An international multicenter study of protocols for liver transplantation during a pandemic: a case for quadripartite equipoise.
Chew, Claire Alexandra Iyer, Shridhar Ganpathi Kow, Alfred Wei Chieh Madhavan, Krishnakumar Wong, Andrea Sze Teng Halazun, Karim J Battula, Narendra Scalera, Irene Angelico, Roberta Farid, Shahid
Chew, Claire Alexandra
Iyer, Shridhar Ganpathi
Kow, Alfred Wei Chieh
Madhavan, Krishnakumar
Wong, Andrea Sze Teng
Halazun, Karim J
Battula, Narendra
Scalera, Irene
Angelico, Roberta
Farid, Shahid
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2020-05-23
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Abstract
Background & aims: The outbreak of COVID-19 has vastly increased the operational burden on healthcare systems worldwide. For patients with end-stage liver failure, liver transplantation is the only option. However, the strain on intensive care facilities caused by the pandemic is a major concern. There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources.
Methods: We performed an international multicenter study of transplant centers to understand the evolution of policies for transplant prioritization in response to the pandemic in March 2020. To describe the ethical tension arising in this setting, we propose a novel ethical framework, the quadripartite equipoise (QE) score, that is applicable to liver transplantation in the context of limited national resources.
Results: Seventeen large- and medium-sized liver transplant centers from 12 countries across 4 continents participated. Ten centers opted to limit transplant activity in response to the pandemic, favoring a "sickest-first" approach. Conversely, some larger centers opted to continue routine transplant activity in order to balance waiting list mortality. To model these and other ethical tensions, we computed a QE score using 4 factors - recipient outcome, donor/graft safety, waiting list mortality and healthcare resources - for 7 countries. The fluctuation of the QE score over time accurately reflects the dynamic changes in the ethical tensions surrounding transplant activity in a pandemic.
Conclusions: This four-dimensional model of quadripartite equipoise addresses the ethical tensions in the current pandemic. It serves as a universally applicable framework to guide regulation of transplant activity in response to the increasing burden on healthcare systems.
Lay summary: There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources during the COVID-19 pandemic. We describe a four-dimensional model of quadripartite equipoise that models these ethical tensions and can guide the regulation of transplant activity in response to the increasing burden on healthcare systems.
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Chew CA, Iyer SG, Kow AWC, Madhavan K, Wong AST, Halazun KJ, Battula N, Scalera I, Angelico R, Farid S, Buchholz BM, Rotellar F, Chan AC, Kim JM, Wang CC, Pitchaimuthu M, Reddy MS, Soin AS, Derosas C, Imventarza O, Isaac J, Muiesan P, Mirza DF, Bonney GK. An international multicenter study of protocols for liver transplantation during a pandemic: A case for quadripartite equipoise. J Hepatol. 2020 Oct;73(4):873-881. doi: 10.1016/j.jhep.2020.05.023. Epub 2020 May 23
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