Introduction: In the UK, the SARS-CoV-2 status of deceased donors is assessed by specific questionnaire and by universal Nucleic Acid Test (NAT) for SARS-CoV-2 RNA in nose and throat swabS (NTS) and endotracheal aspirateS (ETA). Initially, only asymptomatic and NAT-negative donors were accepted. Improved understanding of the relationship of SARS-CoV-2 replication to viral RNA detection as well as a more detailed testing approach have enabled consideration of NAT-positive donors.

Methods: Donor information and detailed SARS-CoV-2 RNA screening results were collected in real-time. SARS-CoV-2 NAT positivity triggered repeat sampling for the clarification of significance. Laboratory-proven diagnosis of SARS-CoV-2 infection in deceased donors or recipients of solid organs in England were captured by data linkage between the organ transplant registry and the National laboratory reporting system. Recipient infection within 14 days from organ transplantation was reviewed for the possibility of donor-transmitted infection.

Results: Between 1st March 2020 and 9th February 2022, 3537 potential donors were assessed in the UK. Thirty-seven tested NAT positive during donor assessment, with 17 not proceeding to donation due to the result (15) or due to other reasons (2). Of the remaining 20, the majority had a result profile indicating previous resolved infection, with detection of residual viral RNA; in the absence of evidence of previous infection some of the very weakly reactive NAT results might have been due to false positivity. Two donors had results compatible with current but resolving asymptomatic infection. Organs from these 20 donors were offered for transplantation, resulting in 57 organ transplants into 53 recipients (3 heart, 14 liver, 3 pancreas, 31 kidney). Six lungs were transplanted from donors with NAT negative ETA and whose positive NTS results were at the limit of assay detection and not repeatable upon re-sampling.  No donor-transmission of virus has been identified, with good transplant outcomes achieved.

Conclusion: SARS-CoV-2 RNA positivity should be verified and interpreted in conjunction with clinical, epidemiological and virological information. In an asymptomatic individual, other than a current infection, positivity could also be due to previous, resolved infection with detection of residual viral RNA; current, resolving infection; or a false-positive result. This enables consideration of organs that would otherwise be deemed unsafe for transplantation. Our preliminary results suggest that organs other than lungs can be safely transplanted, without SARS-CoV-2 transmission, from selected NAT-positive deceased donors in whom SARS-CoV-2 infection is considered either historical or non-evolving.