Organ Transplant Program Success Rooted in Skill, Technology
Organ Transplant Program Success Rooted in Skill, Technology
The invention of the bubble-defoam oxygenator heart-lung machine by Leland Clark, PhD, allowed doctors to perform open-heart surgery and ultimately, heart transplants.
Before the mid-1960s, organ transplants were uncommon and almost unknown in the pediatric population. The first successful adult kidney transplant (using a living twin donor) had been performed in 1954 in Boston. On June 5, 1965, at Cincinnati Children’s, Lester Martin, MD, assisted by Luis Gonzalez, MD, performed one of the first pediatric kidney transplants in the nation on 8-year-old Tom Doherty. He’d been born with a single kidney, which later failed due to hydronephrosis. His mother was the donor. The hospital did not publicize this milestone in advance, but word leaked out. Years later, Martin recalled that some news photographers tried to get into the operating room! The transplant was a success, and over the next 4 years, 14 more transplants were performed; all but one of the recipients were still living 25 years later.
Two years after Dr. Christiaan Barnard made headlines, physicians at Cincinnati Children’s performed their first pediatric heart transplant, on February 8, 1969. The surgeon, UC’s James Helmsworth, MD, had been collaborating since the early '50s with Sam Kaplan, MD, director of Cardiology at Cincinnati Children’s, and Leland Clark, PhD, researcher extraordinaire, to create the bubble defoam oxygenator heart-lung machine, which was used in this operation. The recipient was 6-year-old Christine Cohrn, born with a single ventricle, TGF and an atrial septal defect. Her new heart came from a 7-year-old boy who’d suffered severe brain damage in an auto accident. Local media interest was intense; daily post-op bulletins were issued, and the fledgling "Staff Bulletin" devoted two issues to this story, reporting on the procedure and its aftermath with almost the detail of an op-note! Tragically, although Cohrn’s post-op course was relatively uneventful, she suddenly succumbed to acute rejection, dying one month later on March 11.
In 1969, no one except Thomas Starzl, MD, in Denver had had any experience, let alone success, in performing pediatric liver transplants. On May 1, 1969, Drs. Lester Martin and William Richardson performed a liver transplant on Valori Ann Scott, a 14-month-old infant with biliary atresia. The donor was an anencephalic newborn. Serendipitously, Thomas was in Cincinnati for a speaking engagement and was present in the operating room during most of the operation. Once again, the "Staff Bulletin" reported on this procedure with great enthusiasm and in great detail. Unfortunately, Valori died of a hepatic artery thrombosis (blood clot), within weeks of the procedure.
Lester Martin, MD (right), performed one of the first pediatric kidney transplants in the nation.
Taking a Step Back These outcomes led to a reassessment of transplant protocols and procedures. At this early stage, perfecting surgical techniques was the least of the challenges. HLA (human leucocyte antigen) typing was just being standardized, and the organ rejection process was not well understood. Safe and effective anti-rejection therapy was still being sought.
But the real major obstacle was the unavailability of suitable organs. There was no national system for identifying or ranking patients in need of transplant or procuring donor organs. This problem was especially acute in pediatrics, as organs needed to be “right-sized.” An adult kidney could sometimes be successfully transplanted into a child’s abdomen, but hearts and livers had to fit. Many children died while waiting for organs that never materialized. Out of necessity, hospitals developed their own regional consortiums to help facilitate the identification, matching, and transportation of organ donors and recipients.
Heart and liver transplants did not resume at Cincinnati Children’s until 1986. By this time, several major developments in anti-rejection therapy, notably the discovery of cyclosporin, had significantly improved transplant patients’ long-term survival. The United Network for Organ Sharing (UNOS) and similar organizations were finally being formed.
Fred Ryckman, MD, arrived at Cincinnati Children’s as a surgical fellow in 1982, having performed many kidney transplants during his residency. After meeting liver-transplantation pioneer Thomas, who was in Cincinnati as a visiting professor, he started experimenting with liver transplantation techniques in the surgical lab. A serendipitous conversation with Bill Schubert, MD, on an elevator one day led to the funding of his project. Around the same time, Bill Balistreri, MD, was beginning to develop a comprehensive, multidisciplinary Liver Care Center to coordinate the management of children with a variety of liver conditions, including those in need of transplant. He and Fred and other colleagues began to collaborate, and in July, 1986, Fred and John Noseworthy, MD, performed a successful liver transplant on 14-year-old Cameron McDonald. That same year, in December, cardiac surgeon Warren Bailey, MD, performed a successful heart transplant on 11-year-old Jermayne Hudson. Two more heart transplants followed a few years later. Solid organ transplantation was back!
Fred Ryckman, MD (left), and Bill Balistreri, MD, with 9-month-old Michelle Offik, who received a segmental liver transplant in 1988.
The Liver Team also performed several other liver transplants, most successful, some not, but continued to be distressed by the number of children dying before an appropriately sized liver could be found. They began considering the possibility of transplanting just a segment of a donor liver. The opportunity presented itself in July, 1988. Nine-month old Michelle Offik, born with biliary atresia, had received a right-sized liver transplant, but to everyone’s consternation, it failed four days later. The likelihood of finding another infant-sized liver seemed remote. Michelle’s parents, knowing their daughter’s death was otherwise imminent, persuaded the team to attempt a segmental liver transplant. It worked!
Today, thanks to surgical advances, improved immunotherapy, anti-viral drugs, and coordinated, multidisciplinary care, the immediate post-op survival for most solid organ transplants is close to 100 percent, with overall long-term survival near 95 percent. At Cincinnati Children’s, transplant candidates are managed by teams including medical specialists, surgeons, advance practice nurses, social workers and psychologists, and even financial advisors.
Thanks in part to pioneers at Cincinnati Children’s, solid organ transplantation has now become standard of care and a life-saving option for many!