*Purpose: COVID-19 pandemic has significantly decreased rates of organ transplantation, with most programs curtailing living donor transplantations. This has led to an increase in waitlist deaths. We implemented a “COVID-free” pathway to minimize the risk of COVID infection in living donors and recipients to enable resumption of living donor transplantation.

*Methods: The pathway consisted of a three-tier testing, quarantine and screening strategy (fig1). Most outpatient appointments were changed to televisits. Inpatients were roomed in units that do not have COVID patients. Rationale for the pathway was based on available data on the transmissibility dynamics of SARS-CoV-2 virus. We prospectively analyzed the impact of the pathway implementation on the number of living donor liver and kidney transplantation and its relationship to community 7-day COVID testing positivity rate, and COVID-related outcomes.

*Results: A total of 54 patients (28 living donors and 26 living donor recipients) entered the COVID-free pathway from April 2020 until February 2021. Unsuspected asymptomatic COVID infection was detected in a living donor and kidney recipient pair (spouses) using our testing protocol which led to a postponement of their procedures. The rest of the living donor and recipient procedures proceeded as scheduled. None of the donors or recipients became infected with COVID during their hospitalization. One of the living donor liver recipients contracted COVID after discharge. The postponed pair who tested positive tested negative 2 months later with appropriate seroconversion and underwent uneventful donor nephrectomy and kidney transplantation. The rate of living donor transplantation was inversely related to the local COVID-19 positivity rate (fig2).

*Conclusions: Our “COVID-free” pathway was useful in avoiding surgery in unsuspected infected living donor and their recipients. The comprehensive pathway allowed us to resume living donor transplant activity during the pandemic, though does not completely protect our patients after discharge.

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