BY JOYCE ROMINE
Scientists and physicians experimented with organ transplantation using animals and humans as early as the 18th century. And though replacing a failing organ with a foreign organ has always been a significant surgical feat, it alone couldn’t save lives. Once the new organ was in place, the recipient’s body strenuously objected, mounting a deadly response. For decades, organ rejection was the stumbling block, the thing that drove researchers back to their labs, where they worked for decades looking for answers.
It wasn’t until these pioneers gained an understanding of the human immune system and subsequently developed anti-rejection drugs to circumvent it that organ transplantation became a lifesaving technique for hundreds of thousands of people.
The history of organ transplant circumnavigates the globe and includes a long list of researchers and surgeons. Here’s how it unfolded at Washington University and Barnes-Jewish Hospital.
William Newton, MD, performs the Midwest’s first kidney transplant.
A surgery team performs the first living-donor kidney transplant.
The kidney transplant program begins, led by Charles Anderson, MD, a pioneer in using blood transfusions to induce tolerance.
Washington University researchers were pioneers in preventing organ rejection by inducing tolerance. The process involves introduction of cells from the organ donor into the recipient (a relative of the donor) via blood transfusion. Performed before transplantation, the transfusion gives the recipient’s immune system time to build tolerance to specific foreign cells. “A lot of immunology research happened as a result of inducing tolerance through transfusion,” says Gregorio Sicard, MD, emeritus professor of surgery and radiology at Washington University School of Medicine. “The technical aspect of putting in a kidney wasn’t the hard part. The immune response and rejection that kills the organ after transplant was the hard part and where the field has evolved.” Ultimately, the advent of immunosuppression drugs eliminated the need to induce tolerance.
Gregorio Sicard, MD, becomes the first transplant fellow at the hospital and joins its new kidney transplant team. In subsequent years, the team makes presentations throughout the world and hosts visiting transplant teams.
The Food and Drug Administration approves cyclosporine, an immunosuppressive drug that helps prevent organ rejection, for clinical use in the U.S. As a result, transplantation programs proliferate.
The liver transplant program begins, one of nine in the U.S. and the 16th program in the world at that time.
The heart transplant program begins. Ralph Bolman III, MD, formerly of the University of Minnesota, leads the team, bringing with him an immunosuppression protocol that becomes the standard of care.
The lung-transplant program begins, one of the earliest of its kind in the U.S. Pulmonologist Bert Trulock III, MD, is named medical director. Joel Cooper, MD, who performed the world’s first successful single-lung transplant surgery in 1983 and the first successful double-lung transplant in 1986, both in Toronto, joins the team.
Advances in lung transplant
The human lung’s propensity for infection and rejection rendered it the last of the major organs to be successfully transplanted. Joel Cooper, MD, was a pioneer in this field, training new specialists who subsequently developed advances. Alexander Patterson, MD, now a Washington University cardiothoracic surgeon, trained with Cooper in the 1980s, then joined the hospital as surgical director in 1991. Patterson and colleagues performed some of the earliest successful single-lung transplants in people with chronic obstructive pulmonary disease. And their research initiatives led to improved organ preservation techniques now used in transplant programs throughout the world. “Because we were one of the first centers to perform lung transplants, we have served as a model for other programs in the U.S.,” Trulock says. John Lynch, MD, a former transplant physician and the current president of Barnes-Jewish Hospital, notes that as the lung-transplant program gained prominence, specialists from around the world visited the hospital to observe lung-transplant surgeons and nurse coordinators.
A surgery team performs the first single-lung transplant procedure in a patient with pulmonary hypertension.
COLLABORATION, COORDINATION AND INTERDISCIPLINARY EXPERTISE DRIVE MORE INNOVATION IN ALL AREAS OF TRANSPLANT..
A surgery team performs the world’s first laparoscopic nephrectomy, removing a kidney from a living donor using a minimally invasive method.
Surgeons Alexander Patterson, MD, and Joel Cooper, MD, FACS, (now at the University of Pennsylvania) develop a procedure that becomes the gold standard for double-lung transplants and offers people with cystic fibrosis the option of transplantation.
A surgery team performs the first adult liver transplant in the U.S. that uses an organ from an unrelated, living donor.
Surendra Shenoy, MD, removes a kidney from a living donor using his innovative procedure, called mini-nephrectomy, which results in a 2-inch incision and allows for faster recovery times. Shenoy, director of the living-donor program, and colleagues use this technique to advance paired exchanges, which match living donors and recipients at the hospital and throughout the U.S.
William Chapman, MD, chief of abdominal transplant surgery, pioneers a program to treat bile-duct cancer with transplantation.
Better outcomes in liver transplantation
Jeffrey Crippin, MD, the former medical director of liver transplant and current co-chair of the Transplant Steering Committee, notes that, in the early days of liver transplantation, some patients were not good candidates for the surgery or would have poor outcomes, given the types of disease they had. “For example, when a patient with liver cancer had a transplant, the cancer frequently returned after surgery. Today we have better ways to manage that disease.” A better understanding of anti-rejection drugs—powerful medications that affect patients’ lives after transplantation—has also improved outcomes. “We’ve found that, for liver transplants, we can use less anti-rejection medication than for other types of transplant surgeries,” Crippin says.
WILLIAM CHAPMAN, MD, (AT RIGHT) CHIEF OF THE ABDOMINAL TRANSPLANTATION SECTION, PERFORMS LIVER TRANSPLANT SURGERY.
Photo courtesy of Barnes-Jewish Hospital
The pancreas transplant program begins—and now performs 15 to 20 such procedures annually.
The Washington University and Barnes-Jewish Transplant Center is formed, bringing all solid-organ transplants, including heart, lung, kidney, liver and pancreas, into a single center.
Strength in unity
When the various transplant programs joined together to form a single center, they combined their reputations for excellence in outcomes, research and innovative protocols. As a result, the Transplant Center is now a national leader, helping to set policy governing donor-organ allocation and use. Gene Ridolfi, director of the Transplant Center, says, “This model allowed us the opportunity to standardize the various programs, and adopt policies and procedures that safeguard quality and outcomes for our patients.” He adds that the “collaboration, coordination and pooling of resources and interdisciplinary expertise drive more innovations in all areas of transplant.”
Researchers at Washington University and 13 additional medical centers begin studying a new process for preserving and improving donor livers after procuring them.
Improving organ viability
In 2001, Washington University and Barnes-Jewish Hospital worked with Mid-America Transplant, an organ-procurement organization, to establish an organ recovery center, the first collaboration of its kind in the world. The facility is located two miles from the hospital, where it serves three additional centers and another 120 acute-care hospitals. “This concept is gaining momentum,” says William Chapman, MD, adding that the organ recovery center works to increase the number of donor organs that are healthy and viable for transplantation.
THORACIC SURGEONS DANIEL KREISEL, MD, PHD, (LEFT) AND VARUN PURI, MD, PERFORM A PROCEDURE AT MID-AMERICA TRANSPLANT TO RECONDITION LUNGS PRIOR TO TRANSPLANTATION.
Image courtesy of Mid-America Transplant
The Transplant Center’s team of liver surgeons performs an all-time high of 132 transplants in one year. Kidney transplants at the center also increase from 100 to 250 for the year.
A Transplant Center team performs the center’s 10,000th organ transplant. The recipient received a kidney from a living donor identified through the hospital’s internal paired-exchange program.
The future of heart transplant
A device called an LVAD (left ventricular assist device) has changed the life-or-death wait for some people who need a new heart. In some cases, a surgeon can attach an LVAD to a patient’s left ventricle, where it will work to keep the heart pumping while the patient waits for a donor heart to become available. Greg Ewald, MD, medical director of the heart transplant program, has been involved in the evolution of LVADs since they were developed more than 20 years ago. “When I joined the team in 1997, some patients waited in the hospital for a year for a transplant,” he says. “Then LVADs came along, and we could implant them in some patients who could then live outside the hospital and be in better shape for transplant when the time came.” Ewald believes the future of heart transplant will change because of improvements in mechanical assist devices such as the LVAD. “As a result, many patients may get an LVAD instead of a new heart and will survive just as well. I think we will see more device therapy tailored to people who need transplants. There are a lot of advances ahead of us.”