[Graft safety and need satisfaction: searching for a crucial balance]

In 1998, 3,033 organs were transplanted and 3,186 stem cell and 4,053 cornea grafts were performed in France. Organ shortage varies for each organ but is particularly critical for kidneys. Given the physiological and therapeutic efficacy of grafting, an increase in organ procurement is likely to raise safety problems. This paper concerns donor-transmitted infections, mainly viral infections. Regulations on health risks express a social and cultural refusal to accept any hazard. This collective concern is however in opposition with the interests of individual patients who are likely to accept a greater risk for an obvious benefit. Although the assessment of the risk/benefit ratio is clearly different between organ and tissue transplantation, further thought needs to be given to the problem of acceptance of infectious risk in organ transplantation. In France, special exceptions are now legally authorized for specific situations. Infectious agents transmitted by grafting have not been largely reported, mainly because screening tests were not available. The number of transmitted infections is increasing with the expansion of transport facilities and with the various geographical origins of the population. In some cases, search for histocompatibility between relatives living in endemic areas introduces new risks, for example tropical diseases. Diagnosis is often made by serological or molecular biological tests which may be difficult to analyze depending on their specificity. Organ transplantation is often an emergency requiring rapid decision making, for the donor or the recipient. However, with a quality assurance process based on accepted guidelines, the appropriate answers to operational problems can be given rapidly. Patient satisfaction can be achieved only if the public health challenge is met. Increasing organ procurement can clearly be expected to be beneficial, but at the cost of higher risks. Nevertheless, benefit and risk are quite different, benefit is for the time being while risk is delayed and may be uncertain depending on individual survival. Because of the variability of human disease, especially in situations where an ultimate therapy is involved, automatic application of a standard procedure must be avoided as it would inevitable lead to a cut-back in organ procurement in an attempt to achieve a theoretically safe situation which would be contrary to individual patient's self-interest. Health care workers should have good knowledge of the epidemiology of these diseases in order to assess risk. The patient must be able to express informed consent.