Impact of COVD-19 on liver transplantation in Australia and New Zealand

ABSTRACT

Background and Aim: The COVID-19 pandemic has led to significant disruption to the delivery of health care worldwide. The impact of the pandemic on liver transplant (LT) services in Australia and New Zealand has not yet been established. In March 2020, the Transplantation Society of Australia and New Zealand COVID-19 Taskforce raised the minimum eligibility for LT to patients with high short-term mortality (i.e. Model for End-Stage Liver Disease [MELD] score > 20). This directive was later removed, but services continued to be affected by broader government and hospital pandemic responses. This study aimed to examine the impact of the various responses to the pandemic on LT services in Australia and New Zealand. Method(s) We performed a retrospective analysis of all LT activity on the Australia and New Zealand Liver and Intestinal Transplant Registry from 2012 to 2021. The primary outcome was delisting from the LT waitlist (WL) due to disease progression or death. Outcomes were assessed at the end of each year and categorized as transplanted, died, or delisted. Delisted patients were defined as those who were removed and not relisted onto the WL within 180 days. Additional registrations onto the WL for retransplantation in the same patient were considered separate events. Annual trends in LT and WL activity were observed for the entire study period, using interrupted time series analysis. Differences between the pandemic cohort (1 January 2020 to 31 December 2021) and a corresponding pre-pandemic cohort (1 January 2018 to 31 December 2019), were then analyzed using chi2 and Mann-Whitney U tests as appropriate. Additionally, organ donation rates were obtained from the publicly accessible Australia and New Zealand Organ Donation (ANZOD) registry. Result(s) From 2012 to 2021, there were 3219 LTs performed, 3920 WL registrations, and 416 patients who died or were delisted due to disease progression. On interrupted time series analysis, there was a predicted annual increase of 17 LTs from 2012 to 2019 (95% CI, 12-22;P < 0.001);however, in 2020-2021, there was an annual reduction of 43 LTs (95% CI, 38-48;P < 0.001) compared with 2018-2019 (Fig. 1a). Concurrently, there was a predicted annual increase of 12 new WL registrations (95% CI, 7-17;P = 0.001) before the pandemic, which reduced by 18 new registrations annually in 2020-2021 (95% CI, 14-24;P < 0.001) (Fig. 1b). The number of patients remaining on the WL at year's end remained stable. ANZOD donor data found a corresponding predicted annual reduction of 86 actual/intended donors (95% CI, 80-93;P < 0.001) in 2020-2021 compared with before COVID-19 (Fig. 1c). Compared with the pre-pandemic cohort, the pandemic cohort had more severe liver disease at listing (median MELD score, 18 [12-24] vs 17 [11-22];P = 0.020) but no other baseline differences. The Australian pandemic cohort had a higher proportion of death or delisting due to disease progression (8.6% vs 6.0%, P = 0.043) and a corresponding lower proportion transplanted (66.9% vs 72.6%, P = 0.011) compared with the pre-pandemic cohort. In contrast, New Zealand transplant activity and outcomes were unchanged. Overall WL numbers and median days on the WL were unchanged before and after the pandemic in both nations. Conclusion(s) Despite low community rates of COVID-19, the effects on LT in Australia were similar to those seen in nations with high COVID-19 prevalence. Reduced Australian LT activity corresponded with reduced donor numbers and was associated with more severe disease at WL, as well as higher rates of disease progression. In New Zealand, LT activity was less disrupted and outcomes were unchanged.