Liver Transplantation for T2 Hepatocellular Carcinoma during the COVID-19 Pandemic: A Novel Model Balancing Individual Benefit against Healthcare Resources.

Umberto Cillo,Giuseppe Feltrin,Michael L Volk,Paolo Feltracco,Giuseppina Brancaccio,Anna Chiara Frigo,Patrizia Burra,Silvia Trapani,Massimo Cardillo,Alessandro Vitale,Paolo Angeli,Annamaria Cattelan,Sara Lonardi

doi:10.3390/cancers13061416

Abstract

Simple SummaryUsing Italian national data from more than 8000 patients, we proposed a novel model calculating the net benefit of liver transplantation (individual benefit minus harm to others on the waiting list) in T2 hepatocellular carcinoma (HCC) patients in different scenarios of transplant activity reduction. Our results show that the transplant net benefit is closely related to the decrease in the number of organs, but it is also higher in T2 HCC patients than in non-HCC patients with the same model for end-stage liver disease (MELD) scores. Our model supports liver transplantation for T2 HCC with the highest net benefit also during crises such as COVID-19.The COVID-19 pandemic caused temporary drops in the supply of organs for transplantation, leading to renewed debate about whether T2 hepatocellular carcinoma (HCC) patients should receive priority during these times. The aim of this study was to provide a quantitative model to aid decision-making in liver transplantation for T2 HCC. We proposed a novel ethical framework where the individual transplant benefit for a T2 HCC patient should outweigh the harm to others on the waiting list, determining a “net benefit”, to define appropriate organ allocation. This ethical framework was then translated into a quantitative Markov model including Italian averages for waiting list characteristics, donor resources, mortality, and transplant rates obtained from a national prospective database (n = 8567 patients). The net benefit of transplantation in a T2 HCC patient in a usual situation varied from 0 life months with a model for end-stage liver disease (MELD) score of 15, to 34 life months with a MELD score of 40, while it progressively decreased with acute organ shortage during a pandemic (i.e., with a 50% decrease in organs, the net benefit varied from 0 life months with MELD 30, to 12 life months with MELD 40). Our study supports the continuation of transplantation for T2 HCC patients during crises such as COVID-19; however, the focus needs to be on those T2 HCC patients with the highest net survival benefit.

Highlights

Liver transplantation (LT) is theoretically the best therapy for patients with hepatocellular carcinoma (HCC), its main limitation remains the great discrepancy between the transplant demand and the supply of donor organs [1]
This ethical tension can be represented as a vector computation (Figure 1) where individual transplant benefit for T2 HCC patients should outweigh the harm to others on the waiting list (WL) to define appropriate organ allocation
We found that 8567 adult patients with end-stage chronic liver disease entered the WL for liver transplantation (LT) in Italy from January 2012 to December 2018: 6476 (75.6%) patients underwent LT, 1345 (15.7%) dropped out from the WL, and 746 (8.7%) still wait or were removed from the WL for disease improvement

Summary

Introduction

Liver transplantation (LT) is theoretically the best therapy for patients with hepatocellular carcinoma (HCC), its main limitation remains the great discrepancy between the transplant demand and the supply of donor organs [1]. This dramatic imbalance has imposed the choice of clear allocation principles for patients with and without HCC, such as utility, urgency, or transplant benefit. Transplant survival benefit is defined as life expectancy with transplantation minus life expectancy without transplantation It is a very interesting principle with the potential to offer a fair distribution of resources between HCC and non-HCC patients [4,5,6]. None of the available criteria for individual clinical decisions for LT take into consideration population characteristics in terms of healthcare resources and waiting list (WL) features

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