Nobel prize winners who contributed to Transplantation

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The Nobel Prize in Physiology or Medicine, administered by the Nobel Foundation, is awarded once a year for outstanding discoveries in the fields of life sciences and medicine. It is one of five Nobel Prizes established in 1895 by Alfred Nobel himself. Nobel was personally interested in experimental physiology and wanted to establish a prize for progress through scientific discoveries in laboratories. The Nobel Prize is presented to the recipient(s) at an annual ceremony on 10 December, the anniversary of Nobel’s death, along with a diploma and a certificate for the monetary award. The front side of the medal provides the same profile of Alfred Nobel as depicted on the medals for Physics, Chemistry, and Literature; its reverse side is unique to this medal (1, 2).

The idea of replacing diseased parts of body has been around for millennia. Envisioned were complex transplants such as the “successful” transplantation of an entire leg by the 3rd century sainted physicians Cosmos and Damien. As early as 600 b.c., the use of autogenous skin flaps to replace missing noses was conceived, and by the sixteenth century, Gaspare Tagliacozzi and other pioneering plastic surgeons were successful with such procedures. But not until the twentieth century was it ever mentioned that grafts might fail. Even the great eighteenth century experimentalist John Hunter, who transplanted human teeth and autotransplanted cocks’ spurs into their combs, seemed unaware that homografts would fail (3). As true the 20th century has changed a lot in the transplantation field.

One among the others whose achievement was awarded with the Nobel Prize was Alexis Carrell (Figure 1). He was borne on 28 June 1873 near Lyone, France. Carrel’s interest in transplantation was first manifested in 1902 in Lyon, when he transplanted a kidney from a dog’s abdomen to its neck. The kidney produced urine immediately, and the animal died after a few days from an infection. In 1904, Carrel left France after failing in several examinations to qualify for a faculty position there. He moved to Chicago, where he partnered with the physiologist Charles Guthrie. They collaborated for barely 12 months, but during this time, they successfully transplanted the kidney, thyroid, ovary, heart, lung, and small bowel, averaging a publication on this work every 14 days (4). Carrel first published his work on organ transplantation in October 1905 (ie, the “Functions of a Transplanted Kidney”), which was co-authored by Charles Guthrie. Carrel’s success with organ grafts was not dependent on a new method of suturing but on his use of fine needles and suture material, his exceptional technical skill, and his obsession with strict asepsis. Carrel and Guthrie developed the so called Carrel’s patch for kidney transplantation. This technique, still used today, removes a patch of aorta with the renal artery attached, in order to avoid the dangers of thrombosis posed by a small blood vessel anastomosis. Unfortunately relationship between Carrel and Guthrie cooled and in 1906 Carrel moved from Chicago to the Rockefeller Institute in Chicago. Next few years Carrel focused his research on surgical procedures on the heart. He was many decades ahead of his time, performing mitral valvulotomy, mitral valvuloplasty, and coronary artery grafting. He did the world’s first coronary artery bypass graft, suturing one end of a long segment of canine carotid artery to the aorta and the other to a coronary artery. Carrel was rewarded for his groundbreaking work by receiving the Nobel Prize in Physiology or Medicine in 1912, “in recognition of his work on vascular sutures and the transplantation of blood vessels and organs” (4, 5). At the age of 39 years, he was also the youngest Nobel Laureate. When he reached age of 65 he was forced to retire so he came back to France. That was in 1939, After France capitulation, the Vichy government offered Carrel the opportunity to continue his work at his own institute, to be called the “Institute of Man.” The institute opened in 1941. Because of his relationship with Nazi-supported Vichy, Carrel was widely regarded by his countrymen as a Nazi collaborator. After the liberation of France in 1944, he was relieved of all duties related to his institute and was placed under surveillance. An investigation began to evaluate the extent of his collaboration with the Nazis and the Vichy government, but no conclusions were reached. Unremitting attacks by the press left Carrel deeply depressed. He was a broken man when he died on November 5, 1944 (6). Already Carrel noticed that vascular grafts, he used did not survived too long, but nobody had idea why. This has changed thanks to the work of Sir Frank MacFarlane Burnet and Peter Brian Medawar. They shared the Nobel Prize in 1960 for discovery of acquired immunological tolerance.

Sir Frank Macfarlane Burnet (Figure 2) was born at Traralgon, Victoria, Australia, on September 3rd, 1899, completed his medical course at the University of Melbourne, where he graduated M.D., in 1923. n 1944 he became Director of this Institute and Professor of Experimental Medicine in the University of Melbourne. It is impossible to give, in a brief space of fundamental importance of Burnet’s work (7). His work on the agglutinins of typhoid fever was followed by the work on viruses for which he is nowadays justly famous. In 1935 he isolated a strain of influenza A virus in Australia, and subsequently did much work on serological variations and on Australian strains of the swine influenza (8). Burnet was a productive scientist, authoring about 30 books and countless publications that spanned six decades. His greatest work described concepts of immune tolerance and clonal selection. In 1941, published a monograph entitled The Production of Antibodies, which is now widely regarded as a classic publication in the field of immunology (9). In this work, he proposed notions of ‘self’ and ‘non-self’, which described how an individual’s immune system was able to differentiate between the cells and protein that make up its own body from those of foreign micro-organisms or substances. In 1959 he authored another book, called The Clonal Selection Theory of Acquired Immunity, which described how the human body developed and produced antigen-specific antibodies (10). His hypothesis that the body could learn to reject or accept particular antigens, a concept now known as ‘immune tolerance’, was more than a fanciful abstraction, as it exerted a powerful impact on the direction and momentum of medical immunology. In part because of Burnet’s work, patients worldwide have gained longer and better lives with transplanted hearts, livers, kidneys and other organs (11). He died from colorectal cancer in 31 August, 1985.

His partner in the Nobel Prize, Peter Brian Medawar was born on 28 February 1915, in Rio de Janeiro (Figure 3). Medawar’s earlier research, was done on tissue culture, the regeneration of peripheral nerves and changes of shape of organisms that occur during this development. During the early stages of the Second World War he was asked to investigate why it is that skin taken from one human being will not form a permanent graft on the skin of another person. In 1947, Peter Medawar had been appointed Mason professor of zoology in Birmingham, where he continued his transplantation studies, with Rupert Billingham and Leslie Brent. He was elected to the Royal Society in 1949. Following his appointment as Jodrell professor of zoology and comparative anatomy at University College, London in 1951, he embarked, again with Billingham and Brent, on the critical work in inbred mice, to test whether experimentally induced chimerism would also result in tolerance to skin grafts from the donor strain (12,13). Medawar’s key paper fully supported Burnet and Fenner’s idea of adaptation of ‘recognition of self’ in the developing immune system (14). It was followed in 1956 by a monograph exploring the parameters of both tolerance and immunity to allogeneic transplants, and showing they were ‘cell mediated’ rather than humoral. This work affected the perception of those caring for patients in end-stage organ failure, e.g. kidney, since they raised the possibility of transplantation of allogeneic kidneys under a regime that protected them from immune attack, in the knowledge that actively acquired tolerance was a possible outcome. These results also contributed greatly to basic immunological knowledge, and allowed further development of the field of cellular immunology (15). His research career was prematurely interrupted in 1969, on account of a stroke. In 1986, he published his autobiography, a year before his death, the title of which highlights the contrast between his life with the physical limitations caused by the disease and his preserved lucidity (12). Died in London on 2 October, 1987.

The Nobel Prize in Physiology and Medicine from 1980 was awarded jointly to Baruj Benacceraf, Jean Dausset and George D. Snell for their discoveries concerning genetically determined structures on cell surface that regulates immunological reactions (16). Historically first discoveries were published by George D. Snell.

George David Snell (Figure 4) was born on 19th December 1903 in Bradford, Massachusetts, USA. In 1935, he joined the Jackson laboratory in Bar Harbour, Maine and remained there until his retirement as senior staff scientist emeritus in 1973. Jackson laboratory was considered an international hub for mouse genetics. He was already working in transplantation at the end of World War II. He realized that immunology would burgeon and that his work on the MHC would help it to do so. G. Snell initiated work on immunological enhancement and reviewed developments in immunology on several occasions. He, along with immunologist Peter Gorer, conducted studies that resulted in the identification of the H-2 gene complex in mice, a term he introduced to determine whether a tissue graft would be accepted or rejected. G. Snell was a founder of the scientific journal titled ‘Immunogenetics’, and served as its first editor. He authored several books including ‘Cell Surface Antigens: Studies in Mammals Other Than Man’ (1973), ‘Histocompatibility’ (1976) and ‘Search for a rational ethic’ (1988) (17,18). He died on 6 June 1996 at Bar Harbor, Maine, at the age of 92.

The next of this “Big Three” was Jean Dausset (Figure 5) born on 19 October 1916 in Toulouse, France. During the II World War J. Dausset joined the Free French Forces in North Africa as an ambulance worker. In this occasion he got his first taste of hematology when he had to perform numerous blood transfusions on wounded soldiers. As the war was winding down in 1944, he returned to Paris where he worked in the Regional Blood Transfusion Center at the Saint-Antoine Hospital. In 1948, Dausset went to work as an intern in the Children’s Hospital in Boston. He worked there in a hematology lab for about four years. On his return from Boston, he became interested in the new immune-hematology techniques applied on red blood cells (Coombs test) and decided to transpose the methods to white blood cells in cases of leucopenia(19). In 1952 J. Dausset discovered that white blood cells were agglutinated by antibodies from patients who had received blood transfusions, and realized this was due to genetic differences between donor and recipient. He described the first leukocyte antigen, now called HLA-A2, in 1958. He realized that the human HLA system was similar to the H-2 gene system in mice, which had been identified by Snell shortly before, and thus that mice could be used as an experimental model for human immunogenetics. By grafting skin from volunteer donors to volunteer recipients he worked out the complex relationship between tissue compatibility and graft survival, and found that the closer the tissue types, the better the chances of success. Professor Dausset was a member of the French National Academy of Sciences, professor at the College de France, a foreign member of the National Academy of Sciences, USA, an honorary member of the American Academy of Arts and Sciences, and a member of the founding Council and Vice President of the Human Genome Organization. Jean Dausset died the 6 of June 2009 in Palma de Mallorca, Spain, surrounded by his family (20).

The third awarded in 1980 was Baruj Benacerraf (Figure 6) who was born in Caracas, Venezuela, on Oct 29, 1920. In 1947, Baruj Benacerraf was a young medical doctor who had just been discharged from the US Army Medical Corps. Returning to the USA where he had studied, Benacerraf decided to make the switch from clinical medicine to research. Over the next decade or so, he continued his research into the mechanisms of the immune system, working in the USA and in France before settling at New York University School of Medicine. The breakthrough came when Benacerraf noticed that a proportion of guineapigs injected with particular antigens failed to mount an immune response. He realized that this was an important phenomenon and did further breeding experiments to show that the animals’ responsiveness to these antigens was controlled by dominant autosomal genes that he termed immune response genes. Benacerraf was elected President of the American Association of Immunologists in 1973, President of the American Society for Experimental Biology and Medicine in 1974, and President of the International Union of Immunological Societies in 1980. That same year he was appointed President of the Sidney Farber Cancer Institute, an institution he led until 1992. After stepping down as president, he maintained an active presence at the Institute and continued working daily in his own lab into his 80s, he died of pneumonia on Aug 2, 2011, in Jamaica Plain, MA, USA, aged 90 years (21,22).

The Nobel Prize in Physiology and Medicine was shared by Joseph E. Murray and E. Donnall Thomas for their achievement in organ and cell transplantation.

Joseph Eduard Murray (Figure 7) was born on April 1, 1919 in Milford, Massachusetts. He was of Irish and Italian descent. After graduating with his medical degree Murray was inducted into the Medical Corps of the U.S. Army. He served in the plastic surgery unit which cared for thousands of soldiers wounded on the battlefields of World War II, working to reconstruct their disfigured hands and faces. His interest in transplantation grew out of working with burn patients during his time in the army. After his military service, Murray completed his general surgical residency and joined the surgical staff of the Peter Bent Brigham Hospital. On December 23, 1954, Murray performed the world’s first successful renal transplant between the identical Herrick twins, an operation that lasted five and a half hours. He transplanted a healthy kidney donated by Ronald Herrick into his twin brother Richard, who was dying of chronic nephritis. Richard lived for eight more years, following the operation. In 1959, Murray went on to perform the world’s first successful allograft and, in 1962, the world’s first cadaveric renal transplant. In 2004, Murray and Ronald Herrick were honored at the U.S. Transplant Games, held at the Metrodome in Minneapolis, Minnesota. He suffered a stroke at his home on Thanksgiving and passed away on 26 November 2012, at the Peter Bent Brigham Hospital (later Brigham and Women’s Hospital) in Boston at the age of 93. It was in this same institution that he performed the first successful kidney transplant (23-26).

1920. Donnall Thomas (Figure 8) known as “Don” to his friends, was born in a small town – Mart in central Texas, USA on 15 March 1920. He entered Harvard Medical School in 1943 and received his M. D. in 1946. Don Thomas completed one year internship in hematology after this he took a break in his studies to serve as a physician in US Army during the period 1948-50. After his stint with the US army, he worked as a postdoctoral fellow at the Massachusetts Institute of Technology. In 1953, he worked as an instructor at Harvard Medical School. Don Thomas developed his interest in bone marrow and leukemia during medical school. Inspired by the successes of Sydney Farber with antifolate therapy for acute lymphoblastic leukemia, he initially studied marrow-stimulating factors under John Loofborrow, then later in his own laboratory. In 1955, he was recruited to be chief of the Mary Imogene Bassett Hospital in Cooperstown, and it was there that he began his BMT studies in dogs and his first clinical attempts to perform BMT in patients. By 1957, the first six patients had died within 100 days, the sole survivor a patient with leukemia who received a marrow infusion from his twin sibling. That patient survived the transplant, but unfortunately later died from a relapse of his malignancy. Many patients had been cured of leukemia using this technique by the late 1970s. Since then Don Thomas and his colleagues improved their success rate significantly. In addition to leukemia and other cancers of the blood, bone marrow transplants are used to treat certain inherited blood disorders and to aid people whose bone marrow has been destroyed by accidental exposure to radiation. He was a member of 15 medical societies, including the ‘National Academy of Sciences’, ‘Medical and Scientific Advisory Committee’ and ‘National Cancer Institute’. He was President of ‘American Society of Hematology’ and served on the editorial boards of eight medical journals. He received honorary ‘Doctorate of Medicine’ from ‘University of Cagliari’, Sardinia in 1981, ‘University of Verona’ in 1991 and ‘University of Parma’, in 1992. He was also awarded the honorary degrees from ‘University of Barcelona’ in 1994 and ‘University of Warsaw’ in 1996. E. Donnall Thomas died at the age of 92 on 20th October 2012 in Seattle (23, 27-29).

Transplantation would not developed without discovering of the immunosuppressive drugs. The first step for sure was steroid treatment, but synthesis of azathioprine was the real breakthrough. This was noticed by the Nobel Prize Committee and in 1998 among three awarded were Gertrude B. Elion and George H. Hitchings who discovered this drug.

Gertrude Belle Elion (Figure 9) was born in New York City on January 23, 1918. Her mother arrived in the United States from Poland at the age of fourteen. Elion decided to dedicate her life to medicine after the deaths of her grandfather from stomach cancer. She received her degree in 1941 and found work and valuable experience as a chemist at a food company, and at Johnson and Johnson. Later that year, Elion was offered another position working with nucleic acids alongside Hitchings at Burroughs Wellcome Company. Hitchings assigned Elion to investigate purines, which are building blocks of DNA. They soon discovered, from observing the role of purines in nucleic acid metabolism, that bacterial cells require certain purines to make DNA. Along the way, Elion published 225 papers on her findings. By 1950, Hitchings and Elion successfully synthesized two compounds—diaminopurine and thioguanine. For the first time, a treatment that could interfere with the formation of leukemia cells and induce remission. Elion discovered 6-mercaptopurine (thioguanine), which she created by replacing one sulphur atom with an oxygen atom. Treatment using thioguanine is responsible for curing 80 percent of children with leukemia. This compound is also used to treat acute myelocytic leukemia (AML) in adults. In addition to 6-MP, Elion went on to discover a series of drugs that attack the life cycle of nucleic acid, including allopurinol—which inhibits uric acid synthesis, making it a viable treatment for gout—and azathioprine (Imuran), an effective immunosuppressive drug. Her discovery of azathioprine was extremely important to transplantation, because it made possible for people to receive organ transplants without their body rejecting them. On the heels of Hitchings’ retirement in 1967, Elion became head of the Department of Experimental Therapy. Her next success was synthesis of the acycloguanosine, also known as acyclovir. Elion retired in 1983, eight years after Hitchings. Though she was unable to complete her Ph.D., George Washington University and Brown University awarded Elion honorary doctorates. In 1991, she became the first woman to be inducted into the National Inventors Hall of Fame, and was presented with the National Medal of Science by President George H.W. Bush. She died on 22 February 1999, in Chapel Hill, North Carolina (30-36).

George H. Hitchings (Figure 10) was born on April 18, 1905, in Hoquiam, Washington, USA. The illness and untimely death of his father had a profound impact on the young boy and he decided to become a doctor on growing up. He received his bachelor’s degree in 1927 and stayed on at the University of Washington to earn a master’s degree in 1928. Hitchings then attended Harvard University, where he received his PhD in biochemistry in 1933. His work at Harvard centered on analytical methods used in physiological studies of purines, which are a class of compounds composed of a two-ringed structure containing carbon and nitrogen. For the next decade Hitchings held a variety of temporary appointments. In 1942, however, he joined the Wellcome Research Laboratories—then located in Tuckahoe, New York—as a biochemist. This research facility was operated by the British pharmaceutical firm Burroughs Wellcome and Company, which is now part of GlaxoSmithKline. Two years later Hitchings hired Gertrude Elion as a laboratory assistant, thereby beginning a lifelong collaboration on drug development. By 1950 used line of research had paid off. Hitchings and Elion synthesized two antimetabolites, diaminopurine and thioguanine as described above. This latter discovery led to a new drug, azathioprine, and a new application, organ transplants. Azathioprine suppressed the immune system, which would otherwise reject newly transplanted organs. In the 1960s Hitchings and Elion determined that infectious diseases could be fought if drugs could be targeted to attack bacterial and viral DNA. This work resulted in pyramethamine, which was used to treat malaria, and trimethoprim, which was used to treat meningitis, septicemia, and bacterial infections of the urinary and respiratory tracts. In 1967, Hitchings became Vice President in Charge of Research of Burroughs Wellcome. He also served as Adjunct Professor of Pharmacology and of Experimental Medicine from 1970 to 1985 at Duke University. In 1976 he became Scientist Emeritus at Burroughs Wellcome Co.

He founded what is now the Greater Triangle Community Foundation in 1983, and served as its director for life. In the last years Hitchings suffered from Alzheimer’s disease and died on February 27, 1998 in Chapel Hill, North Carolina, USA (35-37).

The last described Noble Prize winner was Ralph N. Steinman (Figure 11). He was born into an Ashkenazi Jewish family on 14 January 1943, in Montreal, Canada. Steinman received a Bachelor of Science degree from McGill University and received his M.D. (magna cum laude) in 1968 from Harvard Medical School. He completed his internship and residency at Massachusetts General Hospital. After completing his medical training, he was drawn to biomedical research. He joined The Rockefeller University in 1970 as a postdoctoral fellow in the Laboratory of Cellular Physiology and Immunology. He spent his entire career at Rockefeller, where he was appointed assistant professor in 1972, associate professor in 1976, and professor in 1988. He was named Henry G. Kunkel Professor in 1995 and director of the Christopher Browne Center for Immunology and Immune Diseases in 1998. In 1973, Steinman and Cohn discovered dendritic cells, a previously unknown class of immune cells that constantly formed and retracted their processes. This discovery changed the field of immunology. For the next four decades, until his death in 2011, Steinman’s laboratory was at the forefront of dendritic cell research. He and his colleagues established that dendritic cells are critical sentinels of the immune system that control both its innate and adaptive responses – from silencing to actively resisting its challenges. He also showed that dendritic cells are the 2 main initiators of T cell-mediated immune responses. In 2010, he initiated at The Rockefeller University Hospital a phase I clinical trial with the first dendritic cell-targeted vaccine against HIV. Diagnosed with pancreatic adenocarcinoma in March 2007, Steinman believed that dendritic cells had the potential to fight his aggressive tumor. Ralph N. Steinman died on 30 September 2011, three days before his Nobel Prize was announced. Unaware of his death at the time of its announcement, the Nobel Committee made an unprecedented decision that his award would stand (38-40).

Across the XX century many scientist focused on the field of transplantation. Achievement of few of them was awarded with the Nobel Prize. I hope that the XXI century will be more fruitful for transplantation and the Nobel Prize Winners involved in this part of science.

 

Publications:

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The history of renal transplantation in France

Abstract

The history of renal transplantation in France began with 2 surgeons from Lyon, M. Jaboulay and A. Carrel. The latter initiated the proper techniques of vascular suture, performed the first experiments in animals, initially in Lyon, then in Chicago with C. Guthrie and demonstrated that failure in obtaining a prolonged success was due to an immunological rejection of the graft. Trials in humans began in France in the 1950s with transplants from healthy donors. All ended in failure, although in 1953 the conjunction of a donor mother and a previous irradiation of the recipient allowed a survival of 3 weeks in the patient. J. Hamburger in France and J. Murray in the USA tried transplantations in monozygotic twins, then dizygotic ones, which represented the first successes. A decisive jump occurred with the arrival of immunosuppressors (combination of azathioprine and prednisone) which allowed R. Küss to win the first success in recipients that were unrelated to their donors. At the same time, J. Dausset described the Human Leucocyte Antigen (HLA) groups, markers of tissular immunogenicity, thus allowing the most appropriate donors to be selected. To the living donors were added soon the patients in irreversible coma, which made it possible to increase the number of grafts. Despite obstacles and doubts, kidney transplantation developed rapidly and was accepted as the most efficient treatment of chronic renal failure. The role of French and American physicians was decisive in this success.

Keywords: transplantation, kidney, history

The early beginnings

Organ transplantation is an old idea. It is not easy to say with precision where and by whom the first trials were realized. It is reported that Saint Cosmo and Saint Damian grafted a Moorish leg to replace the necrotic leg of a patient, an event that was considered to be a miracle. In the sixteenth century, Gaspare Tagliacozzi successfully performed autografts of the nose but failed in the allografts (1). The eighteenth century saw the development of unsuccessful animal graft experiments. The pioneers of renal transplantation in France were two surgeons in Lyon: Mathieu Jaboulay (1860-1913) and Alexis Carrel (1873-1944). Mathieu Jaboulay implemented on the dog an original process of non-stenosing arterial suture with separate U-shaped points after interposition or not of an arterial fragment (2). He tried in 1906 the xenograft of a pig kidney and then of a goat kidney to the bend of the elbow of two women with renal insufficiency (3). It was a failure, but it showed the feasibility of the technique. Alexis Carrel developed the end-to-end vascular suture techniques that are still widely used in transplantation. This was published in the “Journal de médecine de Lyon” (4, 5). In 1906, he moved to the USA where he worked with Charles Guthrie in Chicago. Both of them realized organ transplantations in animals and published a number of scientific articles where they described the successive improvements of their techniques of vascular anastomoses. They demonstrated for the first time that a vein could be substituted to an artery and reported their experiments of organ transplantations (6, 7). Their main conclusion was that using appropriate techniques of vascular suture, autografts were most of the time successful in animals whereas homografts never were. Alexis Carrel wrote at this time: “From a clinical standpoint, the transplantation of organs may become important and may open new fields in biology and therapy” (8). He was awarded the Nobel prize in 1912 “in recognition of his work on the vascular suture and the transplantation of blood cells and organs”, He accepted in 1908 a position at the Rockfeller Institute in New York where he stayed until 1939. He realized the first fully functional renal self-transplantation on a bitch and was the first to study the chemical composition of the urine from the transplant, to describe the histology of the rejected kidney showing “an important infiltration of small round cells around the vessels and the collecting ducts”, to hypothesize the responsibility of the spleen and the bone marrow in the production of antibodies and to suggest utilization of irradiation to diminish the immune capacity of the leukocytes (6, 9). He concluded that: “an animal which has undergone a double nephrectomy and the grafting of both kidneys from another animal can secrete almost normal urine with his new organs, and live in good health, at least for a few weeks. This demonstrates that it is possible to reestablish efficiently the functions of transplanted kidneys” (9). Alexis Carrel can be considered as the main pioneer of renal transplantation. He was also at the origin of tissue culture. He returned to France in 1939. Unfortunately, the end of his life was clouded by the defense of eugenism in his book “L’Homme, cet inconnu (Man, this unknown)”.

 

Unsuccessful attempts of renal transplantation in man in France (1950-1952)

The first homograft of a human kidney in man was performed by Yuri Voronoy (1895-1961) in 1936 in Kiev (10). He transplanted in the thigh of a uremic patient a kidney from a healthy man who had died in an accident. The transplant did not function and the recipient died 2 days later. Human kidney transplantations started in France in the fifties. From 1950 to 1952 almost ten renal transplantations were performed after removal of a kidney from guillotined criminals immediately after their execution or from patients in whom a kidney had to be removed for therapeutic reasons. Several teams were active: René Küss (Paris), Charles Dubost (Paris), Marcel Servelle (Strasbourg). Early failures occurred in each case, but these trials allowed progress in the surgical technique to be realized. In particular, René Küss described the ideal heterotopic position of the grafted kidney in the iliac fossa with anastomosis of the renal vein to the iliac vein, of the renal artery to the hypogastric artery and of the ureter to the bladder. These unsuccessful trials were published in the “Mémoires de l’Académie de Chirurgie” in 1951 (11-13). These failures did not discourage French surgeons and nephrologists, and in 1952, Jean Hamburger and Louis Michon performed the graft of one kidney of his mother in a young man whose the only kidney had been removed after a fall from a ladder. For the first time a survival of 3 weeks was observed (14). This intervention was widely reported by the media and had a worldwide impact. It showed that the main problem to be solved remained the immunological rejection of the graft as written by the authors: “After the 17th day of the transplant, no complication disturbed evolution; but the satisfaction that was derived from this observation was followed by the most intense anxiety six days later due to the sudden arrest of the transplanted kidney”. The challenge did not seem achievable at that time as evidenced by this 1955 citation of David Hume: “In the present state of our knowledge, renal homotransplatation does not seem to be justified in the treatment of human diseases” (15). There were two approaches to address this difficult issue: to find a donor the most genetically related to the recipient, to treat the recipient so as to attenuate and, if possible, control the reject of the graft.

 

The first successes

The three main pioneers of successful renal transplantation in France were a nephrologist, Jean Hamburger, an urologist, René Küss and an immunologist, Jean Dausset. They addressed the main problem still unresolved that was the immunological rejection of the graft.

 

Jean Hamburger (1909-1992), after having been the assistant of Louis Pasteur Vallery-Radot at Broussais Hospital, created the first department of nephrology in France at Necker Hospital in Paris (Figure 1). His main collaborators were Gabriel Richet, Jean Crosnier and Jean-Louis Funck-Brentano. He was the first president of the International Society of Nephrology and chaired the first International Congress of Nephrology (Evian and Geneva, 1960). In addition to his scientific achievements, he was a writer and published several books on the human fate, in particular “La Puissance et la fragilité: Essai sur les métamorphoses de la médecine et de l’homme (Power and fragility: An essay on the metamorphoses of medicine and man)”. His achievements in the progress of renal transplantation are numerous and were inspired by his conviction that “The great destiny of man is to refuse his destiny”. He succeeded in diminishing the immune rejection with total body irradiation of the recipient and matching the HLA characteristics of the donor and of the recipient. As mentioned above, he was the first to realize a transplant from a mother to her son with a survival of 3 weeks and was the second (5 months after Joseph Murray) to obtain a successful transplant between dizygotic twins genetically different (rejection of a skin graft from the donor by the recipient, dissimilar blood groups) after sub-lethal irradiation and isolation in a sterile room (16). The recipient died 26 years later from a bladder carcinoma. This was followed by a successful transplant from a cousin that was rejected 18 years later, which necessitated a second transplant. The recipient was still living 32 years after the first transplant. In 1964, he transplanted a cadaver kidney in a patient who lived more than 25 years. He also demonstrated the successful treatment of acute rejection (15 days after surgery) with prednisone. In 1965, Jean Hamburger drew conclusions from the review of his first 45 transplantations (17). He found that 29 of them were in a satisfactory condition after 6 months with a normal blood pressure and a mean glomerular filtration rate of 73 ml/min. Cellular infiltration was visible in all renal biopsy specimens, but tended to diminish later. Glomerular lesions and progressive interstitial fibrosis were observed more rarely. In late crises, even if biopsy specimens showed gross oedema and cellular infiltration, a satisfactory reversal could be obtained. As a whole, one could be optimistic on the future of renal transplantation.

 

René Küss (1913-2006) was head of the department of urology in “La Pitié” Hospital in Paris (Figure 2). His main collaborator was Marcel Legrain, head of the department of nephrology in the same hospital. Their purpose was to realize successful transplantation between unrelated persons. The results obtained by Joseph Murray and Jean Hamburger in dizygotic twins left a persistent doubt about the possible role of an induction of this tolerance by an exchange of cells during the intra-uterine life. The answer to this question was given by René Küss and Marcel Legrain who realized in 1960 at Foch Hospital, for the first time, three successful renal grafts outside of gemellarity, once between brother and sister and twice without any kinship. These successes were due to the efficacy of the conditioning with an immunosuppressive treatment including 6-mercaptopurine and prednisone (18). The grafts functioned for 5, 17 and 18 months, respectively, and were followed by other successful grafts between unrelated donors and recipients (19). Therefore, total body irradiation was no longer needed. René Küss was awarded the Medawar Prize in 2002 for his contribution to kidney transplantation. This prize was simultaneously attributed to Georges Mathé who was the first to realize bone marrow transplantations and participated in the first successful attempts by René Küss.

 

Jean Dausset (1916-2009) was head of the department of hemato-immunology at St Louis Hospital in Paris (Figure 3). He was appointed later professor at the “Collège de France”, which represents the highest distinction for researchers working in all fields of knowledge. He was the first to describe the HLA system of leucocyte and tissue groups which enables the selection of donors, in a series of publications between 1952 and 1963 (20, 21). His main collaborator was Jean Colombani. He was awarded the Nobel prize in 1980 for the discovery of the HLA groups. He created «France transplant»  in 1970 allowing the rapid transfer of a kidney from a donor with a compatible HLA group. Before him, Peter Medawar in UK had performed a series of skin homografts in rabbits in 1944. If he recognized the immunological nature of the rejections, he limited his observations to histological morphology (22). However, some years later, he inoculated intrauterine fetuses with spleen cells of a donor mouse to induce chimerism, which resulted in the acceptance of grafts of the donor by the chimeric mice. Therefore, he could conclude that homograft rejection was not obligatory. This discovery earned Peter Medawar the Nobel prize in 1966 (22).

Progresses in renal transplantation have also to be attributed in France to other researchers than Jean Hamburger, René Küss and Jean Dausset and the teams working with them. In 1959, Pierre Mollaret and Maurice Goulon defined a new entity, the irreversible coma, (“le coma dépassé”) in patients without any cerebral activity who were maintained in artificial survival by artificial breathing and whose hearts were still beating. Kidneys were removed from these patients after agreement of their family and successfully transplanted with results similar to those obtained with transplantations from related donors. Their studies were at the origin of a new stage in renal transplantation allowing their number to be greatly increased (23). To diminish the immune reaction was also the preoccupation of French teams. Jules Traeger and Jean Perrin proposed lymphocyte depletion by cannulation of the thoracic duct. The collected lymphocytes were utilized to prepare an anti-lymphocyte serum which found a place next to the couple azathioprine – prednisone (24). This treatment was quickly abandoned because of its side effects. It is the precursor of the use of monoclonal antibodies.

 

What did occur simultaneously in USA?

In parallel with the studies carried out in France, the United States were actively participating in this race towards the development of effective and well-tolerated renal transplants. In 1950, Richard Lawler (1896-1982) working in Chicago performed an intra-abdominal cadaveric renal transplant in a patient with polycystic renal disease after removal of one of his kidneys that functioned for 53 days (25). David Hume (1917-1973) working in Boston realized nine kidney transplantations between 1951 and 1953. The donors were patients who had died after surgery. Except in one case, the grafted kidneys were placed in the thigh and the ureter brought to the skin. Four kidneys only functioned, briefly for three of them, but for almost 6 months for the latter (26).The first real success was obtained in 1954 by Joseph Murray (1917-2012) with a graft between monozygotic twins. The recipient died 25 years later (27). This was followed in 1959 by 2 successful grafts between dizygotic twins after radiotherapy that were performed in collaboration with John Merrill (1917-1984) (28), but grafts between unrelated persons were rejected (29). Success was soon obtained by conditioning the recipient with azathioprine. Using this drug alone allowed Joseph Murray to win a first long-term success in 1962 (30). Chemical immunosuppression, then used by the different teams, too happy to abandon irradiation, contributed greatly to the development of renal transplantation. One year later, Thoma Starzl exhibited previously unmatched results relating the efficacy of azathioprine and cortisone (31).

 

Conclusion

In spite of all these progresses, everybody was not convinced of the future of renal transplantation at that time, even the most famous immunologists. Frank Macfarlane Burnett (Australia) was awarded the Nobel prize in 1960 for his works on immune tolerance and clonal selection. In a review entitled “The new approach to immunology” he wrote: “Much thought has been given to ways by which tissues or organs not genetically and antigenically identical with the patient might to be made to survive and function in the alien environment. On the whole, the present outlook is highly unfavorable to success…” (32). For this reason, we must be particularly grateful to the French and American medical doctors who persisted despite their failures in pursuing their quest for a successful renal transplant. The best conclusion is given by Thomas Starzl, who wrote in 1990: “These events and subsequent ones could not have transpired in the way they did without French pioneers, Hamburger the physician and Küss the surgeon, and their friends in Boston whose vision was greater than that given to most men and women. Workers in the two cities founded a clinical discipline where none existed before and then persisted despite allegations of folly or worse. The French successes with kidney transplantation over the three-year period from 1959 through early 1962 kept the flames alive when all other efforts were failing” (33).

 

References

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