Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
Three patients developed perinephric infections associated with renal artery anastomotic disruption and required emergency transplant nephrectomy. A fourth patient developed renal artery stenosis and a hypogastric artery aneurysm that required correction 6 months later with preservation of renal allograft function.
Demonstration of imputability or root cause:
Candida albicans and Pseudomonas aeruginosa infections were responsible for the nearly disastrous arterial disruptions and possibly the hypogastric arterial aneurysm. They were cultured from the organ perfusion media culture after the organs had been transplanted (not considered that the media were contaminated prior to use).