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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.

Points essentiels Les regles anterieures de repartition des greffes laissaient une large place a la priorite locale, et la gestion finale a l’equipe, induisant de grandes disparites inter-regionales. Une etude prospective des deces et des retraits de liste d’attente pour aggravation de la maladie initiale (2003–2005) a permis de valider sur les donnees francaises l’utilisation du score MELD (Model for End-stage Liver Disease), qui permet de predire la survie spontanee des cirrhotiques a 3 mois, et qui est utilise aux Etats-Unis pour l’attribution des greffons hepatiques depuis 2002. La reflexion de l’Agence de biomedecine et des equipes de transplantation hepatique a conduit a mettre en place un score d’attribution des greffons hepatiques, a compter du 6 mars 2007. Ce score Foie tient compte du score MELD pour les cirrhoses, de la duree d’attente et du stade TNM pour les cancers, d’un score specifique pour les maladies metaboliques non cirrhotiques ainsi que pour les retransplantations electives, ainsi que d’aspects logistiques comme la distance entre le lieu de prelevement et celui de greffe. Un premier bilan a 5 mois indique que le score Foie permet de diminuer les deces et les retraits de liste pour aggravation, de diminuer le nombre de greffes « prematurees », d’accelerer l’acces a la greffe des malades les plus graves. Plusieurs questions restent en suspens : le score MELD et le score Foie peuvent etre ameliores, la variabilite du MELD liee aux methodes de dosage doit faire l’objet d’une normalisation entre laboratoires.

OBJECTIVE: To evaluate changes in the balance between supply and demand for corneal grafts over the last 15 years in France in the light of the measures implemented and the 2005 national and regional audit. Materials and methods: Corneal transplantation activities were estimated, mainly from a national prospective survey of ophthalmologists (1991-1994), annual surveys of ophthalmologists (1995-2000), tissue banks (1996-2005), and the national waiting list for surgery (since 2000). RESULTS: In 2005, the main indicators available were consistent with a stabilization in the number of candidates added to the waiting list every year (4606 in 2005), accompanied by a large increase in the number of grafts procured (9264 in 2005). There was also a substantial increase in quality testing of these grafts, leading to a high rate of rejection (49.5% of the procured grafts). In addition, the number of grafts exported decreased to a very low level (213 in 2005). The percentage of malades registered on the waiting list who received grafts in the same year also increased (68.5% in 2005). Once the waiting list had been updated, 3016 malades remained on the list at the beginning of July 2006. The gap between supply and demand for corneal transplantation has therefore narrowed. Two actions made particularly large contributions to these changes: the creation in 2000 of 120 full-time staff positions in hospital coordination teams, which has had a major impact on procurement rates; and the organization of the tissue bank sector, making it possible to guarantee the quality and distribution of grafts. CONCLUSION: Corneal procurement and transplantation activities seem to have reached equilibrium in France. A reliable estimation of demand, particularly at the regional level, has led the French agency in charge of tissue transplantation to modify the functioning of the national corneal transplant waiting list, with tissue banks now allowed access to declare transfers and the temporary registration of malades on the list to limit stagnation.

BACKGROUND: The routes of transmission of human herpes virus 8 (HHV-8) remain unclear. In particular, HHV-8 transmission by blood components and organ transplantation is still debated and raises public health issues. The objective of this study was to determine the prevalence of anti-HHV-8 in selected populations of persons or patients with or without risk factors for the transmission of viral infections, in order to determine the routes of HHV-8 transmission. STUDY DESIGN AND METHODS: A total of 1431 persons or patients at low or high risk of sexually, blood-, or graft-transmitted viral infections were tested by means of a standardized immunofluorescence serologic assay detecting anti-HHV-8. RESULTS: The persons or patients could be classified into three distinct groups according to anti-HHV-8 prevalence: a low prevalence group (0.0% to 5.0%), including healthy blood donors, healthy pregnant women, multiply transfused patients with thalassemia major, and IV drug users; an intermediate prevalence group (5.0% to 20.0%), including organ donors, kidney transplant recipients, and multiply transfused patients with sickle cell disease; a high prevalence group (>20.0%), including HIV-negative persons at high risk of sexually-transmitted viral infections, and HIV-infected homosexual men and heterosexuals. CONCLUSION: The sexual route appears to be the main route of HHV-8 transmission; bloodborne transmission of HHV-8, if it exists, is rare. In contrast, organ transplantation recipients might be exposed to HHV-8 transmission by the transplanted organ, which raises the issue of systematic screening of organ donors.

Thousands of patients throughout Europe undergo organ generally remain within Europe. However, it must be noted transplantation each year. This raises two questions from a that, in the field of organ transplantation, few organs are European perspective. The first regards the possible impact actually exchanged. This is mainly due to the general of the European construction on procurement and transorgan shortage. At the same time, patients living in areas plantation and the second, probably more unusual, regards with low procurement rates (such as southern Italy during the possible influence of procurement and grafts on the the 1980s) often seek transplantation in large numbers in European construction. other countries, such as France or Belgium. Our intention is to show that, contrary to common As far as regulation is concerned, there is currently no expectations, transplantation may be more useful to Europe European law or directive on the subject, nor does a than Europe is useful for transplantation. European body in charge of procurement and graft coordination and exchanges exist. However, despite the lack of common regulations, a European dimension of procure1. Is there a European dimension to transplantation? ment and transplantation is likely to develop in the near future, as demonstrated by the following examples: From an epidemiological point of view, common trends can be identified in most European countries with regard to • Grafts are specifically mentioned in article 152 (ex cerebral death prevalence and morbidity related to diseases article 129) of the Amsterdam treaty, thus offering many leading to transplantation indications. opportunities for developing measures at the European While facing similar problems, the various health care level. This point broadens the European field of compesystems have developed different responses. These differtence in health, traditionally restricted to preventive ences are most noticeable in policies regarding regional policies, and needs to be emphasized; planning, the establishment of hospital programs related to • In the related field of tissue banking, the European procurement and transplantation, and the number of teams Ethics Group in Science and New Technologies to the performing these activities. The mix between public and European Commission recently adopted an opinion on private sector participation also varies from one country to ethical aspects, focusing on the need for common high the next, as does the type of procurement organization. standards in safety and ethics. Clearly, this also has Procurement may be the responsibility of a national public implications for organ transplantation. agency, as in France, Spain, Portugal, and the United Kingdom, or of a private body operating nationally, as in Switzerland, or it may be the responsibility of several 2. What can Europe do for transplantation? countries at a European level, such as Eurotransplant, which includes Germany, Austria, Belgium, Luxembourg, Three main areas need to be addressed: ethics, graft and the Netherlands. availability, and safety. In terms of exchanges, patients, organs, tissues, and cells As far as ethical issues are concerned, harmonization efforts at the European level are likely to promote a high *Tel.: 133-44-67-5599; fax: 133-44-67-5555. 1 level of ethical standards. Some countries, such as France, A work from the Etablissement Francais des Greffes, 5, Rue Lacuee, 75012 Paris, France. by passing the so-called ‘Bioethics’ laws of July 23, 1994

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

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.

PURPOSE To study the progress of cornea donation and transplantation in France. METHODS A questionnaire was sent, every year since 1994, to all the heads of ophthalmology departments in public and private hospitals. RESULTS Response rates of almost 100% were obtained each year. In 1997, 153 hospitals carried out cornea harvesting or transplantation. The number of cornea donations decreased sharply between 1991 (3,774) and 1993 (2,383). Donations then increased slowly to reach 3,591 in 1997 [60 per million population (pmp)]. Cornea-transplantation activity followed the same pattern, decreasing from 3,843 transplants in 1991 to 3,210 (54 pmp) in 1997. In 1997, 73% of cornea transplants took place in 90 public hospitals, and only 27% took place in 28 private hospitals. The number of imported corneas has increased, particularly in 1997, in which 764 corneas were imported (24% of the corneas transplanted). Ninety-two percent of imported corneas were grafted in private hospitals. The estimate of the number of patients registered on local waiting lists increased to 8,303 at the end of 1997. There was a weak correlation between the number of corneas transplanted and the number of patients on local waiting lists by hospital (r = 0.65; p < 0.0001). CONCLUSION The rate of corneal grafts in France is similar to that in other European countries, but the number of patients on waiting lists is high. Careful thought and effort should be applied to increasing the level of corneal donation and harvesting and reducing waiting lists in France to levels similar to those in other European countries.

✓ Since 1985, the authors have been using madreporic coral fragments (genera Porites) as a bone graft substitute. Of the 167 coral grafts implanted, 150 were coral “corks” used to obliterate burr holes (diameter 10 mm), five were large implants (length 20 to 40 mm) to repair skull defects, and 12 were coral blocks to reconstruct the floor of the anterior cranial fossa. Previous experimental studies suggested that coral grafts would be well tolerated and become partially reossified as the calcific skeleton was resorbed. The authors describe their experience and detail the main biological properties of these materials, which appear to be very promising for use in cranial reconstructive surgery.