By Sophie Farr
Published 6:46 PM EST, Thurs June 10, 2021
Transplantation began with the basic principle of the Carrel Patch which proved that a vein could be reattached and still support a functioning blood flow. This technique was employed by the Ukranian surgeon Voronoy Kiev and allowed him to accomplish the feat of being the first person to successfully transplant a kidney in a cadaver.
After this promising start to transplantation, medical advancements were catalysed during the Second World War of 1939-1945 and transplantation especially had major breakthroughs. The war meant that severe injuries were more common and novel treatments could be tested as a last resort. Skin grafts were first used to heal airmen’s burns and this prompted the realisation that the immune system may reject transplants, a problem which has continued throughout the surgery’s development.
David Hume, an American doctor, was the first to attempt a kidney transplant in a living patient, albeit in the arm instead of in the normal position in the thorax. The implanted kidney was removed After two days and natural function then resumed and the patient miraculously survived. This is still seen in the NHS today with the “Bridge to Transplant System” which uses ventricular assist devices for prospective heart surgery patients that are then removed and if the relief has assisted function, full transplantation may not be necessary.
In 1951, a doctor in Paris performed the first ever renal transplant, using the kidney of an executed criminal, into a patient in renal failure. Although the surgery failed, the kidney was transplanted into the groin and bladder which forms the basis of the modern technique. Still in Paris, the first ever successful live kidney donor, Mrs Renard, gave her organ to her son Marius in 1952. Mrs Renard’s kidney functioned in Marius for 21 days but then it ceased but this was most likely due to rejection.
Finally, the first successful transplantation was achieved in Boston in 1954, having been done on a set of identical twins. One twin was experiencing kidney failure and the other donated a kidney which was transplanted without rejection because of their identicalness. After renal transplants had been accomplished, liver transplants followed in the 1960s and the first successful heart transplant happened in 1967. This heart transplant was undertaken by Christian Barnard in Cape Town on a female car crash victim and marked the greatest achievement in transplantation, now allowing full heart and lung transplants.
Since the amazing triumph of successful transplants, the world has been focused on decreasing the likelihood of complications. Immunosuppressants have been widely used to reduce the chance of rejection and 6MP and azathioprine are the most commonly used after the immunosuppressive effect was demonstrated in a rabbit by Schwarz and Dameshek and on a dog in 1959 by Roy Calne, who later performed the first European liver graft in 1968 in Cambridge.
Preservation has also been a pressing issue as chance of function is reduced with poor preservation. In the past, kidneys were simply stored in ice, preservation fluid and a plastic ice to remain sterile but this arrangement was less successful with livers so the University of Westconsin Preservation fluid was developed by Jamieson for normal liver function. This fluid, combined with improved anaesthetic and the ability to keep patients warm during surgery to prevent clotting, increased transplantation success rates by the 1980s and further advancements are still improving chances of success today.
The opt-out system of organ donation that the NHS moved to in March of 2020, where all adults are assumed to be donors unless they actively specify against, has mitigated against the issue of how few organ donations the NHS had. This, combined with the risk of reduced function due to storage, means that transplantations have long waiting lists and it is contentious as to who receives them. Currently, storing organs for more than 12 hours in ice means that efficacy decreases by 25% every 6 hours.
In the future, the main developments are likely to surround storage and preservation. Cold storage can cause tissue injury and immediate graft function is roughly 65% effective, compared to the delayed function that is only 35% effective. In order to combat these worrying statistics, ex vivo normothermic machine perfusion, a new technique that restores kidney function out of the body before it is transplanted to remove the issue of cold storage, is being tested as a way to repair kidneys and allow more organs to be successfully transplanted.
Write up based on “Horrible History of Organ Transplantation and its Future” at the Cambridge Festival
Sophie Farr, Youth Medical Journal 2021