When the results came back positive, Kaul wondered, “Could this [have] come from the donor?”
Additional tests would soon confirm Kaul’s suspicions: The unnamed woman, who died of covid-19 two months later, had indeed contracted the virus from her donor’s infected lungs. Kaul’s discovery was published in a peer-reviewed paper by the American Journal of Transplantation earlier this month.
“This is at least the first proven case of transmission of covid-19 via organ transplantation in the United States,” Kaul, director of Michigan Medicine’s transplant infectious-disease service, told The Washington Post on Monday night.
Although the paper identifies a novel new path for the virus, Kaul said the risk of contracting it from a transplant procedure is extremely low and says his report should not discourage anyone from considering a transplant. Instead, he said, it points to the need for more testing to prevent similar cases in the future.
Last year, more than 39,000 transplants were performed in the United States, according to data compiled by the United Network for Organ Sharing (UNOS), including around 2,500 lung surgeries. Some covid-19 patients have also begun receiving lung transplants. Last June, a woman in her 20s whose lungs were punctured by the disease became the first known covid-19 patient to receive a double-lung transplant in the United States.
Kaul declined to disclose specific details about the donor and the recipient, as well as additional details regarding the time frame of the surgery, to protect their identities.
The donor, a woman from the Upper Midwest who became brain dead after a severe car accident, and the recipient, a woman who suffered from chronic obstructive pulmonary disease, were matched last fall, according to Kaul’s report.
Both women underwent multiple tests and clinical assessments before the surgery was approved. The donor, who was given a coronavirus nasal swab test within 48 hours of procurement, tested negative. Lung scans also did not show any indication of covid-19, Kaul said. The woman’s family told doctors she had “no history of travel” or any recent symptoms, including fever, cough, headache or diarrhea.
The recipient also tested negative for the virus 12 hours before the transplant.
The day of the procedure at University Hospital in Ann Arbor, Mich., the surgery went off without any complications, the report states. Later that day, the recipient was taken to the intensive care unit to begin her recovery. But three days later, the woman began exhibiting severe covid-19 symptoms. After her negative nasal swab, doctors also collected a fluid sample from deep inside her lungs, which came back positive.
“I was seeing the patient and I was very concerned that this could have come from the donor because it would be really unusual that it would be down deep in the lungs but not in the upper respiratory tract [nose and throat,]” Kaul told The Post.
He added, “So then, the question became how do we prove that? How do we figure out where did it come from?”
To answer that question, Kaul tested fluid that had been collected from the donor’s lungs during procurement. It came back positive.
“That said: These lungs were infected,” Kaul told The Post. “These lungs had covid in them before they got into the recipient.”
Around this same time, about three days after the procedure, one of the surgeons who had direct contact with the lungs also began showing symptoms. He later tested positive for the virus, but did not require hospitalization, Kaul said.
Kaul performed one last round of tests to confirm that the recipient contracted the virus from the donor’s lungs, a procedure known as sequencing, which he described as similar to the DNA sequencing performed when analyzing a crime scene. “That sequencing showed that it was the same virus that spread from the donor, to the recipient, to the surgeon,” Kaul told The Post.
As weeks went by, the woman’s condition deteriorated. Kaul’s team gave her every treatment they had available, including two rounds of remdesivir and convalescent plasma therapy on two occasions, but her body weakened, the physician said. She was put on a bypass machine to oxygenate her blood, but was disconnected after it became clear she would not sustain another lung transplant. She died 61 days after the surgery.
The surgeon who was infected has since recovered.
Kaul said his report offers important guidelines for doctors and organ donation organizations.
“The lesson that we learned and that we feel strongly about is that all lung donors should have a lower respiratory tract specimen checked” for coronavirus, Kaul said, noting that about 1 in 3 lung donors get this type of test before transplant surgery.
Some laboratories lack experience beyond nasal swab testing, Kaul said, while in other cases, organ donation groups don’t have enough time to perform the tests while the organ is still viable for transplant.
“We need to overcome those barriers and do this testing for every lung,” Kaul said. “The reason that we chose to report this is that we think it’s really important people in the transplant community are aware of this transmission so that we can work to have a system where lower [respiratory] tract specimen are checked on all lung donors.”
It is still unknown whether organs other than lungs could be capable of transmitting covid-19, Kaul said.