A History of Organ Transplantation: Ancient Legends to Modern Practice

17 The Plateau of the Early 1970s

359 17 The Plateau of the Early 1970s I n the early 1970s, there was a hesitation in the development of organ transplantation. The results of kidney transplantation had been encouraging in the late 1960s, but thereafter the pace of improvement stalled.¹ The numbers of kidney transplants also leveled off after 1972, and the results then got mysteriously worse. After the major promise of antilymphocyte serum had faded, the hunt for new drugs ensued, and there was but brief enthusiasm for each new agent tried.² The hopes for a dominant role of tissue typing in cadaveric kidney transplantation declined, and the matter became problematic. The development of liver transplantation, which had restarted in 1967, reached a plateau, with Starzl’s outcome at one year fixed for some time at 35 percent survival. Heart transplantation was restricted to Shumway’s low-key attempts, which were edging slowly toward clinical and political respectability. Transplants of lung, small bowel, and pancreas were rarely attempted. The best news in the transplant world was growing confidence in the technique of human bone marrow replacement.³ One new development was that kidney transplantation was beginning to spread beyond the developed nations and there it met new challenges. Even in the world of immunology there was a hesitation after the buoyant 1960s, with little novelty emerging. The doyen of the new cellular immunology , Niels Jerne, later a Nobel Prize winner, famously stated that “the end of immunology is in sight.”⁴ Some transplant pioneers believed that, although organ transplantation was not finished, there was an impasse . Some moved enthusiastically into other fields, notably cancer immunology and cancer immunotherapy, the promise of which proved to be short lived. To add to the uncertainty of these unsettled times, there were some incidents of scientific misconduct in transplantation research in the early 1970s. 360 The Plateau of the Early 1970s Taking Stock At the Transplantation Society meeting at The Hague in 1970, the society issued a declaration summarizing the place of organ transplantation in the clinical world. Only kidney transplantation was considered to be a routine service, and grafting of other tissues and organs, notably the heart and bone marrow, “deserved careful clinical trial by experienced teams.” This was a coded warning, if one was needed, to prevent any repeat of events in the “Year of the Heart.” Thomas Starzl’s verdict on transplantation at the time was that “surgeons interested in the extrarenal organs brooded in their self-made dungeons, smuggling messages to each other or communicating by secret signals, tapped on their academic walls. There were very few who continued to try.”⁵ Outside of transplant circles, few considered that even kidney transplantation was a treatment generally available. In the cautious world of life insurance, transplantation continued to be viewed with fiscal disdain. In 1973, Richard Simmons in Minneapolis polled seventy-seven major insurance companies in North America, and 90 percent responded that no life insurance could be offered at any premium to those with a kidney graft. Only 12 percent of the companies surveyed would consider life insurance even for a recipient of a kidney from a twin donor. Bone Marrow Grafting The first experimental attempts with marrow grafts in the mid-1950s had been intended to protect animals and hence human patients after radiation injury. The technique was an apparently simple one, but it presented an immunological challenge not faced by the surgical transplanters, namely, that the effects of carrying over even small numbers of foreign lymphocytes with the marrow caused an immediate and troublesome graft-versus-host reaction (GvH). Organ transplantation had been largely free of this particular complication, at least in its overt form.⁶ The Boston-trained physician/hematologist E.Donnall Thomas had been involved in the early use of radiation plus “tolerogenic” bone marrow in the Boston human kidney transplants, and, in 1955, he began studying marrow transplantation as a separate, independent project. Over many years, his persistence, and that of others, solved the many discouraging challenges in this field. Thomas moved to Cooperstown in 1955 but maintained his Boston links, and in 1959, as described earlier, he had treated a human patient with leukemia using a twin as the marrow donor, although the leukemia returned later. Thomas moved to Seattle in 1963 and persevered with radiation to destroy the host marrow. But it was the improvements in tissue typing that proved essential in establishing bone The Plateau of the...