70 deaths, 249 hospitalizations tied to failures to properly screen, keep track of donated organs

Process failures in the collection, screening and transplantation of donated organs in the U.S. have been responsible for at least 70 deaths and the development of 249 avoidable disease, the Senate Finance Committee revealed in a report Wednesday.

The full report, which was obtained by the Washington Post, cites failures to identify diseases lying within organs that would cause issue for the next host, failures to properly match blood types and perfectly good-to-use organs being lost or discarded after mismanagement in the transport chain.

These cases include a man in South Carolina who received transplanted lungs that were incompatible with his body – killing him the next day. On heart transplant patient in Wisconsin was told they would die in three years after it was discovered the heart they just received came from a person with brain cancer.

Fault for these issues is distributed across multiple groups. First, the individual non-profits that control the procurement and transplantation or organs in each region, called organ procurement organizations (OPOs). The United Network for Organ Sharing (UNOS) is responsible for overseeing those groups as well. Then, of course, federal officials are responsible for regulating these groups as well.

According to official data, 105,960 Americans are currently on the transplant list, with 17 dying each day while waiting. A new person is added to the list every nine minutes.

The report filed by the committee included 1,118 reports filed between 2010 to 2020 to UNOS. The death toll of 70 included data from 2008 to 2015.

During the seven year period where the deaths occurred, 174,338 organ were transplanted in the United States.

While significant errors were rare, when they did occur they could be devastating.

The documents record multiple organs that could have been used instead were discarded or lost for unexplained reasons.

In 2020, two healthy kidneys were accidentally discarded in Indiana. Around one-in-five kidneys procured for transplantation went unused that year, without concrete explanation as to why in a majority of cases.

In 2015, a donated kidney was lost while being traveled through air from South Carolina to Florida. Another was lost in 2017 when being transported from the Palmetto state to California.

In both cases, a transplant recipient had their operation canceled as a result of the error.

Sometimes, an organ that had already been transplanted would have to be removed from the recipient after doctors learned after the fact that there was an issue that could cause sever complications.

UNOS leaders said they are ‘dedicated to continuously improving, monitoring and adapting; one that involves thousands of people coming together every single day across the country in order to save lives. Pictured: UNOS headquarters in Richmond, Virginia

These kinds of issues are supposed to be caught well before the transplant, where the organ is evaluated for blood type and for potential risk of causing the person that receives it to develop a dangerous disease.

Some patients will die as a result. Others will have to go through multiple surgeries to undo the mistake before  

A Wisconsin man in 2020 was told by a surgeon that he likely had less than three years left to live after he was given a new heart from a person that had aggressive brain cancer.

People with spreading cancer are not to have their organs used as their is a risk the cancer resumes spread while inside the recipient. 

There is no available information on that heart recipients current condition. 

In 2018, one South Carolina donor had organs harvested to be used in four recipients.

In one case, a man in South Carolina died a day after receiving lungs that were not compatible for transplantation (file photo)

There was a mix up in their blood type, though, leading to all four patients receiving incompatible organs.

The man who received the donors lungs ended up dying the day after receiving them.

In 2017, a Nevada kidney transplant recipient died of tularemia, or the rabbit flu, after receiving an organ from an infected patient.

Another California patient also received a kidney from the same person and was also infected. That patient survived.

‘Ours is a complex system; one that is dedicated to continuously improving, monitoring and adapting; one that involves thousands of people coming together every single day across the country in order to save lives,’ Brian Schepard, chief executive on UNOS said in his testimony to the Senate committee.

‘It is a system Congress set in motion nearly forty years ago, and which, thanks to the decisions and expertise of those who laid the foundation, allows us to best serve patients in need of a transplant.’ 

There is little regulatory oversight on these operations, though. UNOS is a private contractor being employed by the government.

It then doles out work to the OPOs, who operate without competition in each individual region.

The process is opaque and without proper oversight it is easy for mistakes to be made – and for groups to push blame elsewhere when the problems are noticed.