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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.

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.

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.

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 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.