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Published: Thursday, 8/23/2012 - Updated: 2 years ago

UTMC suspends kidney exchange over human error

Living transplant donor's organ ruined; 2 nurses are suspended

BY IGNAZIO MESSINA
BLADE STAFF WRITER
Dr. Jeffrey Gold, left, says the university apologizes for the 'unfortunate incident.' Dr. Michael Rees, right, is the surgeon who removed the kidney before it was ruined. Dr. Jeffrey Gold, left, says the university apologizes for the 'unfortunate incident.' Dr. Michael Rees, right, is the surgeon who removed the kidney before it was ruined.
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A kidney removed by surgeons from a living donor at the University of Toledo Medical Center was ruined by "human error" before it could be implanted into a patient who was waiting in a nearby operating room, a university official said Wednesday.

The hospital suspended its living kidney transplant program after the Aug. 10 botched transplant, which officials revealed in a letter to other potential kidney recipients 10 days later and again Wednesday to the media.

Two operating room nurses were suspended with pay, although a top hospital official refused to identify the employees or reveal what they had done to the kidney.

"We cannot fathom the disappointment that those impacted have experienced over the course of the last week. The university cannot begin to express the sorrow that we feel that this unfortunate incident occurred. We apologize sincerely," Dr. Jeffrey Gold, chancellor and vice president for biosciences and health affairs at UTMC, told The Blade on Wednesday night.

Dr. Gold also refused to identify the donor and intended recipient or their relation, except that they are related.

RELATED CONTENT: UTMC letter on kidney transplant program

"In the process of transferring a kidney from a donor, a human error rendered the kidney unusable," he said. "Efforts were made to restore the kidney to a usable state, however the physician, in consultation with the family, decided to not take the risk knowing there was a good chance for another highly compatible donor."

A source with knowledge of the situation told The Blade the kidney came from a man who was donating it to his sister. The kidney would have been an exact match, but now the sister must wait for another donor match.

Normally, the kidney would have been implanted within an hour after being removed from the donor. Doctors tried unsuccessfully for at least two hours or more to "resuscitate" the organ, in an attempt to make it usable, Dr. Gold said.

The patient needing the kidney is in end-stage renal disease and has not yet received a new kidney.

That person was under anesthesia but surgery had not yet begun. The person needing the kidney was discharged from the hospital that day and the donor was sent home the next day.

The kidney transplant program at UTMC, the former Medical College of Ohio, has operated for 40 years.

"Since the first kidney transplant operation was performed at the University of Toledo Medical Center in 1972, more than 1,700 kidney transplant operations have been performed, with an average patient survival rate of 98 percent and a graft survival rate of 94 percent," the hospital Web site states.

A letter written Monday and signed "the Department of Renal Transplant" implied something had gone awry with a transplant.

"At the University of Toledo Medical Center, we are committed in our mission to improve the human condition by providing quality, patient-centered health care," the letter said. "Recently, a process to achieve this failed, so the kidney transplant program decided to voluntarily suspend providing living kidney donor transplant services on August 10th, 2012. Please note that our deceased donor transplant program and all related services are fully operational and are actively managing our patients and families."

The letter said the hospital still could evaluate potential candidates and living donors and provide transplant recipient follow-up care.

Dr. Michael Rees, the transplant surgeon at UTMC who removed the kidney before it was ruined, was not in his office Wednesday and could not be reached for comment.

Earlier this month, Dr. Rees said UT, in partnership with his Maumee-based Alliance for Paired Donation, had landed a four-year, $2 million federal grant. The research grant awarded to Dr. Rees and the University of Toledo Medical Center was attained with the help of U.S. Sen. Rob Portman (R., Ohio) and U.S. Rep. Marcy Kaptur (D., Toledo). A spokesman for Senator Portman declined to comment and Miss Kaptur's spokesman did not return telephone calls seeking comment.

Dr. Gold said UTMC officials are hopeful the live kidney donor program will be reopened in "the next several weeks."

The hospital is "in the process of assessing how this situation occurred, and we are committed to ensuring safeguards are put in place to prevent such an incident from ever happening again," he said.

"We are reviewing this program from top to bottom using expert resources from both inside and outside the institution."

The hospital reported the incident to the Ohio Department of Health and the United Network for Organ Sharing, which are participating with UTMC in the investigation along with a group of "kidney transplant experts" from another institution that Dr. Gold declined to identify until a contract is finalized.

The kidney is the most commonly transplanted organ, and the surgeries to remove it and then implant it are relatively routine, said Dr. Randall Sung, an associate professor in the section of transplantation surgery at the University of Michigan.

Dr. Sung said the timing of a living donor transplant surgery is typically staggered to minimize the amount of time the kidney is outside of the body.

"It takes longer to remove the kidney from the donor than it takes to get the recipient under anesthesia and ready for the organ," he said.

Both surgeries typically take two to three hours.

After removal, a kidney is flushed of the donor's blood and then gets packed in ice in a sterile plastic bag, which is placed in another container before being moved to the operating room with the waiting recipient, said Dr. Sung, who has performed the surgery more than 700 times.

He said surgeons usually want to implant a kidney within one hour of removing it, but it can remain viable for up to 40 or 48 hours.

"We really don't know for a living [donor kidney] because it goes in so quickly," Dr. Sung said. "A high-quality kidney can go 40 to 48 hours and still be potentially transplantable ... so a living kidney could tolerate that as well."

Dr. Gold said he could not recall a similar incident in which a viable kidney was removed from a living donor and then made unusable by human error.

"I am not aware of an incident identical to this," he said.

Contact Ignazio Messina at: imessina@theblade.com or 419-724-6171.



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