key: cord-0808194-4k5csdv8
authors: Cillo, U.; Vitale, A.; Volk, M. L.; Frigo, A. C.; Feltracco, P.; Cattelan, A.; Brancaccio, G.; Feltrin, G.; Angeli, P.; Burra, P.; Lonardi, S.; Trapani, S.; Cardillo, M.
title: Liver Transplantation during the COVID-19 pandemic: A quantitative model balancing individual patient benefit against population healthcare needs
date: 2021-03-31
journal: Digestive and Liver Disease
DOI: 10.1016/j.dld.2020.12.105
sha: 67b5c15935af1b66c9e01f52dd2193787c722d67
doc_id: 808194
cord_uid: 4k5csdv8

nan

The COVID-19 pandemic stressed the healthcare system and decreased the supply of organs for transplantation, leading to renewed debate about which patients should receive priority during these times. The aim of this study is to provide a quantitative model to aid decision making in liver transplantation, balancing benefit to the transplant patient against the availability of healthcare resources. Methods: To describe the ethical tension arising in a pandemic scenario, we propose a novel ethical framework where individual transplant benefit should outweigh the harm to others on the waiting list determining a "net benefit" to define appropriate organ allocation (Figure) . Italian averages for waiting list characteristics, organ arrival, mortality, and transplant rates were obtained from a national prospective database (n = 8,567 patients), and then included into Markov models to calculate individual transplant benefit minus the cumulative harm to patients on the waiting list (i.e. net benefit). Results: Five-year individual net benefit in a usual organ arrival situation varied from 0 life months with MELD 12 to 31.6 with MELD 40 in non-HCC patients, and from 3.01 life months with MELD 6 to 32.2 with MELD 40 in HCC patients. Net benefit values in a pandemic scenario of 50% organs decrease varied from 0 with MELD 21 (threshold value) to 15.27 with MELD 40 in non-HCC patients, and from 0 with MELD 18 (threshold value) to 16.3 with MELD 40 in HCC patients. Simple equations and a web-calculator to estimate the net transplant benefit in different geographical contexts were implemented. Conclusions: Our study supports the continuation of transplantation during COVID-19 like crises, however the focus needs to be on those patients with highest net survival benefit. Microvascular ischemia-reperfusion injury is the acknowledged cause of EAF. Macrovascular damage (thrombosis of hepatic artery/portal vein) has been recently recognized as a co-factor of EAF in a large multicenter international retrospective study [1] [2] The novel Early Allograft Simplified Estimation (EASE) score [1] [2] reflects the micro and macrovascular damage since it is based on repeated measures of AST, bilirubin and platelets. EASE-score also includes surrogate markers of severity of liver disease (MELD) and surgical complexity at transplant (packed red blood transfused units, PRBC). The aim of the present contribution is the spread of this approach among transplant hepatologists, offering a smartphone APP to ease estimate EAF-risk. Methods: A self-explanatory APP for smartphones was developed. Results: The APP calculates EASE-score showing graphically the EAF-risk for the index case. Furthermore, it estimates the EAFrisk in a simulated case according to hypothetical values of MELD, PRBC, and evidence or not of thrombosis. Discussion: Deciding who really needs to be retransplanted is often challenging. Recovery depends on extension, severity and persistence of damage and by concomitant factors (MELD, PRBC, Thrombosis). While repeated parameters well capture the peculiarity of the damage, severity of liver disease, surgical complexity and thrombosis interact with a detrimental effect. After having entered input data of the current case, the calculator allows the risk-mitigation through interactive action on co-factors. The wide use of APP in the surgical and hepatological community will allow to design a large prospective validation study.

EASE score, novel algorithm

Development and Validation of