Organ transplant tragedy is focus of investigation
Organ transplant tragedy is focus of investigation
Family, health care community ask, How?'
The United Network for Organ Sharing (UNOS) is conducting a review of the circumstances leading to a transplant fatality, in which a recipient received a heart-lung transplant from a donor with an incompatible blood type, the network reports.
Jesica Santillan, a 17-year-old Mexican immigrant, died Feb. 22 of complications suffered when her body rejected the heart and lungs from a transplant performed at Duke University Hospital in Durham, NC. Doctors discovered shortly after surgery that the organ donor’s blood type was different from Santillan’s. A second heart-lung transplant was performed days later, but Santillan developed swelling in the brain due to the original rejection and died.
In its role as administrator of the national Organ Procurement and Transplantation Network (OPTN) for the U.S. Department of Health and Human Services, UNOS is reviewing all facts related to the patient’s listing and the donated organs that were offered to her, the network said in a statement issued Feb 20.
"Ms. Santillan was registered on the national waiting list as a candidate for a heart-lung transplant," the statement indicated. "However, she did not appear on the match run’ — a computer-generated list of potential recipients who were medically compatible with the donor — because her blood type did not match the donor’s."
The UNOS/OPTN investigation is focusing on how the organ offer and acceptance occurred despite her absence on the specific list used for the match.
UNOS/OPTN policies have established a procedure for matching donors and recipients and require that detailed medical information about each donor, including blood type, be recorded and provided to the transplant center. If properly followed, these policies, in conjunction with the quality management procedures utilized by the state-level organ procurement organizations and transplant centers, should prevent erroneous blood-type mismatches.
The OPTN/UNOS Membership and Professional Standards Committee is spearheading the investigation for the network and also has recommended certain immediate changes to prevent future recurrences, says UNOS spokeswoman Ann Paschke.
The committee is calling for all organ procurement organizations to ensure their staff members are thoroughly familiar with the most current information regarding existing network policies and procedures designed to ensure proper allocation of organs. Specifically, the committee requested that information be disseminated immediately regarding OPTN policies that require organs to be allocated only for patients who are included on the official network "match run."
The committee also has required that more detailed information be disseminated on the use of the UNOS computer system to facilitate running a donor/patient match.
Upon completion of its review, the committee will present its final recommendations to the OPTN/UNOS Board of Directors. In addition, a special subcommittee is being formed to conduct an in-depth review of OPTN policies and procedures to determine whether additional safeguards need to be implemented to protect against potential errors in the future.
Questions about citizenship status
Since the transplant tragedy, some experts also have questioned how Santillan was able to receive the transplant at Duke, given that she was an undocumented Mexican immigrant and U.S. transplant policies require non-citizen organ recipients to have legal status here.
UNOS policies do state that recipients must be in the country legally and do prohibit centers from performing more than 5% of their transplants on non-resident aliens, Paschke says. These regulations are stipulated in the federal law creating the OPTN. But, the network does not perform a policing function, she notes.
"Considerations about residency and immigration status do not come into play when deciding whether someone will be on the waiting list," she explains. "We do collect data about a recipient’s residency status, but only to track how centers are adhering to the rules, after the fact. Her residency status would not have affected her ability to be matched. This is not a criterion that is even considered by the computer."
Decisions about who should be listed as a candidate for transplantation are made by transplant coordinators at each center, Paschke said.
The United Network for Organ Sharing (UNOS) is conducting a review of the circumstances leading to a transplant fatality, in which a recipient received a heart-lung transplant from a donor with an incompatible blood type, the network reports.Subscribe Now for Access
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