Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
1 March 2006

ONE LADY’S STORY OF SUCCESS

            Last week’s column was devoted to a description of kidney failure.  This week, I am going to describe the course of a lady who did undergo kidney failure but survived to the present with a kidney transplant done in 1967.

            Kidney failure comes from a number of different diseases.  The most common one today is diabetes mellitus.  Because of our epidemic of obesity, sedentary lifestyle and diabetes, fully half of the cases of kidney failure are the result of diabetic kidney disease.  Other causes include hereditary polycystic kidney disease and a whole host of diseases that go under the name of glomerulonephritis.  In spite of years of research, we still have not got a clue as to what causes the kidney failure in glomerulonephritis cases or how to stop the progression to end end-stage renal failure.   Thus we don’t know the cause of this problem.  When these diseases occur, they affect both kidneys with slow progressive deterioration that usually is not diagnosed until the kidneys have far advanced disease.  That was the case in the lady that I am going to describe below.

            She was 33 years old when the basic problem noted was chronic fatigue.  She was much more tired than she thought that she should be and the problem seemed to be getting worse.  She was referred to Mayo Clinic where a diagnosis of chronic glomerulonephritis was made.  The condition was newly diagnosed and already 80% of her kidneys had been destroyed.  This was 1966 and kidney transplant was a brand-new type of treatment about which very little was known.  The following year, 1967, in May, she returned to Mayo Clinic and now her kidneys had been 88% damaged and she was very weak, fatigued, and not normally functional at this point. She was started on artificial kidney treatments briefly but a kidney transplant was selected as the long term care plan.

            In 1967, transplanting a kidney from one identical twin to another had already been accomplished 10 years previously.  There had also been a number of cadaver kidney transplants done where a person received a kidney from someone who had met an untimely traumatic death.  But by 1967, we had learned that this was a very risky business because the genetic match between a random individual who happened to be accidentally killed and the person who needed the kidney transplant was a random event.  If a genetic match was not very similar, the person receiving the kidney transplant would reject the kidney and the transplant would fail.  Alternatively, the person receiving the kidney transplant would be so vigorously treated to suppress their immune system that they died from infections and other complications.  Kidney transplant in 1967 was in its infancy.

             But an idea that caught on and was recognized as a helpful solution for this problem was the idea of using a living relative to take one kidney and transplant it into the person that needed the transplant.  If the kidney donor was a close relative such as brother or a sister, the likelihood of a genetic match was much better.  And that is what happened to our lady above.  She was fortunate enough to have a sister who was genetically very similar and willing to donate a kidney.  This was accomplished in August of 1967.  She had good function of the transplanted kidney almost immediately and eventually required very few drugs to suppress her transplant rejection.  That was 39 years ago and this lady is still doing well today as is her sister.  Both of whom have who have only one kidney.  While the lady above was getting her kidney transplant at Mayo Clinic in 1967, I was just starting my training as a kidney disease specialist in St. Louis.  I was the kidney disease specialist in training who took care of my first living related donor transplant in December of 1968.  The lady I took care of is also still alive today as is the brother that donated a kidney to her.

            How does a kidney transplant work and how has the care changed over the past 40 years?  The technical part of removing the kidney from a donor is relatively simple.  This is standard surgery that has been known for years.  The only thing new is the necessity to flush that kidney to remove as much blood from it as can be done before the new blood from the recipient is allowed to enter that kidney.  The new kidney is placed in the groin area and the arterial blood supply comes from the big artery that supplies the leg.  The ureter to drain the urine from the kidney is sewed into the bladder and the person urinates in a normal manner.  Those technical parts of surgery were well worked out in 1967 and there has been very little evolution since then.

            But the science of avoiding a transplant rejection has undergone tremendous evolution.  At about the time a person is born, the body’s immune system takes inventory of all of the things that are in the body at that moment and catalogs them.  The body’s immune system then decrees that anything else is foreign stuff and must be removed from the body.  If a piece of skin is transplanted from one person to another and if they are not genetically identical, the recipient will reject that piece of skin through their immune system within about 10 days.  The same is true for any other organ in the body.  The problem of transplant science is how to prevent the receiving person from rejecting the transplanted tissue but still defend themselves against all of the other foreign invaders in this world.  How does the body know enough to not reject the transplant but to reject a fungus or a bacteria or a virus that infects the body?  If drugs are given to suppress the immune system to prevent the transplant rejection, how do we protect the person from pneumonia or tuberculosis?    This was a very difficult question but eventually transplant scientists learned that two drugs called Prednisone and Azathioprine used together seemed to allow many patients to accept a kidney transplant and not have an inordinate risk of infections.  Over the years, these two drugs have been supplanted by more modern medications called cyclosporin, CellCept and Prograf.  These later medications are more effective with fewer side effects and there are yet other drugs in the drug development pipeline at this time.

            Kidney transplant was the first organ transplant tried in significant numbers.  Since then, there are now a large number of people who have undergone heart transplants, lung transplants, liver transplants, and as you recently saw on TV, face transplants.  These have all had their individual challenges and the science of preventing rejection is a little bit different for each one but we are continuing to learn and the results are getting better.

            Through it all, I marvel at success stories such as the lady described above.  Through 39 years, she has lived a relatively normal life.  Without her kidney transplant, she would have had a fatal outcome in 1967.  Every once in a while, these medical science guys get something right.