In February 2003, a transplant that occurred at Duke resulted in the death of a young immigrant patient who received a set of ABO incompatible heart and lungs. Jesica Santillan was a young girl with severe, congenital restrictive cardiomyopathy whose family had illegally immigrated to the US to pursue the only possible treatment, a rare heart double-lung transplant. The family begged for money to pay for the treatment and were later helped by a wealthy North Carolina businessman who began a charity for Jesica. Once the money was raised, a pediatric transplant surgeon at Duke procured organs for Jesica after deciding they were not appropriate for the two patients listed on the UNOS (United Network for Organ Sharing) match list. After more phone calls, the surgeon was given permission to use the organs for Jesica. Tragically, after the organs had been transplanted and perfused, the surgical team received news that the organs were from a Type A donor and Jesica was Type O.
For 30 minutes after transplantation, Jesica's new organs functioned well, but then rejection set in. With Type O blood, Jesica's plasma contained both anti-A and anti-B antibodies, resulting in the rapid rejection of the transplanted organs, which contained blood with Type A antigens. Due to pre-existing antibodies, the humoral-mediated immune response in ABO incompatibility cases is both rapid and severe. Jesica was immediately treated using plasmapheresis, which is used to remove antibodies from the blood in the hope of reducing the severity of rejection. Jesica was also treated with high-dose immunosuppressants to reduce her immune system's attack on the new organs. Two weeks after the initial, mismatched transplant a second transplant surgery was performed using organs from a Type O donor.
Shortly after the second surgery Jesica suffered severe and irreversible brain damage from brain swelling and intracranial bleeding. Neurological tests showed she was brain dead and scans showed there was no brain activity or perfusion. During transplant surgery, patients are put on a machine that circulates their blood, but the anticoagulant drugs used to prevent clotting in the machine increase the risk of bleeding in and around the brain. That afternoon, Jesica was taken off life support and died.
This serious error in the transplant process raised many questions for the agencies, practitioners and hospitals involved. Although the transplant surgeon remembered talking about other compatibility factors, he could not remember talking about blood type, which is the primary requirement for an organ match. Additionally, Duke kept the initial error quiet and out of the media for one week after the inappropriate transplant. Furthermore, the issue of medical care and illegal residency was raised as Jesica's family were illegal immigrants receiving care at one of the top American institutions.
Regardless of the controversial ethical and patient safety concerns raised by this error, the importance of even simple immunology such as blood type can be seen in this case. The advances in treatment that allowed Jesica to survive until the second surgery show the progress of medicine in the field of immunology, but illustrate the importance of simple principles first and foremost. The lessons learned? Always double check important criteria, even if it seems so basic that someone else should have already confirmed it. And the basic principles of immunology do not lose significance at any level of science or medicine, even as our knowledge of immunology increases and reveals new levels of complexity.
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Amazing !! in this day and age, someone does that on such a high profile (heart-double lung) case. There has to be a standard check list made by UNOS or some authority, which makes atleast the matching (however much possible) of donor and host "fool" proof. Seriously that so called pediatric transplant surgeon should reconsider the profession that he/she is in given the collossal effort that must have gone in by the parents and benefactor and the organs wasted in this effort. Thanks for sharing this with us Heather ...
ReplyDeleteThanks Heather. Tragic stories like this remind us to cover all the bases.. so to speak. It is so important!!
ReplyDeleteI think the status of Jessica's citizenship is interesting. Because she was an immigrant, and because of the private nature of this transplant, would her information have even been on the UNOS list?
ReplyDeleteLeslieS495: Jesica was on the UNOS transplant list according to some of the sources that I read, despite her lack of American citizenship. (Perhaps a move of charity of the part of Duke and/or UNOS?) How this listing happened was not clear to me from any of the articles I read.
ReplyDeleteHarmonical_contrast: The surgeon who did the transplant initially rejected the organs for a different patient of his who originially came up on the match list because this patient was not yet ready for a transplant. Then the surgeon asked by name if the organs could be used for Jesica (perhaps because of the high-profile and charity nature of her case), who did not appear on the original match list. Note that this is not the typical manner of procuring organs for a transplant. While this certainly does not pardon the surgeon (and the rest of the surgical team's fatal error), it does somewhat explain the oversight of the most basic match criteria. Further, while the surgeon took responsibility for the error, one must raise the question of why it was not caught by any of the other members of the surgical teams (organ procuring and organ transplanting). Although the fault falls upon the transplanting surgeon, there were many other people involved who should have noticed too.
New regulations have been imposed as a result of this error requiring confirmations regarding blood type at more steps in the transplant process.
I notice that in your response to the other students you state that multiple regulations have been imposed following this incident? What are those and do you think they will prevent something like this from occurring again? Also, what were the repercussions for the surgeon and was anyone else investigated for potential fault? What happened to the family following this?
ReplyDeleteTanyaC: Now at Duke Hospital everyone involved directly in the transplant procedure is required to double check the blood type of the donor organs and the recipient. Additionally, investigations found Duke deficient in compliance with transplant regulations, but the hospital has since taken corrective actions to become fully compliant (very few details to be found on these since they were closed federal investigations). The Santillans did not file a lawsuit against the surgeon and Duke released statements of apology, but did not admit error on their part in order to avoid lawsuits since the surgeon is not a Duke employee. But, the hospital reached a settlement privately with the family, the details of which were not released to the press. Duke never billed the family for Jesica's treatment and Ms Santillan continued to run the charity that began raising money for Jesica which expands awareness about organ donation. Overall, I think that this case represents deficiencies in following simple rules which were already in place that then resulted in a public relations nightmare. The case has not kept media attention since it occurred in 2003, and I could not find any current reports on the surgeon or the Santillan family.
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