Waitlist Outcomes in Candidates With Rare Causes of Heart Failure After Implementation of the 2018 French Heart Allocation Scheme.

BACKGROUND: In 2018, an algorithm-based allocation system for heart transplantation (HT) was implemented in France. Its effect on access to HT of patients with rare causes of heart failure (HF) has not been assessed. METHODS: In this national study, including adults listed for HT between 2018 and 2020, we analyzed waitlist and posttransplant outcomes of candidates with rare causes of HF (restrictive cardiomyopathy [RCM], hypertrophic cardiomyopathy, and congenital heart disease). The primary end point was death on the waitlist or delisting for clinical deterioration. Secondary end points included access to HT and posttransplant mortality. The cumulative incidence of waitlist mortality estimated with competing risk analysis and incidence of transplantation were compared between diagnosis groups. The association of HF cause with outcomes was determined by Fine-Gray or Cox models. RESULTS: Overall, 1604 candidates were listed for HT. At 1 year postlisting, 175 patients met the primary end point and 1040 underwent HT. Candidates listed for rare causes of HF significantly differed in baseline characteristics and had more frequent score exceptions compared with other cardiomyopathies (31.3%, 32.0%, 36.4%, and 16.7% for patients with hypertrophic cardiomyopathy, RCM, congenital heart disease, and other cardiomyopathies). The cumulative incidence of death on the waitlist and probability of HT were similar between diagnosis groups (P=0.17 and 0.40, respectively). The adjusted risk of death or delisting for clinical deterioration did not significantly differ between candidates with rare and common causes of HF (subdistribution hazard ratio (HR): hypertrophic cardiomyopathy, 0.51 [95% CI, 0.19-1.38]; P=0.18; RCM, 1.04 [95% CI, 0.42-2.58]; P=0.94; congenital heart disease, 1.82 [95% CI, 0.78-4.26]; P=0.17). Similarly, the access to HT did not significantly differ between causes of HF (hypertrophic cardiomyopathy: HR, 1.18 [95% CI, 0.92-1.51]; P=0.19; RCM: HR, 1.19 [95% CI, 0.90-1.58]; P=0.23; congenital heart disease: HR, 0.76 [95% CI, 0.53-1.09]; P=0.14). RCM was an independent risk factor for 1-year posttransplant mortality (HR, 2.12 [95% CI, 1.06-4.24]; P=0.03). CONCLUSIONS: Our study shows equitable waitlist outcomes among HT candidates whatever the indication for transplantation with the new French allocation scheme.

Effect of Cardiac Arrest in Brain-dead Donors on Kidney Graft Function.

BACKGROUND: Cardiac arrest (CA) causes renal ischemia in one-third of brain-dead kidney donors before procurement. We hypothesized that the graft function depends on the time interval between CA and organ procurement. METHODS: We conducted a retrospective population-based study on a prospectively curated database. We included 1469 kidney transplantations from donors with a history of resuscitated CA in 2015-2017 in France. CA was the cause of death (primary CA) or an intercurrent event (secondary CA). The main outcome was the percentage of delayed graft function, defined by the use of renal replacement therapy within the first week posttransplantation. RESULTS: Delayed graft function occurred in 31.7% of kidney transplantations and was associated with donor function, vasopressors, cardiovascular history, donor and recipient age, body mass index, cold ischemia time, and time to procurement after primary cardiac arrest. Short cold ischemia time, perfusion device use, and the absence of cardiovascular comorbidities were protected by multivariate analysis, whereas time <3 d from primary CA to procurement was associated with delayed graft function (odds ratio 1.38). CONCLUSIONS: This is the first description of time to procurement after a primary CA as a risk factor for delayed graft function. Delaying procurement after CA should be evaluated in interventional studies.

[Fundamentals of organ and tissue procurement]. / Les fondamentaux concernant le prélèvement d'organes et de tissus.

Transplantation is the treatment of choice for the terminal evolution of many organ failures. This recent solution has been deployed in France, essentially from deceased donors, in a state of encephalic death or after circulatory arrest. The ethical issues raised by these practices are strictly regulated. The Agence de la biomédecine, in conjunction with healthcare professionals and supervisory authorities, is the public operator in charge of organizing and developing the procurement activities. The volume of activity, severely disrupted by the Covid-19 pandemic, is now back on the rise. The 2022-2026 transplant plan sets ambitious but realistic targets to meet the needs of waiting patients.

Impact of the COVID-19 pandemic on liver transplant waitlist outcome in France.

The objective of this study was to investigate the impact of the COVID-19 pandemic on the outcome of patients on the liver transplantation (LT) waitlist in 2020 in France, in particular, the incidence of deaths and delisting for worsening condition, depending on the allocation score component. The 2020 cohort of patients on the waiting list was compared with the 2018/2019 cohorts. 2020 saw fewer LTs than in either 2019 or 2018 (1128, 1356, and 1325, respectively), together with fewer actual brain dead donors (1355, 1729, and 1743). In 2020, deaths or delisting for worsening condition increased significantly versus 2018/2019 (subdistribution hazard ratio 1.4, 95% confidence interval [CI] 1.2-1.7), after adjustment for age, place of care, diabetes, blood type, and score component, although COVID-19-related mortality was low. This increased risk mainly concerned patients with hepatocellular carcinoma (1.52, 95% CI 1.22-1.90), with 650 MELD exception points (2.19, 95% CI 1.08-4.43), and especially those without HCC and MELD scores from 25 to 30 (3.36 [95% CI 1.82-6.18]). In conclusion, by significantly decreasing LT activity in 2020, the COVID-19 pandemic increased the number of waitlist deaths and delisting for worsening condition, and significantly more for particular components of the score, including intermediate severity cirrhosis.

Emergency management of patients with Glanzmann thrombasthenia: consensus recommendations from the French reference center for inherited platelet disorders.

Glanzmann thrombasthenia (GT) is a genetic bleeding disorder characterised by severely reduced/absent platelet aggregation in response to multiple physiological agonists. The severity of bleeding in GT varies markedly, as does the emergency situations and complications encountered in patients. A number of emergency situations may occur in the context of GT, including spontaneous or provoked bleeding, such as surgery or childbirth. While general management principles apply in each of these settings, specific considerations are essential for the management of GT to avoid escalating minor bleeding events. These recommendations have been developed from a literature review and consensus from experts of the French Network for Inherited Platelet Disorders, the French Society of Emergency Medicine, representatives of patients' associations, and Orphanet to aid decision making and optimise clinical care by non-GT expert health professionals who encounter emergency situations in patients with GT.

[French legislation on organ transplantation]. / Épidémiologie de la transplantation d'organes en France.

EPIDEMIOLOGY OF ORGAN TRANSPLANTATION IN France. The number of transplants has been rising for ten years. Nevertheless, the stabilization of the number of brain-dead people identified as potential organ donors, and the persistently high rate of opposition to organ removal, accentuate the substantial gap between the number of candidates for transplantation and the number of transplants performed each year. Strategies are being used to reduce this imbalance, such as broadening the brain-dead donors selection criteria and increasing procurement from living donors and deceased donors after circulatory death. Unfortunately, the Covid-19 pandemic has further aggravated the difference between the supply of transplants and the need.

ÉPIDÉMIOLOGIE DE LA TRANSPLANTATION D'ORGANES EN France. Le nombre de greffes augmente depuis dix ans. Néanmoins, la stabilisation du nombre de personnes en état de mort encéphalique identifiées comme donneurs d'organes potentiels et le taux d'opposition au prélèvement d'organes qui reste élevé accentuent l'écart conséquent existant entre les candidats à une greffe et le nombre de greffes réalisées chaque année. L'élargissement des critères de sélection des donneurs en état de mort encéphalique et l'augmentation du prélèvement chez des donneurs vivants, ou décédés après arrêt circulatoire, sont autant de stratégies mises en place pour réduire le déséquilibre entre l'offre de greffes et les besoins, déséquilibre encore majoré par la pandémie de Covid-19.

The new French kidney allocation system for donations after brain death: Rationale, implementation, and evaluation.

In recent decades, the allocation policies of many countries have moved from center-based to patient-based approaches. The new French kidney allocation system (KAS) of donations after brain death for adult recipients, implemented in 2015, was principally designed to introduce a unified allocation score (UAS) to be applied locally for one kidney and nationally for the other and to replace regional borders by a new geographical model. The new KAS balances dialysis duration and waiting time to compensate for listing delays and provides more effective longevity matching between donors and recipients with better HLA and age matching. We report these changes, with their rationale and main results. Results show improved HLA matching for young recipients and more rapid access to transplant for older recipients. Young recipients also had better access to transplantation. Transplant access decreased for recipients aged 60-69 and required tuning of KAS parameters. In conclusion, our results strongly indicate that national or adequately broad geographic allocation areas, combined with multiplicative interactions between allocation criteria, permit multivariate optimization of organ allocation and thus improve national kidney sharing and balance HLA matching and age matching, at the price of longer cold ischemic times and more logistical constraints than with local allocation.

[Perspectives for future development of the kidney paired donation programme in France]. / Perspectives pour une évolution du programme de don croisé de reins en France.

Almost one third of kidney donation candidates are incompatible (HLA and/or ABO) with their directed recipient. Kidney paired donation allows potential donors to be exchanged and gives access to a compatible kidney transplant. The Bioethics Law of 2011 authorised kidney paired donation in France with reciprocity between 2 incompatible "donor-recipient" pairs. A limited number of transplants have been performed due to a too restricted authorization compared to other European practices. This study presents the perspectives of the new Bioethics Law, enacted in 2021, which increases the authorised practices for kidney paired donation in France. The two simulated evolutions are the increase of the number of pairs involved in a kidney paired donation to 6 (against 2 currently) and the use of a deceased donor as a substitution to one of living donor. Different scenarios are simulated using data from the Agence de la Biomedecine; incompatible pairs registered in the kidney paired donation programme in France between December 2013 and February 2018 (78 incompatible pairs), incompatible transplants performed during the same period (476 incompatible pairs) and characteristics of deceased donors as well as proposals made over this period. Increasing the number of pairs has a limited effect on the number of transplants, which increases from 18 (23% of recipients) in the current system to 25 (32% of recipients) when 6 pairs can be involved. The use of a deceased donor significantly increases the number of transplants to 41 (52% of recipients). This study makes it possible to evaluate the increase in possibilities of kidney transplants by kidney paired donation following the new bioethics law. A working group and an information campaign for professionals and patients will be necessary for its implementation.

France's New Lung Transplant Allocation System: Combining Equity With Proximity by Optimizing Geographic Boundaries Through the Supply/Demand Ratio.

A new lung allocation system was introduced in France in September 2020. It aimed to reduce geographic disparities in lung allocation while maintaining proximity. In the previous two-tiered priority-based system, grafts not allocated through national high-urgency status were offered to transplant centres according to geographic criteria. Between 2013 and 2018, significant geographic disparities in transplant allocation were observed across transplant centres with a mean number of grafts offered per candidate ranging from 1.4 to 5.2. The new system redistricted the local allocation units according to supply/demand ratio, removed regional sharing and increased national sharing. The supply/demand ratio was defined as the ratio of lungs recovered within the local allocation unit to transplants performed in the centre. A driving time between the procurement and transplant centres of less than 2 h was retained for proximity. Using a brute-force algorithm, we designed new local allocation units that gave a supply/demand ratio of 0.5 for all the transplant centres. Under the new system, standard-deviation of graft offers per candidate decreased from 0.9 to 0.5 (p = 0.08) whereas the mean distance from procurement to transplant centre did not change. These preliminary results show that a supply/demand ratio-based allocation system can achieve equity while maintaining proximity.

Procurement of Uterus in a Deceased Donor Multi-Organ Donation National Program in France: A Scarce Resource for Uterus Transplantation?

Uterus transplantation is a new possibility for women suffering from absolute uterine infertility to become pregnant and have children. In the case of a deceased donor, a list of exclusion criteria is defined to ensure the high quality of the uterus graft. This study evaluates the number of potentially available uterus grafts based on the pre-defined exclusion criteria in a national deceased donor multi-organ donation program in France. We analyzed the data reported in the CRISTAL database regarding all women aged 18 to 60 on whom organ procurement was performed between 2014 and 2019. Potential deceased women donors were classified into three categories: very ideal donor, ideal donor, and expanded criteria donor. Between 2014 and 2019, 4544 women underwent organ procurement. Using the very ideal donor, ideal donor, and expanded criteria donor classification, we found that, respectively, only 124, 264, and 936 donors were potentially eligible for UTx. This represents 2.8 per million people (PMP) very ideal donors, 3.8 PMP ideal donors, 8.6 PMP expanded criteria donors (ECDs). The restricted number of grafts requires a complementary strategy of living and deceased donors to meet the demand of all women with AUI.

Critical pathways for controlled donation after circulatory death in France.

INTRODUCTION: In 2015, France authorised controlled donation after circulatory death (cDCD) according to a nationally approved protocol. The aim of this study is to provide an overview from the perspective of critical care specialists of cDCD. The primary objective is to assess how the organ donation procedure affects the withdrawal of life-sustaining therapies (WLST) process. The secondary objective is to assess the impact of cDCD donors' diagnoses on the whole process. MATERIAL AND METHODS: This 2015-2019 prospective observational multicentre study evaluated the WLST process in all potential cDCD donors identified nationwide, comparing 2 different sets of subgroups: 1- those whose WLST began after organ donation was ruled out vs. while it was still under consideration; 2- those with a main diagnosis of post-anoxic brain injury (PABI) vs. primary brain injury (PBI) at the time of the WLST decision. RESULTS: The study analysed 908 potential cDCD donors. Organ donation remained under consideration at WLST initiation for 54.5% of them with longer intervals between their WLST decision and its initiation (2 [1-4] vs. 1 [1-2] days, P < 0.01). Overall, 60% had post-anoxic brain injury. Time from ICU admission to WLST decision was longer for primary brain injury donors (10 [4-21] vs. 6 [4-9] days, P < 0.01). Median time to death (agonal phase) was 15 [15-20] min. CONCLUSIONS: French cDCD donors are mostly related to post-anoxic brain injury. The organ donation process does not accelerate WLST decision but increases the interval between the WLST decision and its initiation.

Long-term survival benefit from dual kidney transplantation using kidneys from donors with very extended criteria-a French cohort between 2002 and 2014.

BACKGROUND: This national multicentre retrospective cohort study aimed to assess the long-term outcomes of dual kidney transplantation (DKT) and compare them with those obtained from single kidney transplantation (SKT). METHODS: Our first analysis concerned all first transplants performed between May 2002 and December 2014, from marginal donors, defined as brain death donors older than 65 years, with an estimated glomerular filtration rate (eGFR) lower than 90 mL/min/1.73 m2. The second analysis was restricted to transplants adequately allocated according to the French DKT program based on donor eGFR: DKT for eGFR between 30 and 60, SKT for eGFR between 60 and 90 mL/min/1.73 m2. Recipients younger than 65 years or with a panel-reactive antibody percentage ≥25% were excluded. RESULTS: The first analysis included 461 DKT and 1131 SKT. DKT donors were significantly older (77.6 versus 74 years), had a more frequent history of hypertension and a lower eGFR (55.1 versus 63.6 mL/min/1.73 m2). While primary nonfunction and delayed graft function did not differ between SKT and DKT, 1-year eGFR was lower in SKT recipients (39 versus 49 mL/min/1.73 m2, P < 0.001). Graft survival was significantly better in DKT, even after adjustment for recipient and donor risk factors. Nevertheless, patient survival did not differ between these groups. The second analysis included 293 DKT and 687 SKT adequately allocated with donor eGFR and displayed similar results but with a smaller benefit in terms of graft survival. CONCLUSIONS: In a context of organ shortage, DKT is a good option for optimizing the use of kidneys from very expanded criteria donors.

COVID-19 pandemic and worldwide organ transplantation: a population-based study.

BACKGROUND: Preliminary data suggest that COVID-19 has reduced access to solid organ transplantation. However, the global consequences of the COVID-19 pandemic on transplantation rates and the effect on waitlisted patients have not been reported. We aimed to assess the effect of the COVID-19 pandemic on transplantation and investigate if the pandemic was associated with heterogeneous adaptation in terms of organ transplantation, with ensuing consequences for waitlisted patients. METHODS: In this population-based, observational, before-and-after study, we collected and validated nationwide cohorts of consecutive kidney, liver, lung, and heart transplants from 22 countries. Data were collected from Jan 1 to Dec 31, 2020, along with data from the same period in 2019. The analysis was done from the onset of the 100th cumulative COVID-19 case through to Dec 31, 2020. We assessed the effect of the pandemic on the worldwide organ transplantation rate and the disparity in transplant numbers within each country. We estimated the number of waitlisted patient life-years lost due to the negative effects of the pandemic. The study is registered with ClinicalTrials.gov, NCT04416256. FINDINGS: Transplant activity in all countries studied showed an overall decrease during the pandemic. Kidney transplantation was the most affected, followed by lung, liver, and heart. We identified three organ transplant rate patterns, as follows: countries with a sharp decrease in transplantation rate with a low COVID-19-related death rate; countries with a moderate decrease in transplantation rate with a moderate COVID-19-related death rate; and countries with a slight decrease in transplantation rate despite a high COVID-19-related death rate. Temporal trends revealed a marked worldwide reduction in transplant activity during the first 3 months of the pandemic, with losses stabilising after June, 2020, but decreasing again from October to December, 2020. The overall reduction in transplants during the observation time period translated to 48 239 waitlisted patient life-years lost. INTERPRETATION: We quantified the impact of the COVID-19 pandemic on worldwide organ transplantation activity and revealed heterogeneous adaptation in terms of organ transplantation, both at national levels and within countries, with detrimental consequences for waitlisted patients. Understanding how different countries and health-care systems responded to COVID-19-related challenges could facilitate improved pandemic preparedness, notably, how to safely maintain transplant programmes, both with immediate and non-immediate life-saving potential, to prevent loss of patient life-years. FUNDING: French national research agency (INSERM) ATIP Avenir and Fondation Bettencourt Schueller.