Alert over donor organs riddled with cancer, mad cow disease and hepatitis

Alert over donor organs riddled with cancer, mad cow disease and hepatitis
Donor organs for transplant have been found to be infected with deadly diseases, carry cancerous tumours and have been too damaged to use, an alert to the health service has warned.

By Rebecca Smith, Medical Editor
Published: 7:00AM BST 12 Oct 2009

Doctors reported one instance where a kidney arrived for transplant in a poor state but the operation was carried out anyway only for a 'massive bleed' to occur from he organ meaning it had to be removed again. It was sent for testing and found to contain a cancerous tumour.

The incident prompted a search of the National Patient Safety Agency database which uncovered 11 similar reports of faulty organs.

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An alert sent to the health service said other examples included `fatty’ organs, which can be caused by the donor patient being obese and fatty liver can also be caused by alcoholism and may lead to cirrhosis; the donor patient found to be infected with vCJD – the human form of mad cow disease and hepatitis B; and cuts and damage to an organ during the retrieval operation.

The report said there were also incidents relating to mismatching of tissue typing and patient identification errors.

It is not known if the transplant operations went ahead in all cases or if the recipients suffered any adverse effects.

The quality of transplant organs has been called into question before when it emerged that donations were being accepted from drug addicts due to the critical shortage.

There are around 10,000 people on the waiting list for an organ transplant and around 1,000 die each year waiting for a match.

The waiting list grows by around eight per cent each year and advances in intensive care medicine and surgery mean more patients who would become donors are surviving their injuries.

Representatives from the National Patient Safety Agency called an urgent meeting with NHS Blood and Transplant, the special trust which oversees transplants, after the incidents came to light.

The report added: "There was encouraging news on very recent changes where, for the first time, there will be a robust, secure and funded national system for organ retrieval, staffed by well-trained surgeons and other healthcare professionals.

"NHS Blood and Transplant is setting up a system for monitoring the quality of organs and this will be supplemented by a photographic assessment of livers that is currently being evaluated.

"While these changes address many of our concerns, NHS Blood and Transplant strongly encourages staff to continue reporting all adverse events and any concerns about preventable harm to donated organs."

The National Patient Safety Agency database contains 3.5 million incident reports from England and Wales made by NHS staff since 2001 which can be analysed for patterns.

Keith Rigg, president of the British Transplant Society, said there has been a shift in donors with fewer young people dying of head injuries and more older people dying of brain haemorrhages which meant organs tended to be older.

But he added that all potential organs are inspected before the recipient is anaesthetised.

Mr Rigg, who is a transplant surgeon in Nottingham, added: "People are aware that quality and safety is an important issue and the cases highlighted here are a very small minority. Surgeons are careful about what they transplant and do not take unnecessary risks."

A Department of Health spokesman said: "We are committed to supporting new initiatives to optimise the number and quality of donor organs.

"Following the Organ Donation Taskforce recommendations, NHS Blood and Transplant are investing in the development a new national system for organ retrieval with a UK-wide network of highly trained organ retrieval teams, working to ensure high quality organ removal.

"This will be complemented by a new digital imaging service that allows surgeons to inspect livers online before accepting them.”

In a separate case, it was disclosed yesterday that an Iraq war veteran died after a transplant in which he was given a pair of cancerous lungs donated by a smoker.

http://www.telegraph.co.uk/health/healthnews/6282248/Alert-over-donor-organs-riddled-with-cancer-mad-cow-disease-and-hepatitis.html