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Preliminary Analysis of the Impact of the Coronavirus Disease 2019 Outbreak on Italian Liver Transplant Programs

Liver Transplant Programs in Italy have faced a sequela of management and clinical decision-making problems due to the high incidence in some regions of the country of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). The Italian Society for Organ Transplantation (SITO) and the Board of Liver Transplant Program Directors issued a survey to assess the initial impact of this pandemic event on the routine activity of 22 Italian Liver Transplant Programs. One hundred percent of participants completed the survey within a few days. The analysis is presented dividing the centers in two macro-areas: north-central Italy and south-central Italy. The reason for this is that the two areas had a different incidence of the infection and because they have distinctive rates of cadaveric donation. Overall, all centers remained open although a reduction in the activity was noted. Transplant Programs reduced their outpatient activity both in terms of pre-transplant evaluation (68% of the centers) and transplant recipient follow-up (100%); a reduction in transplant activity was observed in the first two weeks of March only in the north-central macro area (23 LTs vs 39 in 2018 and 60 in 2019); overall, SARS-CoV-2 infection was registered for 24 liver transplant recipients and 37 health care providers in liver transplant units. In the perspective of the increasing magnitude of the epidemic, more data will be required to define appropriate strategies for the increasingly complex management of liver transplant patients.

even in the light of multiple logistic scenarios deriving from the different incidence rates of infection across the country (Fig. 1B). Within a similar scenario, on March 16, 2020, the Italian Society for Organ Transplantation and the Board of Liver Transplant Program Directors issued a survey to assess the initial impact of this pandemic event on the routine activity of 22 Italian LT programs, and 100% of participants completed the survey in a few days.
The survey included 9 questions mainly focusing on 3 aspects: The results of the survey are summarized in Table 1. The analysis is presented dividing all centers into 2 macroareas: north-central Italy and south-central Italy. The reason for this is that the 2 areas had a different incidence of the infection and that they had distinctive rates of cadaveric donation.
Overall, all centers remained open, although a reduction in the activity was noted due to the donor shortage resulting from the different patient allocation needs in Italian intensive care units (ICUs) that are now almost exclusively dedicated to the care of COVID-19 patients. south-central area has not been impacted. Up to March 15, 2020, in the north-central Italy macroarea only, we registered 24 LT recipients positive for COVID-19 infection, of whom 3 (13%) were admitted in the ICU and 5 (21%) died. There were a total of 17 physicians among the 37 health care providers who tested positive to the infection, the majority of whom (94%) were, of course, in the northern macroarea. Also 82% of the programs performed the nasopharyngeal swab evaluation on all potential recipients upon admission for transplant, regardless of the presence of clinical suspicion or respiratory symptoms. The final section of the survey focused on LRLT: of the 7 centers performing LRLT, 3 temporarily suspended their program, whereas the remaining ones reduced their activity.
The survey paints a picture of how LT programs are managing this pandemic event in Italy and how routine activity has been impacted. Some considerations can, therefore, be made based on this preliminary analysis: the Italian system, based on a network of relationships among centers and between the centers and the Italian Transplant Authority, holds well despite the aggressiveness of this major event. Donor teams were provided by the program nearest to the donor's hospital, regardless of where the organ was allocated, thus resulting in a limited exposure of surgeons to the epidemic widespread. Centers located in the red zone were able, with extraordinary effort, to ensure that LTs were performed for the sickest patients.
However, in the perspective of the exponentially increasing magnitude of the epidemic (Fig. 1A), other problems remain, and more time will be required to appropriately manage them. A more detailed analysis will be performed shortly.
An increasingly complex management of sick patients waiting for an organ and an elevated risk of dropout and mortality on the waiting list are the 2 major concerns of the Italian LT community. With the commitment of ICUs to primarily provide care to COVID-19 patients, the rate of deceased donations is not expected to improve in the short term.
In addition, several patients, among those in a relatively better clinical condition (mainly oncological ones), have already been reported to have refused transplantation, due to their concern for contagion and to their deceptive perception of no urgency to be transplanted.
Priorities include solving logistical problems, such as defining safe pathways for transplant patients inside the hospitals, and identifying appropriate strategies to  deliver informed consent and all information related to the potential increased risk of infection to transplant patients.
In conclusion, although we are optimistic on the overall approach of the Italian LT community to this violent outbreak, we are aware that additional critical