A personal reflection on  the early days of renal transplantation 

Chris Rudge

‘I first saw a kidney being transplanted in 1969. I was a medical student with a degree in  immunology and I’d done the cytotoxic crossmatch. To me it was amazingly exciting and dramatic and I was hooked.

The overwhelming early impressions were of the drama, the intense time pressures and the way in which organ donation and transplantation existed at the periphery of conventional medicine and surgery. By 1969 a number of UK centres had started renal transplantation, based almost entirely on a small handful of “cavalier” surgeons.  Just as in many hospitals the dialysis units had been banished  to a portacabin or to a smaller local hospital  so transplantation was seen as a nuisance that had to be tolerated – just. There was no training programme, and my only substantive appointments were as a pre-registration house officer and then as a consultant. In between every  job I had was on “soft” money of one sort or another. Being so attracted to transplantation as a house officer I asked my boss whether it would ever “catch on” – did it have a future? He was one of the cavaliers, but he thought for a long time before answering “possibly”.

The commitment of the surgeons involved was extraordinary – they did everything. Transplant coordinators had not been invented and organ retrieval was primitive bordering on the barbaric. Surgeons would drive themselves to the donor’s hospital with surgical instrument packs, perfusion solutions and boxes of ice in the boot of the car, speak to the donor’s family for consent, remove the kidneys, and then drive back to base to transplant the two kidneys. 24-hour working days were common, 48 hours not uncommon. Before the criteria for “brain death” were published  in 1976  some hospitals refused to open an operating theatre for organ retrieval, and several times I saw it done in the patient’s bed in the ward, with the curtains drawn and (on one occasion) the anglepoise lamp from the nursing station used to illuminate the grisly scene. Death was confirmed when the retrieval surgeon could no longer feel the aortic pulse –  conflicts of interests were unrecognised. Organ donation had a very long way to go to be accepted and even in 1979 a deputy coroner said to me that “to wrench the still quivering heart from a freshly dead corpse is not a procedure with which I wish to be associated”.

Transplantation was not much more sophisticated. The operation itself was well established but immunosuppression was not. The starting regime was Prednisolone 100mg bd and Azathioprine 3mg/kg. Wounds didn’t heal, peptic ulcers bled and infections were rampant. Half the recipients died in the first year, half of them from infections. Everyday bacteria and viruses became fatal as did unusual fungi, yeasts and parasites. With no thoracic surgical experience I taught myself to do open lung biopsies as undiagnosable “pneumonia” was so common. In retrospect it is extraordinary that the few successes were celebrated by all whilst the more common disasters were accepted almost unthinkingly. The very notable exception to this was when a transplant from a live donor failed – that caused considerable distress to everyone. However it was very much a case of a successful transplant or death – pressure on dialysis facilities mitigated against patients returning to dialysis after a failed transplant.

I relished working with surgeons, physicians and immunologists, which of course was the founding rationale for The British Transplantation Society in 1972. Nephrologists were dramatically expanding the understanding of renal disease, and in particular recurrent disease after transplantation. I recall my Immunologist boss coming back from a meeting and telling me that the tissue-typing serum we called “Preston 66” was now to be called HLA 1. From the surgical perspective there was plenty of parochialism over the “ownership” of retrieved kidneys with the concept that they are a national resource still decades away. But I probably learnt most from the superb senior dialysis and transplant nurses without whom nothing would have been possible.

There’s little doubt that it was the introduction of cyclosporin in 1983 that was the turning point. Combined with better understanding of histocompatability and improved organ preservation, transplantation at last started to come of age and of course has improved immensely since then. I have no doubt that it is still a very challenging discipline but I am equally sure that it is not quite as exciting as it was when I started.’

Last Updated on July 4, 2023 by John Feehally