Organ Donation From a Brain Dead Donor With Vaccine-induced Immune Thrombotic Thrombocytopenia After Ad26.COV2.S: The Risk of Organ Microthrombi

Germany, Uzen et al, November 2021, Transplantation

Summary

A 50-y-old female developed VITT with severe thrombocytopenia and thrombosis of the cerebral arteries and venous sinuses 12 d after the Ad26.COV2.S (Johnson & Johnson) vaccine. A  computed tomography (CT) scan showed extensive ischemia of both cerebral hemispheres and incipient entrapment of the brain stem. CT angiography revealed occlusion of the middle cerebral artery on both sides, as well as sinus vein thrombosis of the superior sagittal sinus and transverse sinus on both sides. No intracranial hemorrhage was detected.

Initial platelet count was 55 x 109 /L, and d-dimer level was 31 µg/mL. Activated partial thromboplastin time (22 s) and fibrinogen (378 mg/dL) were within a normal range. Antiplatelet factor 4 (anti-PF4)/heparin antibodies were detected (3.48 optical density [OD] units; negative <0.3 OD). Modified heparin-induced platelet activation assay was positive. The patient received IVIG therapy and argatroban.

Brain death was determined on day 3 of hospitalization…

Although our patient had normal biochemical parameters and ultrasonography of the kidneys was normal, we detected an infarction and microthrombi during further diagnostics. Furthermore, an intraluminal blood clot was detected in the liver after organ procurement…

So far, 1 patient was reported who developed anti-PF4 antibodies (2.3 OD) and severe tthrombocytopenia after liver transplantation from a donor
with VITT. Platelet count recovered after IVIG therapy, and the recipient was discharged with a functioning graft.
Another study detected anti-PF4/heparin antibodies in 3 liver recipients; of these, 1 developed thrombosis without allograft loss. Posttransplantation follow-up of the recipient should include platelet count, d-dimer, fibrinogen, and anti-PF4 antibodies.

In conclusion, VITT patients should not be completely excluded as organ donors, but a thorough pretransplantation evaluation of potential risks and functionality of the organs, as well as close monitoring of the recipient during and after transplantation, is necessary.

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