key: cord-0697066-3ibgwl0d
authors: Greenhall, George H. B.; Ushiro‐Lumb, Ines; Pavord, Sue; Currie, Ian; Perera, M. Thamara P. R.; Hartog, Hermien; Hill, Quentin A.; Mohamed, Ismail; Khurram, Muhammad A.; Motallebzadeh, Reza; Jones, Gareth; Marshall, Aileen; Pollok, Joerg‐Matthias; Torpey, Nicholas; Pettigrew, Gavin J.; Mehra, Sanjay; Sharma, Hemant; Calder, Francis; Kessaris, Nicos; Nath, Jay; Roy, Debabrata; Oniscu, Gabriel C.; Clancy, Marc; Santhanakrishnan, Karthik; Mascaro, Jorge; Lim, Sern; Berman, Marius; Madden, Sue; Mumford, Lisa; Mirza, Darius; Watson, Chris; McGowan, Olive; Thorburn, Douglas; Ravanan, Rommel; Hunt, Beverley J.; Callaghan, Chris J.; Roberts, David J.; Forsythe, John
title: Organ transplantation from deceased donors with vaccine‐induced thrombosis and thrombocytopenia
date: 2021-07-19
journal: Am J Transplant
DOI: 10.1111/ajt.16735
sha: 42a98f06e090bc6c78c397c58368c2c2abbf6d6c
doc_id: 697066
cord_uid: 3ibgwl0d

Vaccine-induced thrombosis and thrombocytopenia (VITT) may follow immunisation with the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2. Autoantibodies to platelet factor 4 (PF4) may mediate VITT through antibody-dependent platelet activation, though the underlying etiology is uncertain. Anti-PF4 antibodies are also seen in heparin-induced thrombocytopenia, though most cases of VITT do not have prior heparin exposure. More than 20 million people in the United Kingdom (UK) have received the ChAdOx1 nCoV-19 vaccine.

To the Editor:

Vaccine-induced thrombosis and thrombocytopenia (VITT) may follow immunization with the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2. 1, 2 Autoantibodies to platelet factor 4 (PF4) may mediate VITT through antibody-dependent platelet activation, though the underlying etiology is uncertain. 3 Anti-PF4 antibodies are also seen in heparin-induced thrombocytopenia, though most cases of VITT do not have prior heparin exposure. More than 20 million people in the United Kingdom (UK) have received the ChAdOx1 nCoV-19 vaccine. We carried out an early analysis of organ donation and transplantation from UK donors with VITT, to understand the implications of this emerging syndrome. Articles 6(1)(e) and 9 (2)(h) and (i) of the General Data Protection Regulations provide the basis for NHSBT to use patient identifiable data without prior consent, for the purposes of monitoring the safety of the national transplant program.

We identified 13 consented deceased organ donors, who presented with thrombosis and/or hemorrhage and laboratory features consistent with VITT, 4 between 28 January and 9 April 2021. All had received their first dose of ChAdOx1 nCoV-19 vaccine before admission (see Table 1 ). Ten donors proceeded to donate 27 allografts to 26 recipients. After a median follow-up of 19 days, 21 of 27 (78%) allografts have satisfactory function. Three recipients developed early allograft failure requiring explantation (two livers and one kidney); two transplanted kidneys have impaired allograft function, currently requiring hemodialysis; and one recipient died within a day of transplantation from a presumed cardiac event. There were seven major thrombotic or hemorrhagic postoperative complications (three bleeds and four venous or arterial allograft thromboses) in six recipients, resulting in the loss of three transplants as described above; these events occurred within 9 days of transplantation. Of the six recipients with bleeding or thrombotic events, two had received their UK guidance has been drawn up for the selection, recovery, and transplantation of organs from donors with VITT, as well as recipient monitoring. 5 We suggest that liver, lung, pancreas, and small bowel transplants from donors with VITT should only proceed in urgent situations, as these organs contain high numbers of "passenger" donor lymphocytes. Since anti-PF4 antibodies can provoke platelet activation and thromboses, platelet transfusion should be avoided during organ recovery and transplantation processes where possible. The contribution of systemic heparinization during organ recovery to thrombosis within the allograft is uncertain, and argatroban is an alternative anticoagulant. 5 Current UK guidance recommends that heparin can be used as per standard practice in the recipient unless features of VITT develop. 5 For recipients of organs from VITT donors, monitoring of the platelet count, fibrinogen, D-dimers, and anti-PF4 antibodies is essential. 5 Further experience of organ transplantation from donors with VITT and longer term recipient follow-up will help guide clinical decision-making. In the meantime, transplantation of organs from these donors should only proceed after careful consideration of the methods for organ recovery and of the risks and benefits for a potential recipient, and an appropriate consent discussion.

This is an open access article under the terms of the Creat ive Commo ns Attri bution-NonCo mmercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. (2), pulmonary embolus (1), splenic vein (1) i Numbers represent events; some recipients experienced more than one complication. Excludes death. j Defined as at least one session of hemodialysis/hemofiltration in the first 7 postoperative days in kidney recipients, any need for ongoing extracorporeal membrane oxygenation in heart/lung recipients, or super-urgent listing for re-do transplantation in liver recipients. Excludes graft failure/explant. k In the first 2 weeks after transplantation.

Nicos Kessaris

Rommel Ravanan

Thrombotic thrombocytopenia after ChAdOx1 nCov-19 vaccination

Thrombosis and thrombocytopenia after ChAdOx1 nCoV-19 vaccination

Pathologic antibodies to platelet factor 4 after ChAdOx1 nCoV-19 vaccination

Guidance produced from the Expert Haematology Panel (EHP) focussed on Covid-19 Vaccine induced Thrombosis and Thrombocytopenia (VITT)

Organ Donation and Transplantation from Patients with Vaccine Induced Thrombosis and Thrombocytopenia (VITT) (INF1569/2)