A History of Organ Transplantation: Ancient Legends to Modern Practice

14 Support from Hemodialysis and Immunology in the 1960s

296 14 Support from Hemodialysis and Immunology in the 1960s I n 1960, the medical community made significant progress toward a full understanding of cell-mediated immunity. Most notably, researchers uncovered the central role of the thymus and defined the two types of lymphocyte and their links with cell-mediated immunity. Also in 1960, Peter Medawar was awarded a Nobel Prize for his work on tolerance, a signal that transplantation immunology had come of age. And 1960 was also the year in which regular dialysis was first used to sustain patients in endstage renal failure. Dialysis and kidney transplantation were to be closely linked thereafter. Regular Dialysis Beginning in the mid-1950s, the use of the kidney machine to deal with acute renal failure slowly started gaining acceptance and dialysis techniques steadily improved. But to keep patients with end-stage renal failure alive in the long term with such treatment seemed inconceivable.¹ Not only was the concept considered “unnatural” in some quarters, but there were also practical constraints. For each dialysis treatment in the 1950s, separate surgical procedures were needed to connect the patient’s circulation to the machine. In 1960, there occurred a simple change in the method of this “access ” to the circulation for dialysis, which was immediately successful. This advance came from creative tinkering with bits of the new plastic tubing widely used for covering telephone cables. Regular dialysis was possible, and this new treatment not only immediately opened up many clinical challenges but also changed the practice of medicine, provok- Support from Hemodialysis and Immunology in the 1960s 297 ing a new public debate on a range of issues. This new form of treatment developed exactly as hopes grew from 1960 to 1963 for successful kidney transplantation. This was perhaps simply a historical coincidence, but it certainly seemed at the time that treatment of endstage renal failure was a venture whose time had come. In 1960, Belding Scribner (1921–2004), a nephrologist in Seattle, Washington, devised a method for gaining permanent access to arteries and veins for the purposes of regular hemodialysis . Scribner developed a simple shunt using a length of electrical cable.² The cable was sheathed in the newly available, nonwettable, heat-malleable Teflon, and, removing the cable, he was left with a hollow tube. He thinned down the two ends to give narrow tips, bent the tube into a loop, and inserted and tied one narrow tip into an artery in the forearm and the other into a nearby vein.³ With the loop led outside of the skin, this gave an external conduit for blood flow, and a junction inserted into the loop created an opening for connection to the machine. Blood flowed nicely through the device without clotting, aided by the dispensation of the low viscosity of the anemic end-stage renal failure patients’ blood, plus their subtle clotting defect. The shunt continued to work remarkably well. Tentatively, Scribner started to carry out repeated dialysis treatments in a patient with end-stage renal failure.⁴ It was reasonable to expect that the treatment would simply postpone the inevitable and result in a lingering death with unpleasant and intractable complications . To Scribner’s surprise, the treatment went smoothly from the start, and when a shunt firmly clotted or became infected, a new site could be found. Scribner reported his clinical experience, Belding Scribner developed a shunt that provided permanent access to arteries and veins, to allow repeated hemodialysis. Available commercially, in many variant forms, the shunt could be placed at the wrist or at the ankle. 298 Support from Hemodialysis and Immunology in the 1960s only ten weeks into the treatment of his first case, to the American Society for Artificial Internal Organs meeting in Chicago in May 1960, and he took to the meeting ten of his simple shunt-making kits for others to use. Because of interest in the device, he was allowed to substitute this presentation for a paper previously accepted and already on the printed program.⁵ In Scribner’s unit, four patients started on regular dialysis in the first year, the first living for eleven years thereafter, and the second had eight years on dialysis and lived for a further nineteen after a transplant . Four more patients were taken on in the second year, including a young London doctor, Robin Eady.⁶ Apart from Scribner’s technical success , he could show that the expected nutritional problems...