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Inadvertent completely HLA-mismatched allogeneic unrelated bone marrow transplant: lessons learned

Bone Marrow Transplantation volume 51, pages 1016–1018 (2016)Cite this article

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We here report a serious adverse event in which a patient was transplanted with stem cells from an incorrect donor due in large part to the inappropriate use of a supposedly unique donor identifier. The purpose of this report is to make the international transplant community aware of this severe adverse event, which has the potential to occur anywhere, and to emphasize the importance of a global unique donor identifier.

Allogeneic haematopoietic stem cell transplantation is a widely used treatment, and potentially curative for a variety of malignant and certain life-threatening non-malignant diseases.1 When no suitable sibling donor can be found, a search for a suitable HLA-matched unrelated donor is initiated.2, 3 The search for a potential unrelated donor is performed in international databases, which contain data and HLA type on voluntary stem cell donors and managed by stem cell donor registries. The process of searching and selecting a donor and whom to contact is a complex procedure.4 The search is initiated on behalf of the requesting transplant center and usually performed through the local registry. The search creates a search report listing all potential donors from different countries and registries, each associated with a unique donor identifier. When a donor of interest is identified on the search report, further information has to be gathered from the donor (e.g., health information) and HLA typing needs to be verified. To that end, information and blood samples are exchanged between institutions. Subsequently, if the donor is found to be a suitable match, donor is recalled for workup, and again, information has to be exchanged between institutions (i.e., updated health information and transport of stem cell products). Usually donors are managed by donor- and collection centers, whereas the registry maintains the donor database and the search, but the organizational relationships between registries and donor centers vary. Registries may act as a donor center or can cooperate with one or several independent donor centers and/or collection centers. Regardless of organization, this procedure involves communication between many institutions: transplant centers, registries (national and international), donor centers and collection centers. Often pre-workup communication happens between registries, whereas communication in the workup and collection process can be directly between transplant center and donor/collection center. One crucial item throughout this communication is the unique donor identifier. The unique donor identifier is used for identification of donor both in communication between institutions and inside institutions, and for correct identification of blood samples and stem cell products. The World Marrow Donor Association (WMDA) standards state that each donor should be given a unique donor identifier.5 The unique donor identifier is used to ensure confidentiality and anonymity of the donors, so that the identity of the donors and their rights are protected. The number must be unique to ensure traceability between donors and their associated data, and biological material and their participation in the donation process in long term.

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Authors and Affiliations

  1. Department of Clinical Immunology, The Danish Bone Marrow Donor Registry, Aarhus University Hospital, Aarhus,, Denmark

    B S Sorensen

  2. World Marrow Donor Association Serious (Product) Events and Adverse Reactions (WMDA S(P)EAR) committee, Leiden, The Netherlands

    J Szer, B Shaw, M Korhonen, T Mengling, M Fechter, H Elmoazzen, B Lindberg, J Chapman, L Foeken & W Y K Hwang

  3. Department of Clinical Haematology and BMT Service, The Royal Melbourne Hospital, Melbourne, VIC, Australia

    J Szer

  4. CIBMTR, Froedtert and the Medical College of Wisconsin, Milwaukee, WI, USA

    B Shaw

  5. Finnish Stem Cell Registry, Finnish Red Cross Blood Service, Helsinki, Finland

    M Korhonen

  6. DKMS German Bone Marrow Donor Center, Tübingen, Germany

    T Mengling

  7. Europdonor Foundation, Leiden, The Netherlands

    M Fechter

  8. Canadian Blood Services, Ottawa, ON, Canada

    H Elmoazzen

  9. National Marrow Donor Program, Minneapolis, MN, USA

    B Lindberg

  10. Medicine and Cancer, Westmead Hospital, Sydney University, Westmead, NSW, Australia

    J Chapman

  11. Department of Hematology, Aarhus University Hospital, Aarhus, Denmark

    J M Nørgaard & B Nielsen

  12. World Marrow Donor Association, Leiden, The Netherlands

    L Foeken

  13. Singapore General Hospital and Duke-NUS, Singapore, Singapore

    W Y K Hwang

Authors
  1. B S Sorensen
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  2. J Szer
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  3. B Shaw
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  4. M Korhonen
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  5. T Mengling
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  6. M Fechter
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  7. H Elmoazzen
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  8. B Lindberg
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  9. J Chapman
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  10. J M Nørgaard
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  11. L Foeken
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  12. W Y K Hwang
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  13. B Nielsen
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Corresponding author

Correspondence to B S Sorensen.

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The authors declare no conflict of interest.

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Sorensen, B., Szer, J., Shaw, B. et al. Inadvertent completely HLA-mismatched allogeneic unrelated bone marrow transplant: lessons learned. Bone Marrow Transplant 51, 1016–1018 (2016). https://doi.org/10.1038/bmt.2016.59

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