the recipients, because they are immunosuppressed, they are at high risk. They have a lot of comorbidities like diabetes, advanced age, so they are at risk of getting more severe COVID after transplant. And I think that’s perhaps being lost a little bit,” said Humar. I really feel they should be prioritized for vaccination and other preventative strategies.”
