Successful lung transplantation using an allograft from a COVID-19-recovered donor: a potential role for subgenomic RNA to guide organ utilization

Abstract

Although the risk of SARS-CoV-2 transmission through lung transplantation from acutely infected donors is high, the risks of virus transmission and long-term lung allograft outcomes are not as well described when using pulmonary organs from COVID-19-recovered donors. We describe successful lung transplantation for a COVID-19-related lung injury using lungs from a COVID-19-recovered donor who was retrospectively found to have detectable genomic SARS-CoV-2 RNA in the lung tissue by multiple highly sensitive assays. However, SARS-CoV-2 subgenomic RNA (sgRNA), a marker of viral replication, was not detectable in the donor respiratory tissues. One year after lung transplantation, the recipient has a good functional status, walking 1 mile several times per week without the need for supplemental oxygen and without any evidence of donor-derived SARS-CoV-2 transmission. Our findings highlight the limitations of current clinical laboratory diagnostic assays in detecting the persistence of SARS-CoV-2 RNA in the lung tissue. The persistence of SARS-CoV-2 RNA in the donor tissue did not appear to represent active viral replication via sgRNA testing and, most importantly, did not negatively impact the allograft outcome in the first year after lung transplantation. sgRNA is easily performed and may be a useful assay for assessing viral infectivity in organs from donors with a recent infection.

Keywords: COVID-19; SARS-CoV-2; donor-derived infection; lung transplant; subgenomic RNA.

Fig. 1

Clinical data from lung transplant recipient. (A) Serial pulmonary function testing demonstrates improvement in forced expiratory volume (FEV1) and forced vital capacity (FVC) between 3 and 12 months post-lung transplantation. (B) Chest radiograph at 12 months after lung transplantation demonstrating clear lung parenchyma. (C) Hematoxylin and eosin staining of the recipient’s explanted lung tissue showing a diffuse alveolar injury with patchy organizing pneumonia.

Fig. 2

RNA in situ hybridization (RNAscope) and viral sequencing for the detection of SARS-CoV-2 in recipient and donor lung tissues. (A) Positive chromogenic signals (brown) from the probe for SARS-CoV-2 spike RNA on explanted recipient lung tissue. (B) Positive chromogenic signals (brown) from the probe for SARS-CoV-2 spike RNA on donor lung tissue. (C) Positive chromogenic signals (brown) from probe Hs-PPIB, a pan-mammalian housekeeping gene, on donor lung tissue (positive control for the assay). (D) No chromogenic signal from the probe for bacterial gene RNA on donor lung tissue (negative control for the assay). Original magnification for all images: ×40. (E) Donor and recipient lung samples display significant sequence diversity. Coverage plots (top) and the schematic (bottom) showing consensus changes across the SARS-CoV-2 genome in donor lung and recipient lung samples. Coverage is plotted as log10 of the raw read depth; dotted line is of 3× coverage. Bars in the schematic indicate regions where consensus changes are found in each sample, compared with the Wuhan/Hu-1 strain. Black bars show consensus changes present in both samples, blue bars show consensus changes unique to a single sample, red bars indicate unique consensus changes in which the coverage in the other sample does not reach the cutoff of 3×, and red open boxes indicate an identified consensus change that is present in <3 reads.

Fig. 3

Potential algorithm incorporating subgenomic RNA (sg RNA) testing in prospective lung transplant donors with a recent SARS-CoV-2 infection. BAL, bronchoalveolar lavage; PCR, polymerase chain reaction.