La décision d'attribution des greffons pulmonaires en France : quelles garanties de justice ?

La transplantation pulmonaire est une thérapeutique en développement. La façon d’attribuer la ressource précieuse constituée par les greffons se pose. La France, via les règles établies par l’Agence de la Biomédecine, revendique un modèle de justice distributive basée sur l’équité. Cependant, dans un contexte d’extension nationale et internationale des scores d’allocation au sein des systèmes d’attribution, le système d’attribution des greffons pulmonaires est désormais singulier, puisqu’à l’exception de priorités nationales, le choix du receveur est laissé à chaque équipe après proposition d’un greffon. Le processus et les déterminants de cette décision sont assez flous. L’objectif de ce travail est d’étudier à travers l’analyse de leurs pratiques, la place accordée à l’équité de la décision d’attribution par le médecin transplanteur, d’un greffon à un receveur. Pour ce faire, 14 entretiens semi-directifs ont été réalisés auprès de professionnels, pneumologues ou chirurgiens thoraciques, responsables de la décision d’attribution. Cette étude révèle une hétérogénéité des pratiques entre les centres interrogés. Un enjeu semble apparaître autour de la distribution du « meilleur greffon », en plus de la priorisation. La place accordée au principe de justice est cependant difficile à évaluer, notamment du fait du contexte d’incertitude médicale dans cette thérapeutique encore à ses débuts. La position du transplanteur, entre sa responsabilité envers la société, son équipe et son patient est également en cause. La place de ce dernier, ainsi que celle de la société semble avoir sa pertinence dans la réflexion d’une attribution plus juste

First use of imlifidase desensitization in a highly sensitized lung transplant candidate: a case report

International audienceLung transplant candidates who are highly sensitized against human leucocyte antigen present an ongoing challenge with regards to finding immunologically acceptable donors. Desensitization strategies aimed at reducing preformed donor-specific antibodies have a number of limitations. Imlifidase, an IgG-degrading enzyme derived from Streptococcus pyogenes, is a novel agent that has been used to convert positive crossmatches to negative in kidney transplant candidates, allowing transplantation to occur. We present the first case of imlifidase use for antibody depletion in a highly sensitized lung transplant candidate who went on to undergo a successful bilateral lung transplant

Blood MMP-9 measured at 2 years after lung transplantation as a prognostic biomarker of chronic lung allograft dysfunction

Abstract Background Long-term outcomes of lung transplantation (LTx) remain hampered by chronic lung allograft dysfunction (CLAD). Matrix metalloproteinase 9 (MMP-9) is a secretory endopeptidase identified as a key mediator in fibrosis processes associated with CLAD. The objective of this study was to investigate whether plasma MMP9 levels may be prognostic of CLAD development. Methods Participants were selected from the Cohort in Lung Transplantation (COLT) for which a biocollection was associated. We considered two time points, year 1 (Y1) and year 2 (Y2) post-transplantation, for plasma MMP-9 measurements. We analysed stable recipients at those time points, comparing those who would develop a CLAD within the 2 years following the measurement to those who would remain stable 2 years after. Results MMP-9 levels at Y1 were not significantly different between the CLAD and stable groups (230 ng/ml vs. 160 ng/ml, p = 0.4). For the Y2 analysis, 129 recipients were included, of whom 50 developed CLAD within 2 years and 79 remained stable within 2 years. MMP-9 plasma median concentrations were higher in recipients who then developed CLAD than in the stable group (230 ng/ml vs. 118 ng/ml, p = 0.003). In the multivariate analysis, the Y2 MMP-9 level was independently associated with CLAD, with an average increase of 150 ng/ml (95% CI [0–253], p = 0.05) compared to that in the stable group. The Y2 ROC curve revealed a discriminating capacity of blood MMP-9 with an area under the curve of 66%. Conclusion Plasmatic MMP-9 levels measured 2 years after lung transplantation have prognostic value for CLAD

Additional file 1 of Blood MMP-9 measured at 2 years after lung transplantation as a prognostic biomarker of chronic lung allograft dysfunction

Additional file 1: S1. COLT study protocol. S2. Description of variables of interest. Figure S1. Study protocol. Figure S2. Comparison of MMP-9 blood levels of Y2 analysis according to CLAD phenotypes. Figure S3. Precision-Recall (A) and ROC (B) curves for the Y1 MMP-9 analysis. Figure S4. Comparison of MMP-9 blood levels of Y2 analysis according to CLAD phenotypes. Figure S5. Longitudinal analysis of MMP-9 blood levels for recipients with available samples before transplantation, at Y1 and Y2