Introduction: Kidneys from deceased donors with SARS-CoV-2 infection during donor evaluation have not been accepted by most transplant centers due to concerns for productive COVID-19 infection and organ injury from COVID-related complications or viral transmission leading to de novo recipient infection. Our transplant center developed protocols to accept such kidneys. We aimed to compare clinical outcomes of kidney transplants (KT) from deceased donors with and without SARS-CoV-2 infection (CoVDpos and CoVDneg, respectively).

Methods: We retrospectively reviewed donor and recipient data and key clinical outcomes for all CoVDpos KTs performed at our center between 02/01/2021 and 01/31/2022, and compared such data to all consecutive CoVDneg KTs performed during the same period. Donor organ acceptance was pre-established by a protocol developed specifically to select CoV positive deceased donors. No COVID-directed therapies were provided to CoVDpos KT recipients. Standard of care induction therapy (lymphocyte-depleting agents) and a CNI-based maintenance regimen was used for all transplant recipients independent of donor type. Recipient vaccination prior to transplantation was not required in early 2021 but mandated after November 2021.

Results: There were 221 KTs, including 112 (51%) KT recipients (from a total of 63 CoVDpos deceased donors) and 109 KTs from CoVD neg deceased donors. Median time from positive SARS-Co-2 PCR test to donation was 16 days with a mean PCR threshold cycle of 30. Mean KDPI was 36+/-21 vs 45%+/-24 for the CovDpos vs CovDneg, respectively. DCD donors were more common in CovDpos when compared to CovDneg KTs (71% vs 47%, p <0.001).  Of the 63 CoVDpos donors, 30 (48%) died of COVID complications, mostly hypoxic respiratory failure, with 5 on VV ECMO. Pretransplant vaccination was 96.5% of CoVDpos recipients and 87.2%of CoVDneg KT recipients. Having a CoVDpos kidney transplant was not associated with increased incidence of DGF (15.2% vs 22%, p=NS). KT recipients of CoVDpos organs had similar eGFR at last follow up when compared to recipients of CovDneg kidneys (47+/-20 vs 2+/-23 ml/min/1.73m², p=NS). In a multivariable analysis, only recipient age, recipient BMI and DCD were independently associated with post-transplant GFR, while donor Covid-19 infection status was not found to be statistically significant. There was 1 patient death (from progressive pre-existent interstitial lung disease in the absence of SARS-CoV-2 detection from lower airway by BAL) 4 months post-KT, compared to 4 patient deaths in the CovDneg group, all from non-COVID-19 related illnesses. No kidney transplant recipients developed COVID-19 immediately post-transplant.

Conclusions: Kidney transplant outcomes including graft function was similar in recipients of CoVDpos to those of CoVDnegs out 12 months post-transplant. There was no clinical evidence of SARS-CoV-2 transmission demonstrating the safety of this protocolized approach. Careful utilization of kidneys from CoVDpos donors could minimize unnecessary discard of organs.