Response to “The COVID-19 outbreak in Italy: Initial implications for organ transplantation programs”

Abstract

To the Editor: I read the article on the overall reduction of solid organ transplantation (SOT) activity in Italy 1 with growing concerns, as also the national regulatory bodies (NRBs) of Spain and the UK report substantial reduction of activity in their bulletins; currently, in the UK only 5 Kidney Transplant Centers (TxCs) are still operational. It is notable that another study reported in the United States restricted SOT, with >70% of U.S. TxCs having suspended living donor kidney transplantation (LDKT). 2 The impact of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) on LDKT in Italy is mentioned only briefly in the article. 1 However, it should be a matter of careful consideration, as the Italian NRB reported since 2015 an increment of only 0.6/per milion population 3 , 4 ( Figure 1A). Official data reveal that >70% of the Italian LDKT activity appears to be concentrated in those regions more tragically affected by the SARS-CoV-2 pandemic 5 (Figure 1B,C). Notably, only 30% of the TxCs perform more than 12 LDKTs per year. 3 These official data demonstrate an asymmetric distribution of the national LDKT services; such historical, consolidated, and asymmetric activity currently reveals an intrinsic fragility of the services. FIGURE 1 A, LDKT/million population over the last 5 y in Italy. B, Regional distribution of LDKT activity 2019. C, Regional distribution of SARS-CoV-2 April 12, 2020. LDKT, living donor kidney transplantation; SARS-CoV-2, Severe Acute Respiratory Syndrome Coronavirus 2 [Color figure can be viewed at wileyonlinelibrary.com] FIGURE 1 It is foreseeable that SARS-CoV-2 will leave deep scars in the Italian National Health Service, maintaining, or even accruing, the reported 25% reduction of SOT for many months to come. Therefore, the national LDKT activity is in a position of danger, confronting a realistic risk of extremely low future activity. In these extraordinary circumstances, the regional devolution of health care in Italy may represent a limiting factor for LDKT services of most Italian regions. Now, more than ever, there is the need for a national strategy for the LDKT services overarching the regional health care system. The mission of such strategy should be to protect patients and services, aiming to shield the numerous excellent services already operating on our territory, as well as supporting those regional services needing structured assistance. Ensuring adequate funding, establishing appropriate workforce, contributing to the development of efficient infrastructures with dedicated services pathways, providing educational resources, and strengthening regional collaborations may represent altogether the pillars for a successful national LDKT service. The challenge for the Italian and global SOT services is unprecedented. A successful response to the current crisis can be achieved only through a well-coordinated international cooperation. International professional bodies, NRBs, and wider stakeholders of SOT will need to cooperate in producing regularly updated guidelines for safe practice, until that time when robust evidence may be available. Such guidance will need to be translated into national and local protocols. The benefit that LDKT is a planned procedure may contribute to risk minimization of viral infection, particularly if LDKT may be performed in non-Coronavirus Disease-19 (COVID-19) hospitals and in geographic areas with relative lower incidence of COVID-19. Potentially, structured LDKT services may counteract the increased pressure on waiting lists caused by accrued organ shortage; such benefit may be increased through regional/national alliances. Undoubtedly, the future SOT activity in every country is linked to the global response articulated by the international transplant community.