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Controlled donation after circulatory death (cDCD) is used for "extended criteria" donors with poorer kidney transplant outcomes. The French cDCD program started in 2015 and is characterized by normothermic regional perfusion, hypothermic machine perfusion, and short cold ischemia time. We compared the outcomes of kidney transplantation from cDCD and brain-dead (DBD) donors, matching cDCD and DBD kidney transplants by propensity scoring for donor and recipient characteristics. The matching process retained 442 of 499 cDCD and 809 of 6185 DBD transplantations. The DGF rate was 20% in cDCD recipients compared with 28% in DBD recipients (adjusted relative risk [aRR], 1.43; 95% confidence interval [CI] 1.12-1.82). When DBD transplants were ranked by cold ischemia time and machine perfusion use and compared with cDCD transplants, the aRR of DGF was higher for DBD transplants without machine perfusion, regardless of the cold ischemia time (aRR with cold ischemia time18 h, 1.57; 95% CI 1.20-2.03, vs aRR with cold ischemia time ≥18 h, 1.79; 95% CI 1.31-2.44). The 1-year graft survival rate was similar in both groups. Early outcome was better for kidney transplants from cDCD than from matched DBD transplants with this French protocol.

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.

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 Conclusions In a context of organ shortage, DKT is a good option for optimizing the use of kidneys from very expanded criteria donors.

BACKGROUND In France, the need for continuous monitoring of transplant center performance has recently become apparent. Cumulative sum (CUSUM) monitoring of transplantation is already been used to monitor transplant outcomes in the United Kingdom and in the United States. Because CUSUM monitoring can be applied by different methods, the objective was to assess and compare the performance of different CUSUM methods for detecting higher than expected (ie, excessive) graft failure rates. METHODS Data come from the French transplant registry. Lung and kidney transplants in 2011-2013 constituted the control cohort, and those in 2014-2016 the observed cohort. The performance of CUSUM monitoring, according to center type and predefined control limits, was measured by simulation. The outcome monitored was 3-month graft failure. RESULTS In a low-volume center with a low failure rate, 3 different types of control limits produced successful detection rates of excessive graft failures of 15%, 62%, and 73% and false alarm rates of 5%, 40%, and 52%, with 3, 1, and 1 excess failures necessary before a signal occurred. In a high-volume center with a high failure rate, successful detection rates were 83%, 93%, and 100% and false alarm rates were 5%, 16%, and 69%, with 6, 13, and 17 excess failures necessary before a signal occurred. CONCLUSIONS CUSUM performances vary greatly depending on the type of control limit used. A new control limit set to maximize specificity and sensitivity of detection is an appropriate alternative to those commonly used. Continued attention is necessary for centers with characteristics making it difficult to obtain adequate sensitivity or sufficiently prompt response.

Background Although kidney transplantation (KT) is considered the best treatment for end-stage renal disease (ESRD), there are concerns about its benefit in the obese population because of the increased incidence of post-transplant adverse events. We compared patients who underwent KT versus patients awaiting KT on dialysis. Methods We estimated the life expectancy [restricted mean survival time (RMST)] for a 10-year follow-up by matching on time-dependent propensity scores. The primary outcome was time to death. Results In patients with a body mass index (BMI) ≥30 kg/m2 (n = 2155 patients per arm), the RMST was 8.23 years [95% confidence interval (CI) 8.05–8.40] in the KT group versus 8.00 years (95% CI 7.82–8.18) in the awaiting KT group, a difference of 2.71 months (95% CI −0.19–5.63). In patients with a BMI ≥35 kg/m2 (n = 212 patients per arm), we reported no significant difference [8.56 years (95% CI 7.96–9.08) versus 8.66 (95% CI 8.10–9.17)]. Hence we deduced that KT in patients with a BMI between 30 and 35 kg/m2 was beneficial in terms of life expectancy. Conclusion Regarding the organ shortage, KT may be questionable for those with a BMI ≥35 kg/m2. These results do not mean that a BMI ≥35 kg/m2 should be a barrier to KT, but it should be accounted for in allocation systems to better assign grafts and maximize the overall life expectancy of ESRD patients.

International audience; Despite national guidelines, medical practices and kidney transplant waiting list registration policies may differ from one dialysis/transplant unit to another. Benefit risk assessment variations, especially for elderly patients, have also been described. The aim of this study was to identify sources of variation in early kidney transplant waiting list registration in France. Among 16,842 incident patients during the period 2016-2017, 4,386 were registered on the kidney transplant waiting list at the start of, or during the first year after starting, dialysis (26%). We developed various log-linear mixed effect regression models on 3 levels: patients, dialysis networks and transplant centers. Variability was expressed as variance from the random intercepts (+/- standard error). Although patient characteristics have an important impact on the likelihood of registration, the overall magnitude of variability in registration was low and shared by dialysis networks and transplant centers. Between-transplant center variability (0.23 +/- 0.08) was 1.8 higher than between-dialysis network variability (0.13+/- 0.004). Older age was associated with a lower probability of registration and greater variability between networks (0.04 , 0.20, 0.93 in the 18-64, 65-74 and 75-84 age groups) . Targeted interventions should focus on elderly patients and/or certain regions with greater variability in waiting list access.

In this study we aimed to compare patient and graft survival of kidney transplant recipients who received a kidney from a living-related donor (LRD) or living-unrelated donor (LUD). Adult patients in the ERA-EDTA Registry who received their first kidney transplant in 1998-2017 were included. Ten-year patient and graft survival were compared between LRD and LUD transplants using Cox regression analysis. In total, 14 370 patients received a kidney from a living donor. Of those, 9212 (64.1%) grafts were from a LRD, 5063 (35.2%) from a LUD and for 95 (0.7%), the donor type was unknown. Unadjusted five-year risks of death and graft failure (including death as event) were lower for LRD transplants than for LUD grafts: 4.2% (95% confidence interval [CI]: 3.7-4.6) and 10.8% (95% CI: 10.1-11.5) versus 6.5% (95% CI: 5.7-7.4) and 12.2% (95% CI: 11.2-13.3), respectively. However, after adjusting for potential confounders, associations disappeared with hazard ratios of 0.99 (95% CI: 0.87-1.13) for patient survival and 1.03 (95% CI: 0.94-1.14) for graft survival. Unadjusted risk of death-censored graft failure was similar, but after adjustment, it was higher for LUD transplants (1.19; 95% CI: 1.04-1.35). In conclusion, patient and graft survival of LRD and LUD kidney transplant recipients was similar, whereas death-censored graft failure was higher in LUD. These findings confirm the importance of both living kidney donor types.

International audience; End stage kidney disease increase the risk of COVID-19 related death but how the kidney replacement strategy should be adapted during the pandemic is unknown. Chronic hemodialysis makes social distancing difficult to achieve. Alternatively, kidney transplantation could increase the severity of COVID-19 due to therapeutic immunosuppression and contribute to saturation of intensive care units. For these reasons, kidney transplantation was suspended in France during the first epidemic wave. Here, we retrospectively evaluated this strategy by comparing the overall and COVID-19 related mortality in kidney transplant recipients and candidates over the last three years. Cross-interrogation of two national registries for the period 1 March and 1 June 2020, identified 275 deaths among the 42812 kidney transplant recipients and 144 deaths among the 16210 candidates. This represents an excess of deaths for both populations, as compared with the same period the two previous years (mean of two previous years: 253 in recipients and 112 in candidates). This difference was integrally explained by COVID-19, which accounted for 44% (122) and 42% (60) of the deaths in recipients and candidates, respectively. Taking into account the size of the two populations and the geographical heterogeneity of virus circulation, we found that the excess of risk of death due to COVID-19 was similar for recipients and candidates in high viral risk area but four-fold higher for candidates in the low viral risk area. Thus, in case of a second epidemic wave, kidney transplantation should be suspended in high viral risk areas but maintained outside those areas, both to reduce the excess of deaths of candidates and avoid wasting precious resources.

This study aimed to evaluate how 5 preservation solutions for static cold storage affected kidney transplant outcomes. It included all first single kidney transplants during 2010-2014 from donations after brain death in the French national transplant registry, excluding preemptive transplants and transplants of kidneys preserved with a hypothermic perfusion machine. The effects of each preservation solution on delayed graft function (DGF) and 1-year transplant failure were evaluated with hierarchical multivariable logistic regression models. The study finally included 7640 transplanted kidneys: 3473 (45.5%) preserved with Institut Georges Lopez-1 solution (IGL-1), 773 (10.1%) with University of Wisconsin solution, 731 (9.6%) with Solution de Conservation des Organes et Tissus (SCOT, organ and tissue preservation solution), 2215 (29.0%) with Celsior, and 448 (5.9%) with histidine-tryptophan-ketoglutarate. Primary nonfunction rates did not differ by solution. After adjustment for donor, recipient, and transplant characteristics, the DGF risk was significantly lower with IGL-1 than with all other solutions (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.48-0.64). Conversely, SCOT was associated with a DGF risk significantly higher than the other solutions (OR 2.69, 95% CI 2.21-3.27) and triple that of IGL-1 (OR 3.37, 95% CI 2.72-4.16). One year after transplantation, the transplant failure rate did not differ significantly by preservation solution. The difference between the groups for 1-year mean creatinine clearance was not clinically relevant.

In 2012, an expert working group from the French Transplant Health Authority recommended the use of hypothermic machine perfusion (HMP) to improve kidney preservation and transplant outcomes from expanded criteria donors, deceased after brain death. This study compares HMP and cold storage (CS) effects on delayed graft function (DGF) and transplant outcomes. We identified 4,316 kidney transplants from expanded criteria donors (2011-2014) in France through the French Transplant Registry. DGF occurrence was analyzed with a logistic regression, excluding preemptive transplants. One-year graft failure was analyzed with a Cox regression. A subpopulation of 66 paired kidneys was identified: one preserved by HMP and the other by CS from the same donor. Kidneys preserved by HMP (801) vs CS (3515) were associated with more frequent recipient comorbidities and older donors and recipients. HMP had a protective effect against DGF (24% in HMP group and 38% in CS group, OR = 0.49 [0.40-0.60]). Results were similar in the paired kidneys (OR = 0.23 [0.04-0.57]). HMP use decreased risk for 1-year graft failure (HR = 0.77 [0.60-0.99]). Initial hospital stays were shorter in the HMP group (P < 0.001). Our results confirm the reduction in DGF occurrence among expanded criteria donors kidneys preserved by HMP.

Transplantation represents the last option for patients with advanced heart failure. We assessed between-center disparities in access to heart transplantation in France 1 year after registration and evaluated the contribution of factors to these disparities. Adults (n = 2347) registered on the French national waiting list between January 1, 2010, and December 31, 2014, in the 23 transplant centers were included. Associations between candidate and transplant center characteristics and access to transplantation were assessed by proportional hazards frailty models. Candidate blood groups O and A, sensitization, and body mass index ≥30 kg/m2 were independently associated with lower access to transplantation, while female gender, severity of heart failure, and high serum bilirubin levels were independently associated with greater access to transplantation. Center factors significantly associated with access to transplantation were heart donation rate in the donation service area, proportion of high-urgency candidates among listed patients, and donor heart offer decline rate. Between-center variability in access to transplantation increased by 5% after adjustment for candidate factors and decreased by 57% after adjustment for center factors. After adjustment for candidate and center factors, five centers were still outside of normal variability. These findings will be taken into account in the future French heart allocation system.

International audience; Coronary angiography (CA) is the gold standard evaluation of coronary artery disease in potential multi-organ donors. This use of iodinated contrast media could lead to contrast-induced acute kidney injury and consequently to delayed graft function (DGF). All patients in France who received a kidney from a 45-70-year-old donor without medical contraindication for cardiac donation and with at least one cardiovascular risk factor were included. Recipients of preemptive kidney transplant or multi-organ transplant, or who died within the first 8 days post-transplantation were excluded. Data were obtained from CRISTAL database. From March 2012 to June 2014, 892 kidneys from 483 donors were transplanted. DGF was reported in 38.9% of the 375 kidney recipients grafted with a kidney from the 217 donors who had CA and in 45.5% of the 440 kidney recipients who received a kidney from the 257 donors without CA. Multivariate analysis showed that CA or repeated injection of iodinated contrast media did not influence the risk of DGF. CA did not increase the risk of primary non-function, the duration of DGF or post-transplantation hospital stay and did not affect the graft function at 1 year. Evaluation of potential multi-organ donors with CA does not affect kidney graft outcomes.

It has been suggested that dual kidney transplantation (DKT) improves outcomes for expanded criteria donor (ECD) kidneys. However, no criteria for allocation to single or dual transplantation have been assessed prospectively. The strategy of DKT remains underused and potentially eligible kidneys are frequently discarded. We prospectively compared 81 DKT and 70 single kidney transplant (SKT) receiving grafts from ECD donors aged >65 years, allocated according to donor estimated glomerular filtration rate (eGFR): DKT if eGFR between 30 and 60 mL/min, SKT if eGFR greater than 60 mL/min. Patient and graft survival were similar in the two groups. In the DKT group, 13/81 patients lost one of their two kidneys due to hemorrhage, arterial or venous thrombosis. Mean eGFR at month 12 was similar in the DKT and SKT groups (47.8 mL/min and 46.4 mL/min, respectively). Simulated allocation of kidneys according to criteria based on day 0 donor parameters such as those described by Remuzzi et al., Andres et al. and UNOS, did not indicate an improvement in 12-month eGFR compared to our allocation based on donor eGFR.

En 2006, 4 400 malades, dont 4 % d’enfants, ont beneficie d’une greffe d’organe en France. Cette activite est regulee par l’Agence de la biomedecine, creee en 2005, et qui a repris l’ensemble des activites de l’Etablissement francais des Greffes en matiere de prelevement et de greffe. Elle a pour missions, entre autres, de gerer la liste nationale des personnes en attente de greffe et le registre national des refus de prelevement, de coordonner les prelevements d’organes, de repartir et attribuer les greffons et d’evaluer les resultats. En France comme ailleurs, l’offre de greffons reste inferieure aux besoins meme si l’activite de prelevement et de greffe continue d’augmenter significativement.

BACKGROUND Major inequalities in access to renal transplant waiting lists have been demonstrated among adult patients both in the USA and Europe. In this French nationwide study, we sought to ascertain the influence of patient and centre characteristics. METHODS We included all children (

BACKGROUND Little is known about the socioprofessional situation of adult-aged kidney-transplanted children. This nationwide French cohort study documented the socioprofessional outcomes of adults who underwent kidney transplantation before age 16 years between 1985 and 2002. METHODS Of 890 patients, 624 were eligible for a questionnaire and 374 completed it (response rate=60%; men=193 and women=181). The data were compared with the French general population using an indirect standardization matched for gender, age, and period. RESULTS The median ages were 27.1 years at survey time and 12.3 years at first transplantation. Of the participants, 31.1% lived with a partner (vs. 52.2%; P

In France, the bioethic law of 2004 authorized the extension of the living donor (LD) pool to members of the extended family and any person justifying of a 2 year-long relationship. The number of living donor kidney transplantation (LDKT) increased until reaching a maximum of 246 grafts in 2006 (9% of total activity). Two years later, in 2008, LKG activity slowed down to 7.6% of the total activity (222 grafts).We analyzed all LDKT carried out in France since 2000 according to various indicators. In addition, a questionnaire was sent to renal transplant teams in order to identify potential causes for the decrease in LKG observed in France.From 2000 to 2006, over 1400 LDKT were performed in France. However, donor to recipient relations show that the large increase observed in 2006 was not linked to the extension of the LD pool. LDKT activity then started decreasing as soon as 2007. The questionnaire was sent back by 40/44 (91%) renal transplant teams. Their answers led to the identification of potential constrain impacting LDKT activity in France. Among these obstacles: workload and time-consuming to prepare the transplantation and the donor, ethical constrains and lack of appropriate communication and information delivered to the professionals.The important increase in LKG activity in 2006 is not clearly understood. However, several approaches to develop the activity in the next years have been identified.

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.

International audience; BACKGROUND: The proportion of transplant candidates aged 60 years and over listed on the kidney transplant waiting list is increasing, as is the proportion of potential organ donors of this age. We compared in elderly recipients: kidney graft survival of expanded criteria deceased donor (ECD) to nonexpanded criteria deceased donor (NECD), and survival of patients receiving these grafts to those remaining on the waiting list. METHODS: Between 1996 and 2004, a total of 3001 patients aged 60 years and over were registered on the French kidney transplant waiting list, of which 2099 were transplanted. The data were analyzed using Kaplan-Meier methods and Cox models. RESULTS: ECD was defined as presenting at least one of the following factors: age over 60 years than less (relative risk [RR]=1.26; P=0.02), history of arterial hypertension vs. absence (RR=1.34; P=0.01), history of diabetes mellitus vs. absence (RR=1.6; P=0.01), and death due to cerebrovascular accident vs. other cause (RR=1.3; P=0.01). Patients who did not undergo transplantation had an adjusted risk of death 2.54 times higher than that of transplanted patients of the same age (P

In France, the use of peritoneal dialysis (PD) as the first-choice treatment varies greatly between districts, as it is already known to do between countries. Baseline clinical factors associated with choice of first modality were analyzed in 10815 new end-stage renal disease patients in 59 districts. To describe practices at the district level, we used an agglomerative hierarchical classification, with proximity defined by a likelihood-ratio test that compared multivariate logistic regressions of the following factors: age, gender, diabetes, congestive heart failure, severe behavioral disorders, mobility, and employment. To propose a typology, each cluster of districts was described by a multivariate logistic regression. While populations starting PD in France, as elsewhere, are more likely to be young or employed, they are also more likely to be elderly or have congestive heart failure or severe behavioral disorders. Overall, 14% of patients start with PD, but this rate varies significantly across districts, from 0% to 45%. A specific combination of factors was associated with the first-choice modality in each group of districts. This study highlights the lack of consensual medical criteria for this choice and the likelihood that nonmedical factors may explain the observed differences. The high variability suggests that PD can be used in almost all clinical conditions. Accordingly, patient preference should play a more important role in the decision-making process.