An Overview on Organ Transplantation
Arye Durst, M.D.
Preconditions for Organ Transplantation
What are the conditions required for organ
transplantation? First, it must be surgically possible to transfer the organ in
its entirety from the body of one person to another. Second, a critical factor
(and the one that even today causes the most problems) is rejection of the
transplanted organ by the recipient. Third, and no less important, is the
location of a suitable organ from a live or deceased donor in a state that will
allow it to be transplanted. I emphasize, in a state that will allow it to
be transplanted, for this point has given rise to much ethical
debate and discussion. Organs obtained for transplant can be unsuitable for
various reasons and can harm the patient receiving them.
In the Middle Ages the possibility of organ
transplantation was considered, and evidence for it exists particularly in
Christian texts which describe attempts by various monks to exchange organs. A
famous illustration from the fifteenth century shows a patient undergoing
“transplantation” of a leg in which decomposition has spread. But real organ
transplantation began in 1902, when Karl, a French surgeon working in the
United States, demonstrated a technique for connecting blood vessels. This
represented the first basis for modern transplantation.
a first attempt was made by Varonoy, a Russian surgeon,
to transplant a kidney in a person dying of kidney failure. The transplant held
for thirty-six hours, after which time the patient died. The concept of
rejection was as yet unknown, as were other problems with which we are familiar
today. It is important to note the breakthrough by Sir Peter Midber, who was
the first to note the process of first and second set rejection, introducing
the study and understanding of organ rejection.
In 1951 Kuss, a French surgeon, was the first to describe
the place where the kidney is transplanted, and in 1954 David Hume overcame the
problem of rejection by transplanting a kidney between identical twins in
Boston. Hume performed another nine kidney transplants, each of which were
successful for a number of months. The patients’ bodies eventually rejected the
foreign kidneys and consequently the patients died. Although steroids were
already in use, Hume considered them to be of no benefit in these transplants.
In 1959 Hamburge, at the Keer Hospital in Paris, applied
total body radiation to patients to prevent organ rejection. Indeed, following
his transplantation of a kidney his patients functioned very well as long as he
kept them in total isolation. As soon as the patients were taken out of
isolation, they contracted infections.
The first real move towards clinical transplantation took
place in 1962 when Professor Tom Starzl began transplanting organs with the
help of immunosuppressive agents using a method similar to that which we use
today. In 1966 the HLA (Human Leukocyte Antigen) system was discovered,
assisting in the determination of organ compatibility. In 1980 a new breakthrough was
achieved by Borel, a Swiss researcher from the Sandoz company, who developed
Cyclosporin A, a new immunosuppressive substance which is still widely used.
Dangers of Organ Transplants
What dangers are associated with organ transplants? First,
there can be a technical failure with the connection of the actual organ.
Whether it be obstruction of the veins or arteries or whether it involve
connection of a kidney and ureter, there are problems related both to the
surgical technique and to rejection of the transplanted organ.
Regularly transplanted organs can be divided into two
types. The first type consists of organs which have no mechanical replacement,
such as the liver or the heart. If transplant fails, a repeat transplant is
immediately required. This poses a very serious problem as there is no
“dialysis” for a liver or heart. Therefore, if someone undergoes a heart or
liver transplant and the organ does not function, a new transplant is
immediately required. Hence for every transplant of this type, one must plan
for another heart or liver which may be required for a repeat transplant.
Transplantation of organs which do have mechanical
replace- ment, for example kidneys, is easier for if the new kidney is
rejected, the possibility exists of returning to dialysis.
A second problem in organ transplantation is the risk of
serious infections which attack patients receiving immunosupp- ressive
treatment. The most important issue today is the selection of compatible organs
which will not be damaged as a result of being removed from the donor’s body.
There are cases of serious infection following transplant, a phenomenon which
occurs prin- cipally in patients receiving immunosuppressive therapy. Such
infection is most likely to attack those patients who receive damaged organs
with strong immunosuppressive treatment to suppress rejection.
A kidney removed from the body too long after death may be
damaged and will not function following transplantation.
organs are transplanted today? Clinical transplants of the following have been
carried out for many years: kidneys (since 1962), liver (since 1963), heart and
lungs (1968), and pancreas and intestines in recent years. I have not mentioned
skin transplants or corneal transplants since these do not require connection
of blood vessels.
Kidney Transplants and Trade in Organs
Kidney transplants are routinely carried out almost
worldwide. The kidney may come from a living relative, a live donor who is not
related, or from a dead donor.
Let us concentrate on the second category: a live donor
who is not related. Since he is not related to the recipient of the organ, such
a donor is comparable to a dead donor. Owing to the shortage of organs, organ
trade is flourishing, and it is well known that kidneys may be bought from live
donors not related to the patient. People from all over the world travel to
India to buy kidneys and even undergo the transplants there. Organ trade also
exists in Egypt.
There are well-founded rumors from South America con-
cerning the kidnapping of children, particularly from the poorer sectors. These
children disappear, supposedly taken to resorts for treatment and support, but
it is believed that their organs are removed and sold. With evidence of such
worldwide trade, we are particularly careful in Israel. However we do treat
Israeli patients who have undergone organ transplantation in India,
particularly kidney transplants, and who come back to us for continued
treatment following the operation.
A review of the results of kidney transplants shows that
there is 90% success during the first year for kidneys from live relatives, and
75% success during the first year from dead donors. Currently there are
approximately one hundred kidney transplants carried out each year in Israel,
with the demand reaching around two hundred and fifty. The organ-demand curve
in recent years has been rising exponentially while the supply of organs has
remained constant, giving rise to various phenomena which are entirely
In 1963 Prof. Starzl carried out the first liver
transplant in Denver, Colorado. Thereafter he, with very few others (one
surgeon in South Africa, and Prof. Kilna in Cambridge, for instance), continued
transplanting livers. Since then, progress in surgical procedure has solved a
number of problems which were encountered. In a liver transplant several blood
vessels have to be connected as well as the bile ducts. There are also problems
associated with the size-compatibility of the organ, particularly when an adult’s
liver is transplanted into a child.
In the event of definitive rejection of the organ which
cannot be suppressed by immunosuppressive treatment, a new organ must
immediately be transplanted, and any available source is app- roached for this
purpose since without a liver the patient will die.
Owing to the shortage of organs from dead donors, attempts
are being made to use live donors – a relative of the patient, most often
parents to children – and to remove just a portion of the liver. In the case of
dead donors, the liver is divided into two in order that one organ can be used
for two patients, even though this is a much more complicated procedure and
involves more danger to the recipients.
Liver transplants are carried out only in large medical
centers, unlike kidney transplants which are much simpler and are routinely
performed in most hospitals.
Cyclosporin A and Heart Transplants
Until 1980 transplants, especially of kidneys, were mostly
taken for granted despite the fact that the success rate for tran- splantation
of the heart, liver, pancreas and other organs was not high. The turning point
occurred with the discovery of Cyclosporin A, a more potent immunosuppressive
substance, which was put into use in 1980. Since then transplant results have
began in 1968. This first was carried out in South Africa by Christiaan
Barnard, although there are those who insist that the way was prepared for him
by the laboratory work of Dr. Kantrowitz in California. In any event, many
others sub- sequently attempted heart transplants, but owing to the high rate
of failure, enthusiasm waned considerably. For a time few centers made further
attempts at heart transplants until Cyclosporin came into use in the 1980’s.
Since then heart transplants have become routine and are carried out in many
As mentioned, the problem with heart transplantation is
that if we fail to control rejection using immunosuppressives, a repeat
transplant needs to be immediately carried out.
Today life expectancy of a year after a heart transplant
is about 50%-60%.
A lung transplant is required in the case of chronic lung
failure. The number of patients requiring such a procedure is constantly
rising. The transplant is complicated since the lung is very sensitive, and
hence the failure rate is high. There are only a few medical centers in the
world where lung transplants are carried out. At first the practice was to
transplant the heart and lung as one unit, but today sufficient experience
exists for the transplan- tation of a lung alone to be performed.
Pancreas transplants, too, are becoming increasingly
common. The indication for a pancreas transplant is severe diabetes, especially
juvenile diabetes, which affects the kidneys. (Hence some patients undergo
transplant of both kidney and pancreas.) The organ can come from a dead donor
or from a live relative. Experiments have been carried out at the University of
Minnesota, where a good procedure has been developed for transplantation of a
portion of the pancreas from a living relative.
Some fairly serious technical problems continue to
complicate the connection of the transplanted portion of the pancreas into the
body of the recipient. The pancreas must also be connected to the bladder, into
which its secretions must flow.
During the 1980’s the revolution of Cyclosporin affected
pancreas transplants, as well as other organs, and the number of transplants
started rising exponentially as did the life expectancy figures for the organs
transplanted. This improvement was due not only to the introduction of
Cyclosporin, but also to the increased skill of the surgeons. With a growing
number of such operations their experience in pancreas transplants increased, and
the results improved accordingly.
The transplant of intestines is also an important
development. There are many patients whose intestines cease to function as a
result of arterial or other damage. Such patients live permanently on intravenous
nutrition, and we are therefore looking for ways to transplant intestines. This
operation is still very complicated, the results are not yet satisfactory, and
there are only a small number of centers which perform the procedure. Intestine
transplantation can be said to be still in its experimental stages.
Life Expectancy and Future Aspirations
With regard to life expectancy at the end of the first
year and after five years following transplantation, we see the best results
from kidney transplants from live relative donors. Even after five years the
results in these patients are excellent. Results of kidney transplants from
dead donors are also excellent after a year, and after five years the survival
figure remains higher than 75%. Liver transplants also yield excellent results
today: five years following the operation the recipient’s life-expectancy is
the same as that of the transplanted organ, except for rare cases where repeat
transplants are required. The success rate stands above 50%.
The figures for heart transplants are even better. In
recent years we have also seen a considerable improvement in transplan- tation
of heart and lungs, although the five-year prognosis is not as good as that of
the first year. Here the results refer to the number of transplanted organs
which continue to function after one year and after five years. All in all the
results are excellent signaling a positive forecast for future transplants.
One of the factors that will help to advance the success
of transplants is the intensified fight against rejection using immuno-
suppressives. New substances are continuously being sought, and a long list of
substances are being studied. 506FK, 61443RS, Refermicin and Cytocasein are
among those being investigated today for their possible toxic effects, in order
to ascertain whether they improve results.
Another important area, of course, is that of encouraging
organ donation, which remains very cautious and slow both here in Israel and
A further possibility for advancing transplants is
xenografting (gathering organs from animals). Professor Starzl has carried out
some experiments, including some involving hearts. These exper- iments have yet
to show signs of success, but there are those who attach considerable hope to them.
Attempts are today being made to increase the use of
organs from live donors. Kidneys, liver, pancreas and large intestine are taken
from live donors, relatives who are prepared to donate part of their organs to
a loved one, most often parents to children or between siblings.
I have attempted to summarize the current situation of organ transplants.
We hope that in the future, with the further develop- ment of immunosuppressive
substances, and with increased support in the area of organ donation, we shall
continue to progress.
– Jewish Medical Ethics,
Vol. III, No. 1, January 1997, pp. 7-10