National Trends in Super-Urgent and Macro-Area Urgent Liver Transplantation in Italy (2019-2023): A Registry Analysis Supported by the CNT

Background and Aims

Italy manages life-threatening liver failure through two fast-track pathways: super-urgent listing (classical acute liver failure, national priority within 24–48 h) and urgent listing by macro-area (North/South) for codified indications such as MELD > 30, P1 status after previous LT, or other agreed “in-deroga” cases. We analysed recent registry data to describe activity, timing and outcomes of both pathways, with a focus on the urgent-macro-area cohort.

Methods

CNT registry data (2019-2023) were retrospectively reviewed. Indicators: listings, transplants, mean waiting time (MWT), drop-out, mortality and clinical improvement. Sub-analyses compared North vs South macro-areas and codified vs “in-deroga” urgent indications.

Results

Between 2019 and 2023, the number of LT performed under the super-urgent pathway declined from 177 to 78. In 2023, the national median waiting time (MWT) for super-urgent cases was 1.8 days, with significant regional variation: 1.5 days in northern regions versus 2.1 days in the south. The overall dropout rate for super-urgent patients in 2023 was 12%. Focusing on the urgent macro-area pathway in 2023, a total of 321 patients were listed, representing a 41% increase compared to 2022, with 235 transplants performed (73%). The case-mix included 214 codified listings (91%) and 21 listings classified as “in-deroga” (9%). Among codified cases, 84% had a MELD-Na score ≥30 (n = 180), while 16% were prioritized re-transplants (Re-LT P1, n = 34).Comparison of outcome indicators between 2022 and 2023 showed a worsening in waiting times, with the MWT increasing from 5.3 to 7.1 days. However, dropout and mortality rates improved slightly: dropout decreased from 17.1% (n = 39) to 14.5% (n = 34), and mortality on the waiting list dropped from 11.0% (n = 20) to 7.0% (n = 17). Notably, the number of patients removed from the list due to clinical improvement nearly doubled, from 21 to 41.Marked disparities were observed in 2023 between northern and southern regions in urgent cases. Northern centers performed 166 transplants compared to 66 in the south, while the median waiting time was significantly longer in the south (9.2 days) than in the north (5.1 days), reinforcing the persistent regional gap in access and outcomes.

Conclusions

Between 2019 and 2023 Italy maintained rapid access for super-urgent candidates, yet activity declined and a modest drop-out persisted. Urgent macro-area listings grew markedly, dominated by high-MELD patients. While national performance remains good, the North–South difference in MWT (≈4 days) signals residual organisational imbalance. Recent CNT policies that shorten escalation from macro-area to national priority—and the low proportion of “in-deroga” requests—suggest progress toward more uniform, data-driven allocation. Continuous monitoring and targeted support to slower centres are required to consolidate equity and further reduce wait-list losses.