# Sensitization and Deceased-Donor Kidney Transplant Access in France

## TL;DR

Highly sensitized kidney transplant candidates in France face reduced access to deceased-donor transplants and higher waitlist attrition as sensitization increases.

## Contribution

This study identifies specific sensitization thresholds where deceased-donor kidney transplant access and waitlist outcomes worsen in France.

## Key findings

- Access to deceased-donor kidney transplantation declines sharply at cPRA ≥ 96%.
- Candidates with cPRA ≥ 97% face significantly increased risk of waitlist attrition.
- The acceptable-antigen pathway effectively supports candidates with cPRA 85% to 95%.

## Abstract

Highly sensitized kidney transplant candidates have reduced access to deceased-donor kidney transplantation (DDKT) and worse waitlist outcomes. In France, allocation relies on sensitization-based prioritization through the acceptable-antigen pathway driven by the Taux de Greffons Incompatibles (TGI)’ however, the sensitization threshold at which this system fails to preserve equity remains unclear.

We conducted a retrospective multicenter cohort study including 14,485 adult kidney transplant candidates listed between 2011 and 2021. Sensitization was measured using TGI (0–100) and reported using calculated panel reactive antibody (cPRA)-labeled strata for international readability. Access to DDKT was the primary outcome, with living-donor transplantation, death, and delisting treated as competing events. The secondary outcome was waitlist attrition (death or delisting). Fine–Gray models adjusted for key demographic, clinical, and immunologic variables were truncated at 10 years.

Access to DDKT declined progressively with increasing sensitization and fell sharply from cPRA ≥ 96%. Compared with cPRA 0%, the adjusted subdistribution hazard ratio (SHR) for DDKT was 0.781 at 96%, 0.658 at 97%, 0.701 at 98%, 0.353 at 99%, and 0.082 at 100%. Conversely, the risk of waitlist attrition increased from cPRA ≥ 97% (sHR: 1.793), reaching 2.713 at 100%. Candidates with cPRA of 85% to 95% retained preserved access, consistent with the intended effect of the acceptable-antigen pathway.

In the French TGI-based allocation system, cPRA ≥ 96% marks a threshold of impaired access to DDKT, whereas cPRA ≥ 97% identifies excess waitlist attrition. These findings define an ultrasensitized subgroup insufficiently served by current prioritization and support refined allocation strategies within the 96% to 100% range.