Status:
Ready to upload
Record number:
2107
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Multiple disease transmissions are reported in summary: please refer to Council of Europe Guide for individual assessment of risk per tumor.
For the period of 2008-2017, the DTAC reported 70 donors who transmitted malignancy to one or more recipients.
Time to detection:
Not listed
Alerting signals, symptoms, evidence of occurrence:
Multiple disease transmissions are reported in summary form, specific information regarding individual patients is not listed
Demonstration of imputability or root cause:
Multiple disease transmissions are reported in summary form. The DTAC systematically reviews each report of potential transmission combining an algorithmic approach with peer medical discussion and categorizes the event into proven/probable versus other. Those reports adjudicated as proven or probable form the basis of their reports.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
References:
Suggest new keywords:
Registry Series
Deceased donor
Kidney transplant
Liver transplant
Heart transplant
Lung transplant
Pancreas transplant
Therapy not discussed
Blood and lymphoid Cancer
Renal cancer, type not specified
Liver cancer, type not specified
Cholangiocarcinoma
Melanoma
Lung cancer, type not specified
Kaposi's sarcoma
Urothelial (transitional) cell carcinoma
Neuroendocrine carcinoma
Malignancy
Reference attachment:
Suggest references:
Kaul DR, Vece G, Blumberg E, La Hoz RM, Ison MG, Green M, Pruett T, Nalesnik MA, Tlusty SM, Wilk AR, Wolfe CR, Michaels MG. Ten years of donor-derived disease: A report of the disease transmission advisory committee. Am J Transplant. 2021 Feb;21(2):689-702. doi: 10.1111/ajt.16178. Epub 2020 Jul 25. PMID: 32627325.
Note:
upload 09/20/2020
first review CLFF 05/25/2022
second edits made MN 5/28
Expert comments for publication:
Multiple disease transmissions are reported in summary form for the period of 2008-2017 by the Disease Transmission Advisory Committee (DTAC): out of 2185 reports of potential disease transmission (of any type), 335 were concluded to be proven or probable donor derived disease (DDD) and 70 of these reports involved donors who transmitted cancer to one or more recipients. Kidney, lung, and liver cancers were the most commonly transmitted tumors. Frequency of transmission, short term survival and graft loss figures are provided, and transmission events are further categorized according to transplant organ. The authors note that the patient followup time is short as regards malignancy outcome, (and this has been recognized and expanded from 45 days to 2 years). A large part of the report deals with transmission of infectious diseases, reflecting the larger frequency of this event. A summary of the key lessons learned for recognition of donor disease, possible trends meriting further evaluation, and specific points regarding donor evaluation, reporting and system improvements is provided. The article provides a good overview of the DTAC experience in the period just prior to the Covid pandemic