Record number:
339
Adverse Occurrence type:
MPHO Type:
Time to detection:
6 months
Alerting signals, symptoms, evidence of occurrence:
Two kidneys transplanted from the same donor. First kidney: biopsy shows a clump of malignant cells in a glomerulus, interpreted as an embolism of an undifferentiated tumor. Because of the psychological state of this recipient the transplant was not removed. Six months after transplanttion dies and necropsy reveals an undifferentiated tumor in pleura, liver, pelvic peritoneum and transplanted kidney. Second kidney: graft removed immediately. The patient remained well on haemodialysis; multiple sectioning of the kidney showed no signs of tumour.
Demonstration of imputability or root cause:
A cerebral glioma discovered by angiography and brain biopsy in a kidney donor was subsequently suspected of being a secondary tumour. *Notably, in the text it is stated 'On review the cytological features of this embolus were not the same as those in the brain biopsy specimen from the donor'.
References:
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