The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation.

The critical pathway of deceased donation provides a systematic approach to the organ donation process, considering both donation after cardiac death than donation after brain death. The pathway provides a tool for assessing the potential of deceased donation and for the prospective identification and referral of possible deceased donors.

[Organ procurement and transplantation from non-heart-beating donors]. / Le prélèvement sur donneurs à coeur arrêté dans le cadre de la greffe rénale.

Despite a significant increase in procurement and transplantation activities observed in France in the last eight years, the shortage in grafts is on the rise and demand keeps being much higher than supply. Since 1968 and until now, procurement was limited to heart beating brain donors. The results of kidneys transplanted from non-heart-beating donors have significantly improved and are nowadays comparable to those of kidney transplantations from brain death donors, thanks to a more accurate selection of donors and recipients, to better respect of preventing cold and warm ischemia times and to several major therapeutic innovations. Procurement on non-heart-beating donors are therefore being reconsidered under considerations of feasibility, results and ethical and legal consequences, under a specific medical protocol issued by the agency of biomedicine with the pilot hospital center agreement to comply with the protocol. Referring to foreign experiences, this program is likely to decrease the organ shortage, which is jeopardizing the treatment of a large number of patients awaiting transplantation.

[Evaluation of liver transplant quality in France]. / Evaluation d'un indicateur de qualité du résultat des greffes hépatiques en France.

The French Biomedecine Agency evaluated the outcomes of liver transplantation in France. The one-year graft failure rate in each transplant center was compared with the national rate, after adjusting for recipient, donor and transplant characteristics. All patients transplanted from 1998 to 2002 were included, except when a live donor was used. The validity and completeness of the data were first reviewed by the transplantation centers, and the quality of the database was audited by an independent contractor. The objectives, methodology and results of univariate analysis were discussed with the medical staff in each transplant center before the final analysis. The final statistical analysis used a multivariate logistic regression model including all predictive factors of the one-year graft failure rate. The adjusted failure rate was estimated for each transplant center and compared with the 99% confidence interval of the national failure rate. Twenty-four centres and 3625 transplantations were included. The national failure rate was 19%. Nineteen predictive factors were included in multivariate analysis of the one-year graft failure rate. Two centres were outside the 99% confidence interval of the national failure rate: one was significantly lower and one significantly higher. This study will be repeated each year in order to follow trends in the adjusted one-year failure rates in the different centers. The 3-year graft failure rate will also be studied in the same way. The Biomedecine Agency hopes that this work will encourage transplant centers to improve their quality of care.

Access to kidney transplantation in France of non-French patients and French patients living in overseas territories.

BACKGROUND: In France, foreign patients, whether resident or not in France, can register on the national waiting list under certain conditions. We compared waiting time to kidney transplantation, the level of HLA matching and graft cold ischemia time between foreign patients and French patients living in mainland France or in French overseas territories (FOT). METHODS: We performed a retrospective cohort survey using the nationwide registry. Between 1996 and 2003, 18,595 patients were registered on the French waiting list. Of these, 9.9% were of non-French nationality (0.7% Greek, 1.4% Italian, 1.5% other European, 3.7% North African, 1.8% sub-Saharan African and 0.9% other), and 3.8% were French nationals living in FOT. RESULTS: Median waiting time differed significantly between groups, from 13.8 months for mainland French patients to 39.5 months for sub-Saharan African patients. After adjustment for other factors significantly linked to waiting time, French residents of FOT (RR=0.83; P<0.001) and patients from sub-Saharan Africa (RR=0.75; P<0.0001) were found to wait significantly longer than other patients. HLA matching level, particularly HLA-A and HLA-B, was worse for African patients. After adjustment for the transplant team, cold ischemia time was found to be longer for Greeks (30.4 hr, P<0.0001) and French patients living in FOT (33.3 hr, P<0.0001) than for mainland French patients (21.2 hr). CONCLUSIONS.: Programs promoting organ donation aimed at minorities of African origin should improve their access to transplantation in France. We also need to strengthen international cooperation programs in certain countries to assist access to transplantation and to increase graft quality.

Risk factors for corneal regraft in patients on the French waiting list.

PURPOSE: To determine the frequency of corneal regraft (CR) and to identify risk factors associated with CR for all primary diagnoses, secondary endothelial failure (SEF), and keratoconus. METHODS: This survey included 8904 eyes registered on the French national waiting list that underwent keratoplasty between 2000 and 2002. RESULTS: The frequency of CR was 14.0% for all diagnoses, 16.9% among SEF patients, and 8.3% among keratoconus patients. For all diagnoses, the following factors were found to be independently associated with a significantly increased risk of CR (P < 0.05): primary diagnosis (stromal dystrophy, herpes simplex keratitis, SEF, trauma, and keratoconus with Fuchs dystrophy as reference), vascularization in more than 2 quadrants, planned recipient diameter over 8.5 mm, immunologic disorders, previous lens surgery (aphakic, pseudophakic anterior or posterior chamber intraocular lens), previous surgery for glaucoma or trauma, being grafted in 2001 or in 2002. For SEF patients, the risk factors were younger age, vascularization in more than 2 quadrants, planned recipient diameter over 8.5 mm, immunologic disorders, previous surgery for glaucoma or trauma, associated cataract or dry eye, and graft year. For keratoconus patients, the risk factors for CR were older age, vascularization in more than 2 quadrants, immunologic disorders, and previous lens surgery. CONCLUSION: The frequency of CR increased in France over the 2000-2002 time period. Patients presenting the above risk factors should be followed up closely to limit the loss of the first graft.

[Rules for allocation of livers for transplantation]. / Règles d'attribution des greffons hépatiques.

Previous rules of allocation of livers for transplantation were based mainly on local priorities, with final management left to the local team. This created substantial regional disparities. A prospective survey of waiting list deaths and dropouts due to aggravation of liver disease (2003-2005) validated the MELD (Model for End-stage Liver Disease) score on French data. A new allocation score (Liver Score) for liver transplants, based on specific variables for each liver disease, was introduced in March 2007. An initial evaluation, based on the first 5 months of practice, clearly shows that the Liver Score reduces the rates of deaths, dropouts, and futile transplantations; it also accelerates access to transplantation for the sickest patients. Several points remain unresolved: both the MELD and Liver scores may be improved. The variability of the MELD score related to different laboratory assay methods requires harmonization between laboratories.

Changing kidney allocation policy in France: the value of simulation.

This paper advocates the value of simulation to promote changes in kidney allocation. Due to the scarcity of organs and to the competition between transplantation centers to obtain the best organs for their patients, any change in organ allocation policy remains a sensitive issue in public health decision-making. Organ allocation is not easily available for prospective experimental study. Observational stud-ies only support limited changes. A simulation tool in this context permits the comparison of observed results against simulated ones. In our experience in France, it has shown to be a helpful tool during the allocation design phase providing objective facts for the debates and increasing the potential for change.