Introduction & Aim: 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.