Autopsy after Tissue/Organ Donation
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Autopsy after Tissue/Organ Donation

By 3 Aug 2025October 6th, 2025No Comments

Authors: Amanda Saunders MD MBA & John Walsh* MD MHPE

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Background

  • Autopsy after organ and tissue donation is a common practice, however there are special considerations to take into account in these circumstances. Typically, decedents were inpatient in a hospital prior to organ donation and the pathologist may be aware of the case before organ transplantation is performed.
  • The opportunity to provide a comprehensive final medical report (autopsy) to a family and clinical team after organ procurement can be a challenging but rewarding undertaking. 
  • Almost any tissue and or organ has donation potential. Examples include but are not limited to skin, long bones, ligaments, organ(s), and cornea. 
    • Donation /procurement can occur in various combinations of tissue and organs depending on the clinical circumstances,  family’s wishes, and examining pathologists’ needs. 
  • Close communication among the surviving family members, clinical team, and organ procurement team is critical to a successful autopsy after organ donation. Proactive clear communication of needs and expectations as well as capabilities and limitations of autopsy after organ donation will help prevent downstream issues. 
    • Having a conversation between the surgeon and pathologist prior to organ procurement can ensure all parties are comfortable with what organs are being donated and what may be required for proper death investigation. 
    • Additionally, speaking with the clinician who treated the patient and reviewing all medical records is often a valuable and readily available source of information, especially if the autopsy is being performed in the hospital where the patient passed. 
  • While some clinicians may be hesitant to allow organ / tissue donation to proceed, in cases where an autopsy is known or likely to be performed, research indicates it does not appear to impact the quality of the autopsy. A study in Australia showed that out of 177 deaths that occurred in a 4 year period, there were no cases where the organ donation was thought to negatively impact findings or determination of the cause of death, and only 10 cases where the medical examiner restricted the organs that could be procured . 
  • In the United States, medical examiners are able to authorize or deny organ donation on a case-by-case basis, balancing the wishes of the patient and family and ensuring a proper diagnosis can be rendered. The National Associations of Medical Examiner’s official stance is that organ procurement can be performed in almost all cases without detriment to the evaluation or determination of cause of death. This further supports the idea that this should be an accepted practice and not a concern to autopsy pathologists or clinicians. 
  • Organ transplantation can also, albeit rarely, be associated with donor derived tumors or infections being transmitted to the recipient which makes the results of the autopsy relevant to both the decedent and the organ recipient. Due to this risk, the autopsy should be performed as early as possible and should include a search for occult malignancy as well as toxicology, virology and bacteriology when relevant. Additionally, hospital blood samples should be kept in case additional testing is required, which is why relationships between pathologists and local hospitals are so important. Despite implications to the recipient of the donated organ, it is important to remember that the purpose of the autopsy is still to determine the cause of death of the deceased and provide answers to surviving family members and clinical teams. 

Quick Tips at Time of Autopsy

Clinical History

  • In many cases, history will be provided by the hospital where the patient died and should contain the clinical course, interventions and any relevant diagnoses. This history is often very thorough as screening must be done prior to organ donation to ensure no rejection criteria is met such as ongoing infections, drug abuse, or transmittable medical conditions. Emergency medical records may also be a valuable source of information, especially if the patient died shortly after arriving at the hospital.  If while reviewing the records the death is thought to be suspicious or due to medical errors, the case may be referred to a medical examiner to perform the autopsy. 

External examination

  • The external examination should not be altered by the donation of organs, but evidence of relevant medical procedures associated with organ procurement should be noted. 
  • Some pathologists may choose to create a separate autopsy documentation section that addresses “Evidence of Organ / Tissue Donation or Procurement.” This may help to alleviate confusion about where to place certain findings ie; external vs internal vs medical intervention sections of the autopsy report. Findings and example descriptions:
    • Sutured incisions on body.
    • Displacement and or removal of organs or other tissues:
      • “A sutured incision is present on the chest, the ribs are previously cut and the pericardium previously opened with the heart being absent and the lung displaced from their usual anatomic position.”
    • Placement of foreign material into the body:
      • “Sutured incisions are present on the bilateral lower extremities with the placement of wooden dowels into the soft tissue as replacement for long bong harvesting.”

Internal examination

  • While it is critical to perform a thorough autopsy, special consideration can be given to organs that pose the greatest risk of carrying an occult malignancy such as the kidneys, lungs, mediastinum, ovaries or testis, and thyroid. Additionally, the lymph nodes should be examined for lymphadenopathy or malignancy (lymphoma vs metastatic). If lungs are present, assessing for acute vs chronic tuberculosis should also be done as well as checking for myocarditis if the heart is present. Examination of the brain is also important as changes may be seen that resulted in brain death to the patient and meningitis, encephalitis and tumor may also be assessed. 
  • Any missing organs as well as evidence of recent transplant surgery should be documented in the final report and compared to the medical records. 

Ancillary Testing

  • Specific testing is often not needed simply because organ(s) / tissue(s) have been donated, but rather may be indicated depending on the cause of death. If blood was collected while the patient was admitted, testing for alcohol or drug abuse is relevant if this was not already done. 
    • It is important to understand the difference between a hospital drug screen and a forensic toxicology panel in scope of testing, modality, and cost. 
  • Additionally, if the patient died of trauma and received a massive transfusion, hemodilution calculations should have been performed before donation and may also be relevant to the pathologist. 
  • Microbiology evaluation is warranted if there are any infectious appearing wounds and a swab can be submitted for testing and/or fresh brain if an infectious cause of death is suspected. Skin and liver may also be sampled if a metabolic disorder is in the differential. 

Quick Tips at Time of Histology Evaluation

  • Histology plays an important role in evaluating cause of death for the decedent as well as determining if there is any relevant pathology for recipients. Any lesion that could represent a tumor or infectious process should be sampled and carefully examined or stained for organisms. If the death was unexplained, sampling of the heart to evaluate for hypertrophic cardiomyopathy or myocarditis may provide helpful information. Ideally, the brain is properly fixed over several weeks and examined by a neuropathologist, but if this is not feasible, fresh samples can be used as well. 
  • Additionally, in some cases, transplanted organs are biopsied at the time of transplantation, so additional data may be available from these reports. This becomes especially important if there are unexpected changes found in the postmortem pathology. 
    • Autopsy pathologists should work diligently to ensure that they receive all final reports from the procurement team that are associated with examination of harvested organ(s) / tissue(s). 

Recommended References

Additional References

* The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of Navy, Naval Construction Group (NSG) TWO, Uniformed Services University of Health Science, Defense Health Agency, U.S. Navy Bureau of Medicine and Surgery, Department of Defense, or the US Government. The authors report no conflict of interest or sources of funding.

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