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Nail 22 year old woman and one teenager 15 have died after receiving two kidneys of the same donor infected with Herpes simplex virus (HSV), as the association The Patient Advocate has made public. The case led the National Transplant Organization (ONT) to review its protocols of action in collaboration with scientific societies.
As reported by the Virgen del Rocío Hospital in Seville in a statement, a third patient he also died after receiving handkerchiefs of the donor, although in this case not by the infection but for "the basic pathology of the patient and the complexity of the intervention" to which he was subjected.
The graft both kidneys was performed on June 30th and was satisfactorily transmitted. Both patients showed good progress during the first days, although their recovery was soon after interrupted by a fulminant infection caused by HSV. The teenager died on July 10, while the young woman died the next day.
The hospital immediately launched an investigation to clarify some facts that Beatriz Domínguez, director of the ONT, described as "absolutely exceptional". "Each year, more than 130,000 transplants are performed around the world and we found only 10 similar cases since the 1970s," Dominguez says.
"The herpes virus is very common." The World Health Organization estimates that nearly 70% of the population is already infected and protected against the virus, so specific tests are not included in the test. the protocols nor in international recommendations, "adds Domínguez.
According to the hospital and the ONT, in this case, it appeared that neither of the two recipients was naturally immune to HSV. In addition, the donor had a recent, asymptomatic infection with the virus, which should have occurred shortly before his death. Analyzes conducted during the investigations to clarify what happened revealed that the first samples taken from the donor gave a negative result, while the last samples were positive. ONT is currently studying whether this fact can be clinically relevant.
"Whether it's a special case That does not mean that what happened was a very hard blow, "laments Domínguez. First of all for the patients and their families, tragically interrupted by grafts that have evolved favorably. This was also the case for the entire medical team involved and for the transplant network. That is why we have opened a review process with the scientific companies involved to determine if there is a need to introduce changes in the protocols. The goal is to minimize risks as far as we can, but we also need to know that there is no zero risk, "added the ONT director.
In similar terms, the hospital has manifested itself, which, in one statement, deeply regrets the death of both patients. The health center reminds that "the professionals have applied with the utmost rigor the international recommendations to avoid the transmission of diseases during the transplant and the protocols of the ONT". "The virus," says the hospital, "could not be detected in the absence of clinical data that might suggest its existence."
Ángeles López, mother of the deceased patient, criticizes the fact that "the appropriate prophylactic measures have not been taken to prevent the transmission of the virus". "There have been few previous cases, but there have been cases, it should have been taken into account and not done," the woman criticizes. The Association Patient Advocate, who publicly denounced the case, asked the senior prosecutor of Andalusia to open a procedure to clarify what happened and, if so, "debugging responsibilities"
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