The COVID‐19 second wave risk and liver transplantation: lesson from the recent past and the unavoidable need of living donors

摘要

September 2020 signed the beginning of the second wave of COVID-19 outbreak in Italy (Figure S1) [1]. Since the dramatic experience learned during the first epidemic wave a significant decline of liver transplantations (LTs) will be expected. Every year, approximatively 1200 LTs are performed in Italy [2]. The majority of these are concentrated within four northern regions (Lombardia, Veneto, Piemonte, Emilia-Romagna, LoVePiER), accounting about more than the half of the overall LT performed per year (749/1277 LT, 58.6%, in 2019). Nowadays, LoVePiER was the most involved areas by the COVID-19 outbreak, with a total of 75 738 (71.5%) documented cases until March 31st and 10 174 (81.8%) deaths (Table S1) [1]. Considering the period of the first outbreak month (March 1st–March 31st), a dramatic decrease of about 35% of LT was registered in Italy, compared to the same period in 2019 and comparing the trend of January and February 2020 [2]. Before COVID-19, the average rate of donor availability in LoVePiER was 52.7 donors per million people (PMP/2019), showing the high virtuosity of the transplantation system and people, similar to the highest rates recorded in the world [3]. However, in March 2020 only 43 donors were alerted in LoVePiER, significantly lower compared to the 64 in March 2019 (−33%), as well as in the whole country with a donor decrease of 43% (143 in March 2019 vs. 82 in March 2020) [2]. Donors’ numbers turned growing up since June 2020, near to the numbers of 2019; however, probably, a new sudden decrease will occur during the next months [2]. The average rate of donor availability in LoVePiER was 47.9 donors per million people (PMP/until July 2020), and projections for the entire year would be lower due to the second wave beginning in the autumn [2]. The dramatic impact of the COVID-19 outbreak in Italy gave a frightening perspective for LT candidates (Fig. 1). Considering a virtual cohort of 1000 patients listed on March 1st, 2020, the probability of these patients to be transplanted within the first year was 64%, significantly worst compared to the 80% of the pre-COVID-19 scenario. Similarly, the dropout risk of the 1,000 patients considered in the virtual cohort appeared to progressively increase from the COVID-19 outbreak compared to the pre-COVID-19 scenario (5% vs. 7% at 1 year and 8% vs. 13% at 2 years, respectively, for pre- and post-COVID-19) (Fig. 1). A mix of multiple causes related to missing potential donors, health system crisis, and socio-emotional predisposition may be considered. Concerning the missing potential donors, the numbers of all traumas were significantly reduced due to the isolation of people at home; more people died at home of cardiovascular causes without access to emergency services and the possibility of resuscitation and consequently brain death diagnosis. The National health system was suddenly under stress by the admission of hundreds of symptomatic patients every day for an unpredictable period of time. Many of these needed isolation, ventilatory support, and much nurse and physician support, especially by anesthesiologists, infectivologists, and pneumologists. The Italian donation system is organized from the top down by a Central National Coordination, macroregional allocation areas, regional coordination, and local coordination. All the coordinators are mainly anesthesiologists and healthcare managers, essentially the leading physicians involved in the COVID-19 emergency. This meant less propensity for donation rather than COVID-19-affected patients. More than double the number of intensive care beds available in the LoVePiER were used for COVID-19 patients. This sometimes forced physicians to apply an admission selection based on the survival benefits for the patients, reducing the chance of recovery of potential donors. Lastly, the socio-emotional predisposition of the people is a very weak toward donation, as they are extremely susceptible to all global occurrences. Inde