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UTMC front Two operating-room staff nurses were suspended with pay from the University of Toledo Medical Center, the former Medical College of Ohio, on Arlington Avenue.
Two operating-room staff nurses were suspended with pay from the University of Toledo Medical Center, the former Medical College of Ohio, on Arlington Avenue.
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Published: Friday, 8/24/2012 - Updated: 1 year ago

KIDNEY TRANSPLANT

UTMC nurse tossed out kidney, ruined it

National experts say error is rare

BY IGNAZIO MESSINA
BLADE STAFF WRITER

A kidney removed from a Toledo man at the University of Toledo Medical Center that was supposed to be transplanted into his older sister was instead thrown away with medical waste by a nurse -- a rare accident that medical experts said is probably a one-of-a-kind incident in the United States.

Hospital officials on Wednesday talked about the Aug. 10 incident that rendered the donated kidney ruined, but they refused for a second day to confirm multiple reports about how the removed organ was damaged beyond repair.

Toledo-Lucas County health commissioner David Grossman, whose office is not involved in the investigation, confirmed along with other sources that the kidney was accidentally disposed of by a nurse.

"One of the kidney doctors talked to me," Dr. Grossman said. "He said it had to do with one of the nurses disposing of the kidney improperly. He didn't try to hide anything from us."

Sources with knowledge of the botched surgery said the kidney was removed by a surgeon and then inadvertently thrown away by a nurse. It took about an hour or more to find the discarded kidney, which was among medical waste.

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Two operating-room staff nurses were suspended with pay following the incident. They were identified by UTMC as Melanie Lemay, a full-time nurse, and Judith Moore, a part-time nurse. Ms. Moore was unable to be reached for comment; no one answered the door at the residence of Ms. Lemay.

Dr. Jeffrey Gold, chancellor and vice president for biosciences and health affairs at UTMC, the former Medical College of Ohio, told The Blade on Wednesday that 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 without elaborating on how it was damaged.

UTMC's Jeffrey Gold, left, said doctors tried to save the kidney; David Grossman, right, said the organ was accidentally disposed of. UTMC's Jeffrey Gold, left, said doctors tried to save the kidney; David Grossman, right, said the organ was accidentally disposed of.
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"In the process of transferring a kidney from a donor, a human error rendered the kidney unusable," Dr. Gold said Wednesday. "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."

At UTMC, kidneys removed from live donors are first put in a stainless steel transfer basin, and a typical harvesting team consists of five people. UTMC would not make officials available Thursday to discuss how it disposes of medical waste.

"Most tissue is sent to the pathology department for further study," read a statement from UTMC.

Two agencies could be part of the investigation, along with UTMC's own internal review that was started after the university voluntarily suspended its live kidney transplant program. A spokesman for the United Network for Organ Sharing, an agency that oversees the nation's transplant programs, declined Thursday to comment on UTMC's incident. A spokesman for the Centers for Medicare and Medicaid Services did not return telephone calls and emails seeking comment.

Dr. William Harmon, director of kidney transplantation at Boston Children's Hospital, said kidneys have been removed in the past elsewhere in the nation and have been unusable for various reasons, but the kind of accident that happened at UTMC is unheard of in organ transplant centers.

"It was a good decision not to use it," Dr. Harmon said after being told about the kidney removed from the Toledo patient. "This is unfortunately what medicine is like -- it is not perfect and there have been far worse cases where the donor has died," Dr. Harmon said. "This is tragic, and this is horrendous, and I am sure the people involved are just killing themselves over it."

Dr. Harmon said it was proactive of UTMC to voluntarily suspend the program, and he did not think the program would be sanctioned by the United Network for Organ Sharing.

Dr. W. James Chon, a transplant nephrologist at University of Chicago Medicine, said kidney transplant programs typically have strict safeguards in place to prevent mishaps.

Before a hospital would consider transplanting a kidney from a live donor, both the donor and recipient are medically and psychologically screened.

What is often referred to as a "perfect match" are six-antigen matched kidneys, which can be most easily found with siblings. The brother and sister at UTMC were reportedly a six-antigen match.

"The distance a kidney travels -- you are talking 10 to 5 yards, so the possibility of something going wrong is very rare," Dr. Chon said while describing a typically living kidney donor removal and transplant surgery. "Most of the living donor surgery is done by laparoscopic surgery so they don't make a big incision."

Dr. Michael Rees, the UTMC transplant surgeon who removed the kidney before it was ruined, has not returned calls 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 UT-led project involves testing willing kidney donors even when their kidneys are not compatible with loved ones but could be a match for other patients. It was one of 14 programs funded by the Agency for Healthcare Research and Quality, which is under the U.S. Department of Health and Human Services.

The agency did not respond to questions of whether UTMC could lose the grant money. A university spokesman said the $2 million was not in jeopardy.

Kidneys are the most commonly transplanted organ.

According to the United Network for Organ Sharing, there were 16,816 kidney transplants nationwide last year from live donors and from those who consented to organ donation through state registries should they die from an illness or accident. In Ohio last year, there were 648 kidney transplants.

As of Aug. 17, there were 2,688 people in Ohio waiting for a kidney and 92,841 people waiting nationwide.

Also last year, 136 people in Ohio died waiting for a kidney, and 4,711 people died nationally waiting for a kidney.

UTMC does not regularly do other organ transplants.

A statement Thursday from UTMC said it needs to wait for approval from the United Network for Organ Sharing prior to restarting the institution's live kidney donation program.

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



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