In 2020 due to the coronavirus epidemic there was a decrease in the number of transplants performed in Italian hospitals, but the greatest concern of doctors concerns two other data: the decrease in the number of donors and the increase in the percentage of opposition expressed in the declarations of will collected by the municipalities. These are two major problems for an activity that every year saves the lives of thousands of people, and that could save thousands more while waiting for an organ. Unlike many other sectors of medicine, in fact, transplants depend on donation and not only on scientific progress. So research is not enough: constant awareness raising is also needed.
The reasons behind the increase in opposition are many and have been studied by the experts of the national transplant center, who are taking this data very seriously so as not to compromise the growth of this activity in the coming years.
How many transplants in 2020
I data collected by the transplant information system say that in the first eleven months of 2020 there was a decline in the number of transplants of 7.8% compared to the same months of 2019: from 3449 to 3178. 1648 kidney transplants, 1202 liver, 243 heart were performed , 114 of lung, 36 of kidney and pancreas together and 5 of pancreas. The transplant is considered an emergency intervention, so the activity never stopped even in the months of March and April, during the first wave of the epidemic. Consider the conditions in which the Italian hospitals found themselveshowever, we can speak of a contained decrease.
Donors, i.e. dead people who have had at least one organ removed, fell by 7.5%, from 1379 to 1275. Since 2014 the number of donors has almost always exceeded the 1300 threshold, with a peak in 2017 with 1437 donors. The beginning of 2020 had looked very promising, both for the number of donors and for transplants performed, then the epidemic arrived that slowed everything down.
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According to the director of the national transplant center, Massimo Cardillo, a more marked decline could have been expected because the donations are mainly in intensive care, which have been the wards most under pressure in recent months. “The decrease in the number of transplants is justifiable compared to what happened,” Cardillo explains. “In other European countries such as Spain, France and the UK there has been an even more significant decline. The Italian transplant network is very solid and has held up despite the impact of the pandemic ».
Oppositions to the donation
The data considered most worrying is that relating to opposition to organ donation. Objection to the donation can take place in two ways. The first case concerns people who die in hospital, especially in intensive care units: there are doctors who have the task of talking to family members and informing them of the possibility of allowing organ donation. In the last twelve months, the opposition after the assessment of death in intensive care has reached 29.6%, but from April onwards the percentage has dropped slightly due to the growth in trust in doctors and nurses during the coronavirus emergency.
You can declare your will to donate or oppose the donation of organs even in life, at the time of renewing your identity card. This possibility has been guaranteed since 2015 and in the last five years has allowed 7 million declarations of intent to be entered into the transplant information system.
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According to data updated to December 14, in 2020 there were 1.8 million new declarations compared to 2.3 million in 2019. Also in this case, the decline can be considered contained because since April the registry offices have been closed and the government has postponed the expiry of the cards of identity. Due to the stop to the activities of the associations, the registrations to AIDO, the Italian association of organ donation, have also decreased: from 18496 in 2019 it has passed to 4555 in the last year.
On the other hand, opposition to organ donation communicated with the declaration of intent has increased: in 2020 it reached 34%, the highest percentage ever achieved in recent years, while in 2019 it remained at 32.8%.
There are many territorial differences. The percentage of consent to donation is higher in the regions of northern Italy. In this map it is possible to consult all the provincial data.
The national transplant center has developed a “Gift index” which classifies the “generosity” of Italian cities through various parameters including the consent in the declarations of will collected by the municipalities, the ASL and the number of members of the AIDO. In 2020, Sassari achieved the best result with an 80% higher consensus rate in cities with more than 100,000 inhabitants, ahead of Livorno and Trento. Milan is eighteenth, Rome twenty-seventh, both with an index close to the national average of 52%.
In this map, however, you can see the provincial data with the percentage of opposition in the declarations of will collected by the municipalities.
The consequences of the opposition
It may seem like a paradox, yet having millions of declarations registered at the time of the identity card renewal is limiting the possibility of performing transplants. The will that is expressed in life cannot be changed by anyone, not even by family members. And often the decision to oppose the donation is taken without having full awareness, because it is declared in the act of renewing the identity card through a form presented without notice and with very little information.
In recent years, therefore, the increase in declarations of will has also led to thousands of oppositions. “The more people are informed about the donation, the higher the consent rate,” Cardillo explains. «The opposition is almost always due to lack of information, distrust, unjustified fears. We are very worried about these latest data, because a “no” expressed in life must be respected and the communication efforts of doctors towards family members after death in intensive care are also canceled. The increase in opposition to the donation could be unsustainable in the long term ».
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Quantifying the consequences of the opposition is a simple but significant operation. In 2020 there were 1275 donors: canceling 34% of opposition could potentially have 430 more donors. According to Cardillo, this number would allow about a thousand more transplants per year. “A thousand people whose lives we could save.” Across Italy, there are just over eight thousand people on the waiting list, of whom 222 are children, so the impact of the opposition is considerable.
All the data of the declarations of will have been studied by the experts of the national transplant center who are trying to understand how to lower the percentage of opposition. At the heart of the strategy is information. A large-scale campaign will start in the early months of this year to explain the usefulness of the donation and above all, a prior communication will be sent to all people who need to renew their identity cards. “That is precisely the most critical moment, because the choice is made at a moment that has nothing to do with the donation and therefore exposes to a strong risk of opposition,” says Cardillo. «If a citizen has the opportunity to make a more informed choice, even through prior information, the scenario changes completely. Citizens need to have more confidence in our system, one of the best in Europe. In this way they will allow us to save the lives of thousands of patients waiting for a transplant ».
(Michele Lapini/Getty Images)
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The many good news of 2020
But there is also a lot of good news in 2020, despite the epidemic. The activity of the national transplant center has never stopped and interventions have never been carried out before. In the night between 10 and 11 December, for example, at the Molinette hospital in Turin the first transplant in the world was performed from coronavirus positive donor to coronavirus positive recipient. A 63-year-old man with liver cancer received the organ from a donor, following the wishes expressed by his family. The surgery, which lasted 9 hours, was performed by Professor Renato Romagnoli, and was technically difficult and very tiring due to the personal protective equipment worn by doctors and nurses.
At the end of March, in the most difficult weeks of the first wave, the regional transplant center of Piedmont also received two kidneys from Switzerland. It was not an easy operation, because the borders were closed and the doctors reached the border to receive the container with the organs from their Swiss colleagues. “It’s not something you do every day,” says Antonio Amoroso, director of the Piedmont regional transplant center. “In Switzerland, interventions were at a standstill, but not here. We immediately picked up the offer. We never let ourselves be intimidated by the coronavirus and thanks also to the organization of the Piedmontese hospitals we were able to continue the transplant activity, despite the many difficulties in which intensive care has been found, even in Piedmont “.
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Even in Lombardy, the region most in difficulty during the first wave, interventions have not stopped. In May, at the Milan polyclinic a lung transplant was performed on a patient with Covid-19. The first of its kind in Europe. To receive the organ was an 18-year-old boy, whose lungs Covid-19 had damaged irreversibly.
On 21 March, at the Papa Giovanni XXIII hospital in Bergamo, a 54-year-old patient suffering from pulmonary fibrosis, received two new lungs from a donor who died in a hospital in Lazio. The transplant was done in the third week of March, in a dramatic period in the province of Bergamo, where the coronavirus caused thousands of deaths.
At the hospital in Catania, however, on 22 August the first uterus transplant in Italy was performed. The patient who received the transplant is a 29-year-old woman suffering from Rokitansky’s syndrome, a rare congenital disease in which she was born without a uterus.
The vaccination campaign
Even those involved in transplants hope that the vaccination campaign against the coronavirus will continue at a rapid pace because the many organizational problems caused by the epidemic will be reduced with protection from the virus. People who are on the waiting list for a transplant are considered at risk, so they will be vaccinated after healthcare workers and the elderly. The same is true for the approximately 50,000 people who have received a transplant and who are immunosuppressed, that is, they have low immune defenses, due to anti-rejection therapies. “It is incredible to think that we were able to find a vaccine in such a short time, and for all of us it is an element of strong optimism for the future,” explains Amoroso. «With the vaccination we will overcome all the difficulties of the last few months: we must consider that those on the waiting list are generally not young, have other diseases, are certainly not in good health and therefore are more likely to contract the infection. With the vaccine we will all be safer: we will be able to return to work and grow as before the epidemic ».
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