Carlo Massimetti1, Antonio Bellasi2, Antonio Modoni3, Vito Gomes4, Sandro Feriozzi1
1 Renal Division, Belcolle Hospital, Viterbo, Italy
2 Research, Innovation and Brand Reputation, ASST Papa Giovanni XXIII, Bergamo, Italy
3 Vascular Surgery, Belcolle Hospital, Viterbo, Italy
4 Division of Surgical Pathology, Belcolle Hospital, Viterbo, Italy
Renal Division, Belcolle Hospital,
Via Sammartinese, snc
01100 Viterbo, Italy
Tel. +390761338604, Fax +390761338600,
Calcific uremic arteriolopathy (CUA) is a highly morbid condition usually found in ESRD patients that has rarely been reported after renal transplantation and renal function restoration. Furthermore, little is known about the optimal management of CUA in this setting. Herein, we report on the clinical case of AB, a 70-year-old woman who developed CUA after renal transplantation and renal function restoration. However, other risk factors for CUA such as diabetes and warfarin treatment, due to mechanical aortic valve implantation, were present. Thirty-eight months after renal transplantation she developed erythema and livedo reticularis in both legs and a gradually enlarging skin ulcer in the right leg. A skin biopsy of the ulcer showed features compatible with the CUA, such as sub-intimal calcification and luminal obstruction of the small dermal arterioles, tissue ischemia and signs of adipocytes degeneration. A multidisciplinary approach was adopted, including medical and non-medical treatments such as surgical debridement and vacuum-assisted closure therapy. Medical treatments included a five weeks course of once a week intravenous infusion of pamidronate and intravenous sodium thiosulfate (STS) at increasing doses. Four months after beginning the therapy with STS, a complete healing of the ulcer on the right leg and the disappearance of the livedo reticularis on the left leg was noted. In conclusion, although rare CUA may develop also in renal transplanted patients, a timely and combined therapeutic approach is essential for its resolutive treatment. Sodium thiosulfate therapy has proven to be effective and tolerated.
Calcific uremic arteriolopathy (CUA) or calciphylaxis is a rare and highly morbid condition that is found mainly in patients whit end-stage renal disease (ESRD)  and it has been reported only in a few clinical cases of renal transplant patients. Though largely unknown, CUA etiology is multifactorial and several elements such as hyperphosphatemia, secondary hyperparathyroidism (SHPT), use of vitamin K antagonists, diabetes mellitus, chronic inflammatory states, and female gender are thought to portend high risk of CUA [1–3]. The clinical presentation of CUA is usually characterized by skin lesions, preceded by intense pain and livedo reticularis that tend to progress to ischemic/necrotic ulcers . Some histological features can be identified at skin biopsy, such as dermal arteriolar calcification, intimal hyperplasia, thrombotic occlusion and tissue necrosis . At present, there is no established care of CUA aside of risk management and a multifaceted approach, rather than a single agent or treatment, is usually advocated [1, 2]. Many treatments for CUA have been proposed and, while no blinded randomized studies have taken place for any of these treatments, sodium thiosulfate (STS), either by injection or intravenous administration, is one of the most commonly utilized treatments, along with stringent wound care regimens.
In the last ten years, STS has received considerable attention and it is currently the most commonly used therapy for CUA. The beneficial effects of STS are thought to be due to its ability to promote the solubility and mobilization of calcium crystals from soft tissue calcifications [4, 5]. Furthermore, STS is known to be a powerful antioxidant agent . Other lines of evidence suggest that STS may improve vascular endothelial function and promote vasodilation, reduce vascular smooth muscle cells proliferation and restore proper hepatic synthesis of albumin and fetuin-A; all these factors can contribute to reduce vascular calcification [3, 5] and may also explain the rapid improvement of pain, commonly reported by patients after initiation of STS infusion [3, 5]. Other drugs that have been used in CUA are bisphosphonate and cinacalcet, while a novel compound SNF-472 is currently under investigation [6, 7]. Although some promising results have been reported, the use of these compounds in CUA is based on case reports or case series and no randomized clinical trial (RCT) has been conducted in this domain. Several questions about the use, schedule, dosage and administration of these drugs in different patients remain unresolved, especially in renal transplant patients, in which CUA is an extremely rare condition.
In March 2012, a 70-year-old woman received renal transplantation and started taking prednisone, everolimus, and cyclosporine as immunosuppressive regimen. Nine months after renal transplantation, she underwent percutaneous mechanical aortic valve implantation and was started on warfarin. In June 2014 she developed diabetes mellitus. In January 2016, she developed extensive erythema and livedo reticularis with palpable subcutaneous painful nodules in both legs and, few weeks later, she also developed a skin ulcer in her right leg that gradually expanded (Figure 1). The ulcer was initially treated with surgical debridement and vacuum-assisted closure (VAC) therapy. At this time, the main laboratory tests showed an estimated glomerular filtration rate (eGFR; CKD-EPI) of 28 mL/min per 1.73 m2, serum PTH levels 329 pg/mL, corrected serum calcium levels 10.4 mg/dL, serum phosphate 3.8 mg/dL, and C-reactive protein levels 110.6 mg/L (reference range, <5 mg/L). To shed light on the nature of the skin lesion, a skin biopsy was performed in March 2016, showing features compatible with CUA, such as sub-intimal calcification and luminal obstruction of the small dermal arterioles, tissue ischemia and signs of adipocytes degeneration (Figure 2). Because anti-vitamin K agents, such as warfarin, have been associated with CUA , the case was discussed with the cardiac surgeon and the hypothesis to replace warfarin with direct oral anticoagulants, such as dabigatran or low-molecular weight heparin (LMWH), was evaluated. However, she was continued on warfarin because of a study conducted on patients carrying mechanical valves, showing that patients treated with dabigatran have an excess of thromboembolic and bleeding events, compared with the warfarin group . Another reason was the lack of data on the chronic use of LMWH in patients with prosthetic valves, with indications for short-term anticoagulation therapy only (generally for bridging while vitamin K antagonists therapy is being initiated or temporarily discontinued) .
Because of the unavailability of STS at that time (off-label indication) and in consideration of the secondary hyperparathyroidism (SHPT), it was decided to start treatment with oral cinacalcet (30 mg/day) and intravenous pamidronate (Aredia® 30 mg a week for five weeks), according to what reported by the scheme of Monney et al.  and Floege et al. . However, cinacalcet was soon discontinued due to the appearance of nausea and vomiting (common side effects of cinacalcet therapy), while treatment with pamidronate only partially reduced the pain and the extent of the ulcer. Then, in July 2016, intravenous STS treatment was started at a dose of 12.5 g two times a week, monitoring arterial blood gas and blood pressure . One month after starting therapy with STS a significant reduction in pain was subjectively reported by the patient. Hence, the administration of STS was increased from two to three times a week. Four months after the beginning of the therapy with STS, a complete healing of the ulcer was documented (Figure 3). Notable side effects of STS were nausea, vomiting, metabolic acidosis, hypotension, hypocalcaemia, QT prolongation, and volume overload . During STS treatment the main clinical and biochemical parameters did not change; in particular, the acid-base balance remained unchanged, while there was a significant reduction in both C-reactive protein levels (from 110.6 to 3.5 mg/L) and white blood cell count (from 13,600 to 7,530 per mm3) (Table 1). During treatment with STS, blood glucose and glycated hemoglobin levels did not require special changes in the diabetes mellitus therapy. In fact, fasting plasma glucose levels were always <130 mg/dl (v. n. 60-110 mg/dl) and those of glycated hemoglobin ranged from 38-57 mmol/mol (v. n. 20-42 mmol/mol). The treatment for diabetes mellitus was based on the use of a mixture of insulin lispro solution, a rapid-acting blood glucose-lowering agent, and insulin lispro protamine suspension, an intermediate-acting blood glucose-lowering agent (Humalog® Mix 50/50™). Also, no significant electrocardiographic changes were noticed during STS therapy. Although the patient reported nausea and vomiting during the first two months of therapy, these side effects were never considered by her or by the attending physicians so severe to require STS suspension and were easily controlled with the use of antiemetics. Currently, the patient has no clinical signs of disease activity.
Although typically associated with ESRD, the diagnosis of calciphylaxis must be considered even when treating renal transplant recipient. The early detection of CUA enabled us to treat the problem in the best possible way, including the removal of risk factors for the CUA, multimodal treatment with wound care, VAC therapy, pamidronate, and STS. In the treatment of CUA, one of the main steps is to try to correct its potential risk factors.
In our clinical case, SHPT and warfarin therapy were the 2 identified modifiable risk factor associated with CUA [3, 5]. In order to correct the SHPT without increasing the calcium and phosphate balance, we tried administering cinacalcet, that in Italy can be prescribed in renal transplanted patients with SHPT and hypercalcemia. Although CUA has been more commonly associated adynamic rather than high bone turnover disease , we decided to start cinacalcet therapy because, according to K/DOQI guidelines , our patient had markedly elevated serum parathyroid hormone and calcium, a condition that contraindicated the use of vitamin D or vitamin D analogues (which increase the risk of hypercalcemia), and because their use has been associated by some authors with CUA [3, 5]. In contrast, in a recently published post hoc analysis of the EVOLVE trial, treatment of SHPT with cinacalcet was associated with a 69-75% reduction in the risk of CUA . Unfortunately, cinacalcet was stopped after a few days of treatment due to the onset of nausea and vomiting. The other modifiable factor in our patient was represented by warfarin therapy . Knowing the strong association between warfarin and CUA, we investigated the hypothesis of replacing warfarin with a new oral anticoagulant such as dabigatran or low-molecular weight heparin (LMWH). However, the cardiac surgeon advised against its use because a study conducted on patients carrying mechanical valves showed that patients treated with dabigatran have an excess of thromboembolic and bleeding events as compared with the warfarin group . Similarly, the replacement of warfarin with LMWH was excluded as these are only indicated in patients with prosthetic valves for short-term therapy, generally for bridging while vitamin K antagonists therapy is being initiated or temporarily discontinued .
Medical treatment that can be administered in cases of CUA are biphosphates and sodium thiosulphate (STS) [3, 5]. We used pamidronate as first line agent because STS was not available when the diagnosis was made. Pamidronate seems to inhibit some factors involved in vascular calcifications deposition, osteoclast activity as well as the secretion of proinflammatory cytokines by macrophages . Although pamidronate has been shown to be effective in the treatment of CUA, data in the literature are scanty . To date, the use of STS represents the most important advance in the treatment of CUA and its he beneficial effects are thought to be due in part to its ability to enhance solubility and mobilization of calcium crystals from the soft tissue calcifications [1, 5]. Furthermore, STS is also a powerful antioxidant agent, further corroborating the hypothesis that may exert a positive effect on vasculature . Although based on case reports, data suggest that STS has a number of positive effects including improvement of vascular endothelial function and vasodilation, reduction of vascular smooth muscle cells proliferation as well as restoration of hepatic synthesis of albumin and fetuin-A . Although some authors suggest a therapeutic algorithm for CUA treatment, it is still not clear what is the optimal dose of STS . The dosage regimens most widely adopted in dialysis patients ranges from 20 to 25 grams three to five times per week  but almost no data exists on the use of STS in patients with eGFR <60 mL/min/1.73 m2. However, as 20 to 50% of the administered dose of STS is eliminated unchanged in the urine, it seems reasonable to start therapy with a lower dose compared to dialysis patients. Hence, a reasonable approach is to start with a dose of 12.5 grams twice a week and titrate the dosage according to side effects and CUA evolution. In any case, it is preferable not to exceed 25 grams of STS three times per week in patients with eGFR <60mL/min/1.73 m2 [3, 5]. While there is some consensus on the need to start STS as early as possible, normally at the appearance of skin ulceration , the optimal duration of treatment with STS is currently unknown and it seems reasonable to continue the treatment until the complete resolution of ulcerative lesions, which can take up to several months .
Finally, Non-medical therapy is also part of CUA management: surgical or non-surgical debridement, VAC therapy, antibiotic treatment guided by microbiological results of wound swabs, as well as pain treatment with oral opioid, are commonly employed and should be considered on case by case.
This clinical case demonstrates that a diagnosis of calcific uremic arteriolopathy must be considered even in renal transplant patients presenting an ulcer of unknown etiology; early diagnosis and a prompt multimodal treatment approach, in fact, may allow for the complete healing of this rare disease.
Although STS is now the most common agent used to treat CUA, there is a great need for randomized controlled trials that help determine the optimum dosage of STS and the duration of treatment. Similarly, in light of the poor prognosis of CUA, data on the safety and efficacy of novel compound currently being tested, such as SNF-472 , are much awaited.
Mario Picozzi1, Federico Nicoli2, Gabriella Biffa3, Tullia Maria De Feo4, Renzo Pegoraro5, Giuseppe Piccolo6, Maria Antonella Piga7, Giuseppe Rossini8, Sergio Vesconi9, Aurelio Limido10
1 MD, PhD, Professore Associato di Medicina Legale, Direttore del Centro di Ricerca in Etica Clinica, Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell’Insubria, Varese, Italia.
2 PhD, membro del Centro di Ricerca in Etica Clinica, Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell’Insubria, Varese, Italia; referente del Servizio di Etica Clinica, Casa di cura Domus Salutis, Fondazione Teresa Camplani, Brescia, Italia.
3 U.O. di Psicologia Clinica e Psicoterapia, Ospedale Universitario San Martino, Genova, Italia.
4 MD, PhD, North Italy Transplant program, Fondazione IRCCS “Ca’ Granda Ospedale Maggiore Policlinico”, Milano, Italia.
5 MD, Cancelliere presso la Pontificia Accademia per la Vita, Città del Vaticano.
6 MD, Coordinatore regionale trapianti, North Italy Transplant program, Fondazione IRCCS “Ca’ Granda Ospedale Maggiore Policlinico”, Milano, Italia.
7 MD, Ricercatrice in Medicina Legale e del Lavoro, Università degli Studi di Milano, Italia.
8 North Italy Transplant program, Fondazione IRCCS “Ca’ Granda Ospedale Maggiore Policlinico”, Milano, Italia.
9 MD, membro del Comitato Esecutivo del Sistema Trapianti di Regione Lombardia, Milano, Italia.
10 MD, UO Nefrologia e Dialisi, ASST Fatebenefratelli e Oftalmico, Milano, Italia.
Center for Clinical Ethics
Biotechnology and Life Sciences Department
Università degli Studi dell’Insubria
Via Rossi 9 (pad. Antonini) 21100, Varese, Italy
Tel. (0039) 0332217500 / (0039) 0332217503
Mobile: (0039) 3339667968
Fax. (0039) 0332397509
Background: The amount of time spent in dialysis waiting for a renal transplantation significantly affects its outcome. Hence, the timely planning of patients’ transplant evaluation is crucial. According to data from the Nord Italia Transplant program (NITp), the average waiting time between the beginning of dialysis and the admission to the regional transplant waiting list in Lombardy is 20.2 months.
Methods: A multicenter cross-sectional study was conducted in order to identify the causes of these delays and find solutions. Two questionnaires were administered to the directors of 47 Nephrology Units and to 106 patients undergoing dialysis in Lombardy respectively, during their first visit for admission to the transplant waiting list.
Results: The comparative analysis of the results revealed that both patients (52%) and directors (75%) consider the time required for registering to the waiting list too long. Patients judge information about the transplant to be insufficient, especially regarding the pre-emptive option (63% of patients declare that they had not been informed about this opportunity). Patients report a significantly longer time for the completion of pre-transplantation tests (more than 1 year in 23% of the cases) compared to that indicated by the directors.
Conclusions: The study confirmed the necessity of providing better and more timely information to patients regarding the different kidney transplantation options and highlighted the importance of creating target-oriented and dedicated pathways in all hospitals.
Keywords: Renal transplantation, waiting list, active access to renal transplantation, questionnaire, Lombardy region
Carlo Massimetti1, Gea Imperato1, Sandro Feriozzi1
1Centro di Riferimento di Nefrologia e Dialisi, Ospedale Belcolle, Viterbo
Centro di Riferimento di Nefrologia e Dialisi, Ospedale Belcolle,
Strada Sammartinese, snc
Background – Left ventricular hypertrophy (LVH) is common in renal transplant recipients (RTRs), and persistent secondary hyperparathyroidism (SHPT) is considered to be one of the main causes of its pathogenesis. In this study we evaluated if the control of SHPT with paricalcitol is associated with a reduction of LVH in RTRs. Methods – For this purpose we selected 24 RTRs with LVH and SHPT . Secondary hyperparathyroidism was defined as PTH levels 1.5 times higher than the high normal limits, while LVH was defined as a left ventricular mass index (LVMi) >95g/m2 in females, and >115g/m2 in males. Treatment with paricalcitol started at mean dose of 1µg/day and lasted 18 months. The dose of paricalcitol was reduced to 1µg on the other day when serum calcium was >10.5mg/dl and/or fractional excretion of calcium was >0.020%; administration was temporarily stopped when serum calcium was >11 mg/dl. Results – At follow-up PTH levels decreased from 198 ± 155 to 105 ± 43pg/ml (P < .01), and LVMi decreased from 134 ± 21 to 113 ± 29g/m2 (P < .01); the presence of LVH decreased from 100% at baseline to 54% at F-U. Serum calcium levels showed a modest and not significant increase. Renal function was stable in all patients. Conclusions – Secondary hyperparathyroidism seems to play an important role in the development and maintenance of LVH and its correction with paricalcitol has a favorable impact on its progression.
Keywords: left ventricular hypertrophy; parathormone; paricalcitol; renal transplantation; secondary hyperparathyroidism
The “prehistory” of organ transplantation began in the 19th century, and clinical transplantation might have begun in the 1920s, decades earlier than it did. Organ transplantation required surgical vascular anastomoses, achieved in the late 19th and early 20th centuries. Guthrie and Carrel showed from 1902 that autografts could function, and along with others attempted renal xenografts. But the main result of this activity was the emergence of the idea that some “biological incompatibility” caused their failure.
Its complexity was realized as the many components of the immune reaction were identified – particularly lymphocytes. Modification of this “bio-incompatibility” using benzol, gamma radiation and nitrogen mustard were rapidly described. Thus by the early 1920s, the possibility of organ transplantation with suppression of the reaction by chemical agents and/or irradiation became possible, but in fact were delayed for another 30 years. During the 1920s organ transplantation was hijacked by dubious practices, such as “monkey gland” testis xenografts. Work in the area was shunned as career-damaging for serious scientists.
In 1935 Voronoy first realized the potential of the newly-dead as cadaver donors, but all his grafts failed. Around 1950 transplantation again became a problem which surgeons were prepared to attack, principally in Boston and in Paris. Although all the 30+ grafts in the next 5 years failed, much was learned. Then as predicted by skin transfers, identical twins were transplanted – and succeeded. For other grafts no modification was used at first, but from 1958 radiation was used, new drugs such as corticosteroids then 6-MP and azathioprine were synthesized, and transplantation was launched.
Keywords: Renal transplantation, history of transplantation, immunology of transplantation
Two years ago I had the privilege of addressing the IAHN on the “prehistory” of dialysis, from the first ideas of fluid flow in tissues and in vitro systems in the 18th century, until the first successful clinical dialysis in the 1940s. I now have the additional privilege to address the parallel evolution of the “prehistory” of renal transplantation, from first attempts at free skin grafting in the 18th century to the first successful organ grafts in the 1950s and 60s.
The idea of organ transplantation is deeply embedded in myth, such as the legend of the elephant-headed Ganesha in India, and more recently the much- illustrated (in more than 100 churches) story of the brothers Cosmas and Damian, and their leg transplant from a (dead) moor into a sacristan (1) (Figure 1). In reality, although skin pedicle auto-grafting was invented in India in 600 BC, subsequent attempts to make use of this treatment in injured and burnt patients as free grafts showed that only skin cropped from other areas of the same individual would persist. Much uncertainty remained, however, because whether or not a skin graft had “taken” lacked any good criterion for judgement until the 1950s. The story of skin grafting lies outside my own remit but see Brent (2) Hamilton (3) and Woodruff (4) for details. Likewise tooth “transplantation” has a long history with had a vogue particularly in the 18th century, fuelled by John Hunter’s interest in the subject, but again there was no actual transfer of living tissue, although implantation of teeth persists today.
Organ transplantation: the anastomosis of blood vessels
Organ transplantation in any form had to await techniques of joining blood vessels – vascular anastomosis. Advances in surgery including anaesthesia allowed attempts to do this in the second half of the 19th century. The pioneers who first attempted this difficult task included Nicolai Vladimirovitch Eck (1849-1917) a Russian physiologist (Figure 2) who in 1877 performed what may be the first vascular (venous portocaval) anastomosis in a dog, using silk sutures. John Benjamin Murphy (1857-1916) of Illinois performed an end-to-end arterial vascular repair after a femoral gunshot wound using the same technique in 1897 which was widely publicisedand discussed. For smaller vessels, others in the 1890s used stents of glass or ivory, but Erwin Payr (1871-1946) of Graz in Austria (Figure 2) in the 1890s used magnesium stents which later dissolved, with success (5). Here I must stray – for not the only time – into the territory of the companion talk by Raymond Ardaillou: the talented French surgeon Mathieu Jaboulay (1860-1913) (see below Figure 3) and his colleagues in Lyon returned to careful interrupted silk anastomoses on everted ends of the vessel(s) in 1896, without a stent (6). Working in Lyon also – but in the anatomy, not the surgical department – was the subsequently famous and controversial figure of Alexis Carrel (1873-1944) (7, 8) (Figure 4) who is often credited alone as having solved the problems of vascular anastomosis and vascular transplantation.
Clearly Carrel, besides being a brilliant technician was also an original, imaginative and highly creative surgeon. He must have been aware of the work in Jaboulay’s department, but chose continuous suturing, with the stiches only penetrating part of the vascular wall. He was also able to obtain smaller and thinner needles and cotton thread. These he retained, but later turned to Jaboulay’s methods of stitching. He suggested the triangulation of a vessel with sutures still in use today, as well as the “Carrel patch”, again still in use more than a century later. In 1953 Comroe wrote:
“Between 1901 and 1910…Alexis Carrel performed every feat and developed every technique known to vascular surgery today..”
He was aiming to transplant endocrine glands which were at that time, together with their “hormones”, then a “hot” new topic. The need for his techniques was brought forcefully to the fore when in 1894 an Italian anarchist stabbed the French President Sadi Carnot in Carrel’s home town of Lyon, and severed his portal vein. Carnot bled to death because the surgeons in whose care he was could not suture the vessel, which Carrel could only lament – and did. In 1902 he published his work in a seminal paper in the journal Lyon Médical (7).
The difficulty is that he did not work alone, as so many accounts of his work imply. In 1904 after failing to obtain a senor surgical post in Lyon (we can speculate why), he emigrated to French Canada, then to on the United States. There after a period he entered the surgical laboratory of George Stewart in Chicago, to work under Charles Guthrie (1880-1963) (Figure 5), seven years younger than he (9).
But meanwhile interest in vascular anastomosis and organ grafting in Europe intensified: in 1902 (Imre) Emmerich Ullman (1861-1937) (Figure 6), a Hungarian from Pécs working in Vienna (10), using Payr’s stents, autotransplanted a dog’s kidney from loin to its neck, with some function surviving: the first autotransplant – alongside Carrel and Guthrie’s similar work, also in 1902 (see below). That same year Ullman went on to transplant a kidney from a dog into a goat, which amazingly functioned for some hours, but he did not pursue this research further. Also in Vienna in 1902 in another (the Second Medical) Clinic, Alfred von Decastello-Richtwehr (1872-1960) did similar dog-dog grafts using stents (11). Unappreciated at the time, he also showed a great fall-off in lymphocytes following tying-off the thoracic duct. Again there was no follow-up to either observation. Decastello also described blood group AB in 1904, and myeloma kidney in 1909, and deserves to be better known. Another less well known observation was that of the Romanian N Floresco (12), who in 1905 used hirudin to prevent clotting, and implanted the transplanted ureter into the bladder of his dogs for the first time. But his allograft data are suspect as one native kidney was left in place, although one graft continued to secrete urea-containing urine for a week. In 1907 Rudolf Stich of Breslau (1875-1960) used the pelvic position for his autologous kidneys, as is now standard, as did Jacobus Henricus van Zaaijer (1976-1932) of Amsterdam the following year.
Work in Lyon went on – “la transplantation des organs sont à l’ordre du jour”. In 1906, Jaboulay made the first attempt at human transplantation (13). Reasonably he sought a donor organ from an animal – in two cases from a pig and a goat, the pig kidney being transplanted into the arm using the brachial artery, using a stent this time, in a patient with terminal uraemia. It functioned producing normal amounts of urine until the artery clotted on the third day. The goat kidney transplanted into the thigh of the second patient and similarly did well. Subsequent experiments in the next few years never duplicated these initial successes.
This work in Lyon was followed in Berlin by further trials of more than one hundred renal transplants conducted by surgeon Ernst Unger (1875-1938) (14) (Figure 7) working in his own privately-funded clinic and laboratory, with support from the Countess Bose foundation. Most of these were in dogs, but In 1910 he did a modern-looking experiment, using both kidneys of a pigtailed macaque en bloc into the thigh of his recipient, a young woman in advanced renal failure. It did not function however, despite having a short warm time, and she died two days later in pulmonary oedema. Unger’s paper contains the first illustration of a human renal graft (14). Fascinatingly, the post mortem histology of the kidney showed abundant lymphocyte infiltration – another first.
We must turn back from this European work to review the activities of Carrel and Guthrie in Chicago. Despite the huge difference in character, between the shy, rural and quiet Guthrie, and the bold, thrusting and confident Carrel the two co-operated productively in 1905-6, refining techniques of arterial suturing, and published 21 papers in a single year! – plus 5 more under Carrel’s name alone.
Some of these papers concern autografted kidneys, which Carrel had first performed in 1902 in dogs in Lyon, with success. With Guthrie, Carrel did a number of allografts and xenografts in – and between – cats and dogs from 1904 to 1906. But in 1906, Carrel moved to the Rockefeller institute in New York, and only 6 years later in 1912 was awarded, alone, the Nobel Prize for his work in vascular surgery and transplantation (8). Not for the first time, the prize was awarded in a fashion which others disputed. At that time however the prize was only awarded to individuals, so a joint award was beyond the remit of the current Nobel committee (the rule was changed shortly afterwards and now awards to several individuals are almost inevitable). They had preferred the charismatic Carrel to the unworldly Guthrie. The latter’s only reply was major work on vascular surgery in 1912 (9), which along with the author were rapidly forgotten. Carrel’s subsequent stormy career and political philosophy and involvement has ensured continued interest in this strange, complicated but immensely talented man (8) with a penetrating gaze amplified by two different iris colours.
But all this early work on transplantation of organs has brought to the fore the idea, to quote Carrel and Guthrie, that there was a “biologic incompatibility” between species which precluded successful transplantation, which was to dominate events down to the present day. Carrel was again at the forefront, and his colleague at the Rockefeller Institute, James Baumgardner Murphy (1884-1950) (Figure 8), even more so (15).
The immune system and the transplantation barrier in 1910-20
What was this “biologic incompatibility”? During the early, technical, years of kidney transplantation from 1902-1912, major advances were made also in understanding what we now call Immunity. The history of this subject is vast and I will note here only ideas and facts strongly related to organ transplantation. It needs to be said here that the relevance of a large amount of work done from 1860 onwards using skin served only to confuse, right up to some of the data of Gibson and Medawar in the 1940s (see below). In large part this resulted from difficulties in assessing whether skin grafts had ”taken” or not, and many deceived themselves on this point. More rewarding for organ transplantation was a huge amount done on the transplantation of various tumours from one animal to another.
Details of the genesis of protection against disease by prior exposure was developed over 200 years from the mid-1700s, and continues today (2, 16). The discovery of the various components of the reaction accelerated greatly in the early 20th century, after phagocytic white blood cells as defensive agents had been described by Ukranian Ilya Metchnikoff (1845-1916) in the 1880s, and then antibodies by Paul Ehrlich in Germany (1854-1915) in the 1890s and 1900s which led to unnecessary but productive rivalry, since both groups were correct – as so often happens when two opposing views, both with excellent data to support them, and in opposition. In addition on 1902 Viennese Karl Landsteiner (1868-1943) described human blood groups, and Hans Buchner (1850-1902) of Munich and then Belgian Jules Bordet (1870-1961) working in Paris unlocked alexine, later called by Ehrlich “complement”. All these factors turned out to be important as aspects of recognition and elimination of foreign antigens, including those important in transplantation. All the investigators mentioned in this paragraph were awarded a Nobel Prize.
Thus by only the second decade of the 20th century the idea that organ and tissue grafts were destroyed through mechanisms important in defence against foreign organisms had emerged, but details remained scanty. Georg Schöne (1875-1960) born in Berlin trained with Ehrlich, and did work on skin and tumour transplantation. In his book of 1912 (17), his observations led him to the first use of the term transplantations immunität. He described accelerated loss of second grafts between the same individuals. His contemporary Erich Lexer (1867-1937) of Vienna (18) (Figure 8) had the same idea, describing a “reaction” to the graft, which resulted in destruction of all unmodified homografts. In his book he described also for the first time the longer survival of grafts between close relatives, and most severe and rapid across race differences. In London yet another brilliant pupil of Ehrlich, Ernest Bashford (1873-1923) (Figure 8) (19) confirmed Schöne’s observation of accelerated second-set grafts, and made careful histological studies showing invasion by lymphocytes and plasma cells, whilst no circulating antibody was detectable in the same individuals. He retired, and died young, of alcoholism.
But Bashford was forgotten, as less forgivably was James Baumgardner Murphy (1884-1950) (15), a pupil of Rous working at the Rockefeller Institute, who showed that transfusion of adult spleen cells (mostly lymphocytes) would prevent the taking of tumours on to the yolk sacs of chicken embryos (a technique he pioneered). Only recently since the 1950s has the scope of Murphy’s work on transplantation been rediscovered. But at that time lymphocytes were viewed as static cells, despite several suggestions to the contrary in previous decades, which long handicapped understanding of their crucial importance in graft destruction. Also, a now obscure embryologist John Beard (1857-1924) (20) working in Edinburgh had described in 1899 that the thymus was the origin of lymphocytes (21), but yet again this work was forgotten and the function of the thymus considered a “mystery” for another half-century.
Most surprising of all was the rapid acquisition in this early era of information on how to modify the immune system. Murphy was a lead figure in this, with the clear idea that removal or inactivation of lymphocytes would improve graft survival in tumours. X- irradiation had been described from 1895, but was quickly seen to have effects in suppressing bone marrow and the lymphoid system. Ludwig Hektoen (1863-1951) (Figure 9) in Chicago showed that antibody levels were depressed by X rays (22), and Murphy showed they prolonged the survival of rat tumour grafts, with Hektoen. But easier agents were at hand. Glanville Yeisley Rusk (1875-1943) (Figure 9). In California in 1914 showed that benzol would depress antibody formation (23). This agent had been available since 1890s and proved toxic, leading to a selective marrow depression, principally of white cells. Murphy used this agent as well, and splenectomy.
It is tempting to speculate what exchanges of ideas and experiments there may have been between Murphy and Carrel in adjacent labs at the Rockefeller prior to WW1. David Hamilton (3) trawling the reports of the Rockefeller Institute, discovered a statement by the director, Simon Flexner, from 1914 that Carrel had taken up Murphy’s ideas, and “found that in animals damaged[by irradiation or benzol (see below)] transplantations could be accomplished which in healthy animals were absolutely unsuccessful”.
Benzol was not the only chemical immunosuppressant available. Studies by the husband and wife team of Edward and Helen Krumbhaar at the front in World War 1 from 1915 onwards showed that soldiers exposed to mustard gas developed marrow depression and reduced white cell blood counts (24). In 1921 Hektoen followed his work on benzol with similar studies of nitrogen mustard.
Hamilton (3) describes a major surgical meeting held in New York on the eve of World War 1 in Europe, one of whose three main subjects was – transplantation of organs and tissues. This meeting was attended by Ullman, Morestin from Paris, Lexer, Villard from Lyon – and Carrel, who presented a ”road map” of where studies in the area would go. The New York Times (3) reported the meeting extensively, finishing:
“all our efforts must now be directed towards the biological methods which will prevent the reaction of the organism against foreign tissue and allow the adapting of homoplastic grafts to their hosts…”
Clearly transplantation as a clinical technology was about to take off – in 1914. The “gap” in advancement of transplantation studies which followed has been highlighted and described in detail by David Hamilton (3, 8)
What went wrong?
Undoubtedly the world war on a scale unprecedented had major effects, destroying especially the German economy and institutions, meetings and international exchange of ideas and people. German innovation had been central to the field, as the account above shows. Carrel, although in his 50s, returned from the USA and became an officer in the French Army at the Front during the war, and changed his interests completely in the following decades. Except in the United States, economies such as those of France and Britain were in a poor state, and research declined in quantity.
Also, the continued defeats by rejection of other than autologous grafts, from skin to whole organs, hung heavily over the field. Rather than the successes of the pre-war years in transplantation, these ideas now became dominant. In the increasingly important United States, it was not a field in which to be involved – especially in the light of many scandals which emerged in the 1920s. What little science was done in that decade was confused, with no attempt to build on the fertile idea of modifying the now well-developed reaction to allografting using chemical agents. A few individuals in America kept the flame alight, particularly German immigrant Leo Loeb (1865-1959) in St Louis (25) (Figure 10), and Frank C Mann (1887-1962) at the Mayo clinic working on lymphocytes, but neither moved knowledge much beyond what that been attained before and during the war. However Loeb was convinced that the tissue reactions to foreign grafts was a fundamental inbuilt reaction of importance, and involved cell infiltration. Its basis must be some individual set of markers which could be recognised as foreign by the host, exemplified by his work on interfamilial grafting (25).
Finally, there had been a general shift of emphasis and funding from clinically-oriented research to basic biology.
Even worse, the major events of the 1920s in the transplantation field were the quackery and scandal of gland transplants, particularly involving slices of human testis, and whole testes from apes into humans. This field was led by the work of the Russian Sergei Voronoff (1866-1951) with the object of returning sexual potency, or even of a general rejuvenation. The gland or tissue slices were placed within the scrotum and excellent results reliably obtained, if the propagators were to be believed – which they were. Ovarian grafts were also popular. A large amount of effort and money was dissipated, and the reputation of the idea of “transplantation” effectively destroyed as science. By 1930 the field was a career no-go area for young investigators. I will not waste space or time detailing this shameful period in surgery, when so many deceived themselves, as well as others. Even into the 1950s there persisted proponents of spurious ideas that various glands (thyroid, parathyroid, ovary, testis) were capable of avoiding an immune reaction, if suitably manipulated by culture, storage, cooling or other treatments.
A revival in the 1930s and 1940s?
The next event of importance was a series of human transplants done in an unlikely site, and unknown to almost all surgeons and physicians outside Russia until the 1950s. The major importance was that this surgeon used a new source of potential organs – the newly deceased cadaver. The question of where one could obtain human kidneys (or other organs) for transplantation had never been properly explored, and the idea of living donors had never arisen publicly.
The surgeon was Yuri Yurevich Voronoy (1895-1961) (Figure 11), a Ukranian surgeon with a good training in surgery in the clinic of Vasili Shamov in Kharchiv. In April 3rd 1933 he anastomosed a cadaver kidney into the right thigh a woman with acute renal failure from mercuric chloride poisoning for four days, with anuria (26). He wrote:
“transplantation of primate organs and above all domestic animals… have failed utterly. The only source of grafts is cadavers, since the donor does no suffer a loss.”
Voronoy may well have got this idea from the frequent employment of cadaver blood for transfusion in the Ukraine by Sergei Yudin (1891-1954), a pioneer of blood transfusion – the first civilian blood bank. Voronoy moved to Kherson in Southern Ukraine in 1931, where he planned renal transplantation as a temporary measure at least for patients with mercury poisoning, usually taken to procure abortion or for suicide, but sometimes accidentally. He had observed splenic and lymph node shrinkage in such patients, and reasoned they might better accept a graft. He had also done transplantation in dogs previously.
This first human-human transplant and its course are meticulously described (25): the donor was a 60-year old man dead for 6 hours; the donor blood group was noted to be B, and the recipient 0, i.e. incompatible. The kidney barely worked and an exchange transfusion of citrated group 0 blood was given, in part to remove some mercury. The patient died after 2 days (sadly, as she had wished). The operation was done under local anaesthetic into the right thigh; the ureter was left free.
His work was published in Russia, Germany and even Spain, but did not come to general attention in the West until a search by David Hume of the literature in 1954 (see below). Voronoy did another 5 kidney grafts up to 1949 back in Kiev, but detailed results are not available and none seem to have succeeded for any length of time. This not surprising, since politically-dictated Soviet biological dogma forced the organs to be stored from 1 to 20 days before transplantation!
In retrospect, the next major event was the publication in 1943 of a landmark paper (27), from Tom Gibson (1915 -1993) a surgeon and head of the Glasgow burn unit, and Peter Medawar (1915 -1987 (Figure 12). In the UK, World War II resulted in an input of money and energy into the treatment of the hugely increased number if major burns casualties, fuelling in turn a resurgence of interest in skin grafting.
A badly burned young woman received multiple pinch skin grafts from her brother, and the results became a classic paper, showing finally, and conclusively, that allografted skin did not survive indefinitely, and confirming that second-set grafts rejected more quickly. Odd things had appeared, in that the grafts rejected later than expected, and that they contained little or no cellular infiltrate – leading the pair to the conclusion that rejection depended on antibody rather than lymphocytes. Also they still believed that these were local cells, as they still thought that lymphocytes did not move much or at all, as Gowans destroyed this idea for good only in 1959. The patient was ill and may have had poor immunity, and the donor may have been tissue compatible, accounting for the lack of infiltrate. Medawar’s successor in Oxford, Avrion Mitchison (1928- fl.) restored emphasis to the Murphy-Loeb model of lymphocytes as the main mediators of tissue reaction to grafting, whatever their origin might be.
During the 1940s in particular are rumours of several human kidney transplants done under irregular circumstances, details of one of which are preserved (3, 4). This was the placement of a kidney in Boston in 1945, obtained from a deceased relative of a staff member, on to the arm of a woman with acute renal failure (there was then no dialysis available). The graft functioned for 4 days until the patient’s own kidneys recovered function and she went home. Sadly however she died not long afterwards from hepatitis. The surprise is that this clandestine transplant was done by three interns: David Hume, later a leading transplant surgery, Charles Hufnagel equally a well-known cardiac surgeon, and Ernest Landsteiner, urologist and son of Kurt Landsteiner – at the Peter Bent Brigham hospital. Another “clandestine” transplant is mentioned by Hamilton (3, p 168).
The 1950s – clinical transplantation emerges
For reasons that are now hard to discern, around 1950 surgeons began to ignore the pessimism of the immunologists that allografts simply could not survive immune attack, and started doing human renal transplants nevertheless. They accepted in their collective ignorance that they knew of no agent which they could modify any immune reaction to the graft – even though they might from the start have used at least irradiation, and perhaps benzol or nitrogen-mustard-related drugs. They hoped, not knowing of all the work done around 1910-20, that at least some grafts would be successful without any immunotherapy. This period is rich in testimony from the participant surgeons physicians and immunologists and thus is a field which can be explored by historians.
One of the earliest to do this type of unmodified transplant was Richard Lawler (1895-1982) in Chicago in 1950 (28) (Figure 14), who performed a cadaver kidney transplant into a woman of 44 called Ruth Tucker, with advanced polycystic kidney disease and severe symptoms, of a kidney from a cirrhotic patient who had just died; as he said “ I was only trying to get it started”. Forty-five people packed in to watch the operation. One cystic kidney was removed, and the blood group-compatible kidney place in its bed. The kidney functioned for about 50 days, then decreased in size, and was subsequently removed – but with the patient retaining her superior health and lived further 4 years. The remaining cystic kidney must have increased its renal function. Lawler achieved his aim, as his attempt encouraged teams in Boston and Paris.
Thus the centre of attention turned to France, as Raymond Ardaillou discusses in a companion paper, proposed and carried through principally by Jean Hamburger (1909-1992) (Figure 15) who had planned transplantation from the late 1940s. A good summary of this work, at different sites, is given in Table IV of Woodruff’s book (4, pp. 521-5). In early January 1951, Charles Dubost (1914-1991) in the Necker hospital in Paris, and Marceau Servelle (1912-2002) a vascular surgeon in Strasbourg (Figure 15) obtained the two kidneys of a condemned prisoner who had just been guillotined, which were placed in blood group- matched recipients, into the pelvis. Both patients died at 20 and 17 days of complications – but with functioning kidneys, and at post mortem neither showed much cellular infiltrate. Later in that same month René Küss (1913-2006) (Figure 15, Figure 19) then at the Hôpital Cȏchin, performed the first of 6 mostly cadaver transplants (29) but on this occasion using a “free” kidney, subject to nephrectomy for ureteral problems, as a donor. He also used kidneys from the guillotine, an experience he described later as “extrêmement pénible”. After all this work, in one of his papers in 1952 he made the following prescient statement “... in the present state of knowledge, the only rational basis for kidney replacement would be between monozygotic twins”. He perfected the pelvic placement of the kidney still current today, and the tricky anastomosis of the ureter into the bladder.
Next up was Gordon Murray (1894 -1976)(Figure 17) of Toronto, Canada (30), primarily a cardiac surgeon but who did research on heparin, built and used for several years a static coil artificial kidney from 1946. He performed, after much work in dogs, four, maybe more human cadaver renal transplantations in 1951; but few details (as was usual for Murray) are available. It appears that irradiation was used in at least one of these cases, showing that Murray had been in the library as well as the OR. One of his patients was reported to be at work and well 15 months after transplantation but we know nothing of his residual function of her own kidneys. Murray did further grafts of which no account exists.
Back to Paris in 1952, and Hamburger’s team at the Necker hospital were presented with an agonizing problem (31): a 16 year old carpenter, Marius Renard, fell off a scaffold at work, and ruptured a kidney which continued to bleed. It was removed, as was normal under such circumstances. But he was now anuric; he had had only a single kidney: what to do? – dialysis was not available at the Necker at that time, in any form. Then his mother made an offer: “give one of my kidneys to my son, who is dying before my eyes” (Figure 16). Jean Hamburger and his team replied in the affirmative. The operation itself, the first living donor kidney graft [done using the Küss technique by urologist Louis Michon (Figure 13)] went faultlessly; the kidney functioned immediately and went on functioning until 21 days, when it faltered and stopped on the 22nd. Marius died in uraemia. But so much was learned from this attempt (31). The histology of the kidney showed an intense infiltration of cells. The Küss surgical technique worked; the local and systemic signs of a rejection were observed and recorded, and the histology studied. And one hopes that Mme Renard felt that all had been done to help her son, as she wanted – but she probably did not know about the lack of dialysis, although this would only have postponed the inevitable a week or two because of the then inevitable access failure.
Meanwhile in 1951, the team in the Peter Bent Brigham hospital in Boston, supported by chief surgeon Francis D Moore and led by David Hume (1917-1973) (Figure 17), had rapidly done 6 of a series of grafts (9 were included in their paper of 1955 (32) after preliminary note in 1952). All the remaining kidneys were done during the next two years, together with another probable half dozen, who one imagines may have done worse than those in the publication. The Peter Bent Brigham team had the advantage over the team at the Necker in that had on site John Merrill and his modified Kolff dialysis machine, which could be used before transplantation (as in their first transplant), and for a while at least after graft failure. All these early grafts were placed in the thigh with a free ureter, as Voronoy had done. The most exciting thing about this series was that one graft lasted 5 ½ months in a young physician from South America. The others failed from immediately to a week or two only. One patient with polyarteritis had recurrence of his disease in the graft – an ominous sign of a future problem. Much was learned from this series despite the failure of all the grafts, and some would consider it right to stop the “prehistory” clock with this paper, and that discussed in the next paragraph published about the same time. But I believe that the invention of immuno-suppression is part of prehistory.
In 1954 a new patient with uraemia Richard Herrick, aged 23, was referred to the Boston team by a Chicago physician Dr David C Miller, who pointed out that Herrick had an identical twin Roland, and maybe the twin could provide a kidney, as Küss had suggested could avoid an immune reaction (Figure 18). The new divisional head surgeon after David Hume left, Joe Murray, was a plastic surgeon, and familiar with the work on identical twins and skin grafts from the 1940s. At Christmas 1954, after some regular haemodialysis supervised by Merrill, Herrick was ready to receive his brother’s kidney; acceptance of a skin graft and fingerprinting had demonstrated their identity. After preliminary haemodialysis to improve Richard’s condition, the kidney was placed in the pelvis and the ureter implanted in the bladder in the Küss method (33), and maintained Richard for 8 years, when it failed because of recurrent glomerulonephritis. Roland survived until 2010. Some other of half a dozen twins referred as a result of the huge publicity did even better (34); the Helm twins Edith and her donor Wanda were operated on in May 1956 in Boston, and after having had a baby on the way, Edith survived to die in 2011, aged 76. Wanda survives. Also the Valentine twins, transplanted in 1960 aged 12 years, were still both alive in 2017, 57 years later.
But the blunt fact remained in 1954 that it was known that kidneys behaved just as skin had eventually been proven to: autografts or isografts survived long-term, allografts only days or at most weeks. William (Jim) Dempster (1918-2008) (Figure 13) in London, and Morten Simonsen (1921-2002) in Copenhagen and the UK studied this “ rejection” phenomenon in detail in in the early 1950s, detailing (35, 36) that it was a cell-mediated phenomenon, depended on recognition of individual-specific antigens, and re-discovering the studies of the “lost years” of 1910-20. Dempster believed strongly that the operation had to be proved in animals, before doing any clinical experiments throughout the 1950s: in this he was wrong as species reactions are so different. Dempster was also the first to re-discover irradiation as a tool to modify the process, but in dogs this was rarely successful. Despite his scepticism, he took part in the first renal transplant in the UK in 1956, organized by Ralph Shackman (1910-1981), urologist at the Hammersmith hospital, who later ran the successful programme of renal transplantation there. The key question was now whether in humans could chemical or other methods depress this mechanism of “rejection”; or even, could tolerance be induced in adult humans, as Medawar and colleagues had achieved in neonatal mice in 1953?
Immunosuppression and tolerance
In retrospect it remains surprising, now that attempts to do unmodified transplants in human recipients had begun around 1950, that the earlier data from the 1910s and 20s on radiation and chemical immuno-suppression were not mined earlier. It took until 1958, when about a dozen or more unmodified grafts had been done in non-twins (4), for these ideas to be exploited again. However in this field, just as skin grafts had proved different from kidney grafts, now dogs proved to be different from humans in their reactions to both irradiation and to immunosuppression. This obscured progress and thought in important ways. Eventually empirical trials in humans proved most important route of progression.
Radiation was the first approach to be resurrected in transplantation, now that atomic bombs had been used and nuclear power plants built – but not until 1958. These events, awful and potentially transformational, gave sad but vital data on irradiated humans which re-demonstrated that the bone marrow was suppressed and circulating cells reduced in number, antibodies diminished, and in animals allograft survival prolonged. Protection of the spleen and bone marrow led to survival, but with lymphocytes still pictured as sessile cells until 1959, humoral factors were postulated to explain this. But by 1956 a Kuhnian paradigm shift had occurred, and the idea of migratory immune cells became accepted by nearly all, although not proved until 1959 by Gowans. What had been a search for radiation protection turned into a strategy for inducing tolerance. John Merrill was forward-looking and projected that marrow infusions could lead to tolerance, which was supported by work using donor marrow infusions in irradiated, skin-grafted mice by John Main and Raymond Prein at the National Cancer Institute (37). But how much irradiation should be used? – too much would simply kill the recipient, and too little would be ineffective.
A “fortunate” accident with a nuclear reactor in Yugoslavia led to six patients being treated in Paris by bone marrow transplantation by haematologist Georges Mathé (1922- 2010), which gave data suggesting a dose limitation of about 400-450 rad (the unit then in use) for relatively safe irradiation to allow bone marrow infusion. But the first patients treated in Boston in this fashion, using “free” kidneys from nephrectomy as donors in 1958, both died. The protocol was changed to lower doses of irradiation without marrow transfer- complete tolerance would have to wait (and is still waiting). Grafting re-started in both Boston and Paris using irradiation alone – five more grafts were done beginning in Boston in 1958-62, followed by a dozen in Paris from 1959 also, divided equally between Jean Hamburger’s unit at the Necker, and Küss and Marcel Legrain’s unit at the Hôpital Foch (Figure 19), with survival of some recipients in all three series, and a single functioning graft functioning more than 15 years (3, 4, 38-40) A few grafts were done even from unrelated living donors with success (Figure 19), but the majority were either “free” kidneys removed for surgical reasons (which source now more or less disappeared as surgery of the ureter changed, and the Matson operation became obsolete) or cadaver kidneys.
The brief era of irradiation for allograft immunosuppression of 1958-1962 was superseded by the chemical immunosuppression still with us, which brings us to the end of “prehistory” around 1960, as we enter the full history of widely-performed and increasingly successful renal transplantation.
As with irradiation, the early data from around 1920 had been forgotten by transplant surgeons and immunologists alike. It was the emergence of these drugs as anti-cancer agents, and their unwanted marrow suppression, which brought them back to attention.
Following the First World war with deliberate use of nitrogen mustard, accidents also occurred, and in both circumstances the immunosuppressive and marrow effects were studied. But there was no more interest until the Second World War, during which further disasters occurred. The incident in Bari harbour in 1944 during the Italian campaign was particularly horrifying, as 500 tons of Allied liquid mustard aboard the USS John Harvey escaped after German bombing, killing about 700 sailors and a thousand civilians. The military started reinvestigating nitrogen mustard, and the idea it might kill active malignant cells as well as active bone marrow arose and was tested, and it was used with some success to treat human leukaemias subsequently. An oral mustard, cyclophosphamide, became available in 1959 but was only used occasionally in transplantation, although the few data available suggest it was effective.
The talented and productive pair of Trudy Elion (1918-1999), working in George Hutchings’ (1905-1988) lab at Burroughs Wellcome (Figure 20), synthesised a number of purine antimetabolites (a new concept for which they received the Nobel prize) the first of which was 6-mercaptopurine (6-MP) in 1953 – aimed as a cancer treatment. It took time, however for the concept of long- term continuous treatment to induce and maintain what came later to be called immunosuppression (in 1963 by the Boston group) to emerge. In the meantime, however, Robert Schwartz (1928- fl.) (Figure 20) and William Dameshek (1900-1969) in Boston showed suppression of antibody formation in rabbits in 1957 with 6-MP, and prolongation of survival of allografted skin again in the rabbit, in 1959 (41).
For subsequent events we have a rich testimony of events from participants in the subsequent explosion of ideas and actions, and only a summary is presented here at the end of our trail. In London, personal experience of this work with 6-MP was transmitted to a young surgeon who was to have great influence on the field subsequently, Roy Calne (1930- fl.), (Figure 21) by pathologist Ken Porter (1925-2013), who had just returned from time in Boston. Calne, having unsuccessfully tried irradiation, used 6-MP in dog allografts, achieving some success (42) which led on, with his new mentor John Hopewell at the Royal Free hospital in London, to trials in three human recipients in 1959-60. However all three patients, two cadaver and one living donor died without renal function, so these results were not published until later (43). Calne visited Paris, and gave Küss some 6-MP which he used for graft “rescue” in irradiated recipients, with success. David Hume, now in Virginia, and his colleague Charles F Zukowski (1926-1983) were also using 6-MP in dogs, with much better results than in London (44). Calne then went to Boston on a grant, visiting the Burroughs Wellcome lab in New York on the way, obtaining 6-MP and a new orally active compound Elion and Hitchings had synthesised, then called BW57-322 but now known as azathioprine. In dogs, it worked (45), but in humans almost all the several patients treated in Boston and elsewhere died usually of infection, with one notable exception. Only Hume had slightly more encouraging results, but few grafts were done anywhere in 1962-3. In retrospect, the doses of azathioprine given to most of these early recipients were far too high, and this remained so for some years.
Long-term -prednisolone is today being phased out from transplantation because of its many side-effects, but a number of the grafts done in the 1950s were variously treated with cortisone, following a series of contradictory papers in animal and human skin grafts. But eventually, steroids put grafting on the road to success, despite apparently negative results in Boston in four early patients (32). However, Willard Goodwin (1915-1998) in California, during a brief series of half a dozen grafts, used high doses of cortisone to reverse acute rejection in 1960, but this was not published until 3 years later (46). Another huge contributor to transplantation, Tom Starzl (1926-2017) (Figure 21) must have credit for showing in 1963, when working in Colorado, that prednisolone combined with moderate doses of azathioprine could be the answer to long-term chemical immunosuppression in grafted patients (47), reporting 20 survivors from 27 rapidly-performed* transplants, in a National research Council meeting in Washington in 1963, when 244 living-related and 68 cadaver grafts were presented by 25 units worldwide. The advance was “essentially empirical” he stated.
At this meeting (which for me marks the end of prehistory and the beginning of history), the Human Kidney Transplant Registry was started: the combination of corticosteroids and azathioprine was used as routine (sometimes with additional drugs) until the early 1980s, and transplantation was truly on the road: “pre-history” was over. Led by Murray, Starzl (48) and Calne (49) and then hundreds of others all over the world, renal transplantation was established as a useful treatment, even though the toll of complications during and from rejection and its treatment was huge, and survival figures still dismal at the end of the 1960s. Starzl’s papers and book (48), after Calne’s initial lack of success (and poor, at that time unpublished results at St Mary’s Hospital London) were a major factor in my own conversion to starting an integrated dialysis plus transplant unit at that time. Ironically Starzl as early as the 1950s, and also Calne, were most interested in technically more demanding liver transplantation, but realized that rejection and its treatment could be worked on more easily in the setting of renal transplantation
But in humans tolerance was nowhere on the horizon, and although spontaneously arising in long-term immunosuppressed survivors, its induction remains as elusive even today, 64 years after it was achieved in mice.
*This was in part possible because Starzl (49) at that time had an “arrangement” with the nearby Canon State Penitentiary, whereby prisoners might offer to donate organs, and on occasion as many as 50-60 might be considered, using primitive tissue typing of the era. This arrangement ceased a year or two later (I have not considered the history of tissue typing here as it was not used in practice until the 1960s, after the end of the “prehistory” period as defined here).
The Russian original of Voronoy’s paper is almost impossible to obtain, but a translation in full is to be found in reference (3) on pp 163-166, with an illustration of the femoral placement of the graft (Figure), a technique later used in Boston during 1951-4. See also: Hamilton D, Reid WA. Yu.Yu. Voronoy and the first human renal allograft. Surg Gynecol Obst 1984; 159: 289-294.
Renal transplantation is the best treatment for patients with end-stage renal disease.
Over the last decades, the introduction of new immunosuppressive agents resulted into the reduction of the incidence of acute rejection and early graft loss. Despite this progress, there has been little improvement in the average life of the transplant.
The main reasons of late failure are patient’s death due to several complications (e.g. cancer, infectious or metabolic), and progressive deterioration of renal function caused by immunological and non-immunological factors.
The immunosuppressive therapy can be distinguished into two components: the induction therapy and the maintenance therapy. The former has the aim to implement intense and immediate immunosuppression. This therapy is mostly useful in transplant with high immunological risk, although it is correlated with an increased risk of cytopenias and viral infections.
The latter offers the rationale to prevent organ rejection and minimize drug toxicity. This is generally constituted by the association of two or three drugs with different mechanism of action.
The most common application of this scheme includes a calcineurin inhibitor in combination with an antimetabolite and a minimum dose of steroids.
Immunosuppressive therapy is also associated to an increased risk of infections and cancer development. For instance, each class of drugs is related to a different profile of toxicity.
The choice of treatment protocol should take into account the clinical characteristics of the donor and recipient. Furthermore, this treatment may change anytime when clinical conditions result into complications.