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.

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."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.


http://www.toledoblade.com/Medical/2012/08/24/UTMC-nurse-tossed-out-kidney-ruined-it.html