Newsletter: A Look Back in History

Transplant Trek

Cincinnati Children’s currently offers several highly successful Organ Transplant Programs, but these positive outcomes could hardly have been predicted from their early beginnings.  Like most pioneering efforts, Children’s first attempts at solid organ transplant were characterized by great expectations and grave disappointments. This is not surprising, considering that Children’s was one of the first Pediatric Hospitals to attempt organ transplantation, starting over 50 years ago!

Before the mid 1960’s, 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, Dr Lester Martin, assisted by Dr. Luis Gonzalez, 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, Dr Martin recalled that some news photographers tried to get into the OR! 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. Tom himself lived to be 39 before dying unexpectedly in an auto accident.

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 Dr James Helmsworth, had been collaborating since the early 50’s with Drs Sam Kaplan, Children’s Director of Cardiology, and Leland Clark, 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 ASD. 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 Christine’s post op course was relatively uneventful, she suddenly succumbed to acute rejection, dying one month later on March 11. 

Liver transplantation at Cincinnati Children’s also got off to a rocky start. In 1969, no one except Dr. Thomas Starzl 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, Starzl was in Cincinnati for a speaking engagement and was present in the OR during most of the operation. Once again, the Staff Bulletin reported on this procedure with great enthusiasm and in great detail. Unfortunately, Valori died, as a result of hepatic artery thrombosis, within weeks of the procedure. 

These discouraging outcomes led to a reassessment of transplant protocols and procedures. At this early stage, perfecting surgical techniques was the least of the challenges.  HLA typing was just being standardized, and the organ rejection process was not well understood. Safe and effective anti-rejection therapy was still being sought. The whole notion of transplanting an organ from one being to another raised new controversies. “How does one determine ‘brain death’ in an anencephalic newborn?” “Is it ever permissible to use non-human organs?” Popular novels like Robin Cook’s “Coma” (made into a successful motion picture) fueled fears of sinister organ-harvesting conspiracies.

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 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. 

Dr Fred Ryckman arrived at Children’s as a surgical fellow in 1982, having performed many kidney transplants during his residency. After meeting liver-transplantation pioneer Dr Thomas Starzl, who was in Cincinnati as a visiting professor, he started experimenting with liver transplantation techniques in the surgical lab. A serendipitous conversation with Dr. Bill Schubert on an elevator one day led to the funding of his project. Around the same time, Dr Bill Balistreri 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, Dr Ryckman and Dr John Noseworthy performed a successful liver transplant on 14 year old Cameron McDonald. That same year, in December, cardiac surgeon Dr. Warren Bailey 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 on the menu!

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! How well did it work? According to Dr Balistreri, Michelle is now in her mid-thirties, a former Fulbright Scholar, who has worked as a freelance writer and foreign policy consultant, and is currently the Owner & Founder of a Communications Company.

Today, as a result of 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%, with overall long-term survival near 95%. At Children’s, transplant candidates are managed by teams including medical specialists, surgeons, advance practice nurses, social workers and psychologists, even financial advisors. Back in 1969, the total cost of Christine Cohrn’s heart transplant was a little under $7000, most of which was paid by Blue Cross, with the remainder either donated by well-wishers or written off. These days health insurance, charitable foundations and Go-Fund-Me campaigns are enlisted to cover the …..somewhat higher costs. 

Thanks in part to pioneers at Cincinnati Children’s, solid organ transplantation, once the province of science fiction, has now become standard of care!

Submitted by Elaine Billmire, MD (residency 1978, fellow 1979)