Liver transplant patients General population Severe COVID-19 Highlights The incidence of coronavirus disease 2019 (COVID-19) is higher in liver transplant patients. Mortality rates are lower than those observed in the matched general population. Immunosuppression withdrawal may not be justified. Mycophenolate may increase the risk of severe COVID-19 in a dosedependent manner.

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The World Health Assembly (WHA) recently adopted Resolution WHA 63.22, urging Member States 'to strengthen national and multinational authorities and/or capacities to provide oversight, organization and coordination of donation and transplantation activities, with special attention to maximizing donation from deceased donors and to protect the welfare of living donors with appropriate health-care services and long-term follow-up' [1]. The Resolution was adopted 2 months after participants at the 3rd World Health Organization (WHO) Global Consultation on Organ Donation and Transplantation (Madrid, Spain, March 2010) called for governments to progress toward the concept of self-sufficiency in transplantation and therefore cover the needs of their patients by using resources within their own population and by decreasing the burden of chronic diseases, leading to the need of a transplant and consequently increasing organ availability. The call to address the transplantation needs of a particular population is worth highlighting in a diverse global landscape where huge disparities exist between the countries in terms of donation and transplantation activities. Deceased donation is an essential element of the selfsufficiency paradigm, from which the number of donors, but also the number of organs recovered and transplanted per donor should be maximized. An inability to address transplantation needs and disparities in donation, added to the unequal distribution of wealth in the world, represent the root causes for many patients dying or having a poor quality of life and for unacceptable practices, such SummaryA recent call for self-sufficiency in transplantation issued by the WHO faces variable worldwide activity, in which Spain occupies a privileged position, with deceased donation rates of 33-35 per million population (pmp) and 85 transplants pmp. An evaluation of current challenges, including a decrease in deaths because of traffic accidents and cerebrovascular diseases, and a diversity of cultures in Spain, has been followed by a comprehensive strategy to increase organ availability. Actions include an earlier referral of possible donors to the transplant coordination teams, a benchmarking project to identify critical success factors in donation after brain death, new family approach and care methods, and the development of additional training courses aimed at specific groups of professionals, supported by their corresponding societies. Consensus documents to improve knowledge about safety limits for organ donation have been developed to minimize inappropriate discarding of organs. Use of organs from expanded criteria donors under an 'old for old' allocation policy has resulted from adaptation to the progressive decline of optimal organs. National strategic plans to deal better with organ shortage, while respecting solid ethical standards, are essential, as reflected in the WHO Guiding Principles and the Istanbul Declaration on Organ Trafficking and Transplant tourism.

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012–2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A‐NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A‐NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49–67 years). Adjusted risk estimates were improved with A‐NRP for overall biliary complications (OR 0.300, 95% CI 0.197–0.459, p < .001), ischemic type biliary lesions (OR 0.112, 95% CI 0.042–0.299, p < .001), graft loss (HR 0.371, 95% CI 0.267–0.516, p < .001), and patient death (HR 0.540, 95% CI 0.373–0.781, p = .001). Cold ischemia time (HR 1.004, 95% CI 1.001–1.007, p = .021) and re‐transplantation indication (HR 9.552, 95% CI 3.519–25.930, p < .001) were significant independent predictors for graft loss among cDCD livers with A‐NRP. While use of A‐NRP helps overcome traditional limitations in cDCD liver transplantation, opportunity for improvement remains for cases with prolonged cold ischemia and/or technically complex recipients, indicating a potential role for complimentary ex situ perfusion preservation techniques.

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