Dozens of deaths due to failures in donor organ screening

Failures in the donor organ supply chain have recently killed 70 transplant patients, and sickened another 249, according to a government report.

The full report, submitted by the US Senate Finance Committee and obtained by the Washington Post, details dozens of botched transplant procedures stemming from the insufficient screening of donor organs, including cases in which patients have mistakenly received already-diseased organs or those with mismatched blood types. In some cases, the patient will have to have the donor organ removed, placing them again on the transplant list. Others will die before doctors realize the error.

One case outlined in the report was that of a South Carolina man who received a double lung transplant with incompatible organs — and died the next day. Another patient in Wisconsin was handed a three-year death sentence along with a new heart after doctors learned that the muscle was obtained from someone with an aggressive form of brain cancer.

Investigators also saw the sort of egregious mismanagement of inventory that led to the discarding of perfectly viable organs, particularly among the most common replacement organ groups: heart, liver and kidneys. In one year alone, as a 2019 study published in JAMA Internal Medicine estimates, some 3,500 good kidneys will go unused or discarded, despite the more than 90,000 patients seeking one.

The congressional committee blamed all groups who work to procure, distribute and monitor organ donations, including both the regional and national nonprofits who match and manage transplantation cases, as well as their government regulators, for a lack of oversight and inconsistencies throughout the process.

Nearly 106,000 Americans are currently waiting on a transplant list, with a new person added every nine minutes on average. At the same time, about 17 per day will die waiting for the organ they need.

The report presented last Wednesday included 1,118 complaints filed to the United Network for Organ Sharing between 2010 and 2020, though the death toll of 70 was counted between 2008 and 2015 — out of more than 174,000 transplantations total during that period.

The United Network for Organ Sharing, which oversees the 57 regional organ procurement organizations throughout the US, defended its efforts.

“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,” said Brian Shepard, a UNOS chief executive, 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.”

UNOS is a private government contractor and thus not subject to extensive federal regulations. The Senate report asserts that this lack of transparency leaves them without a clear understanding of where mistakes are made and how to fix them.