HISTORY OF RENAL TRANSPLANTS

ALLAN M. LANSING, M.D.
PRESENTED TO INNOMINATE SOCIETY
NOVEMBER, 1974

 

     Unfortunately I have been away from the Innominate Society for two years because of administrative duties associated with attending a lot of meetings at Jewish Hospital, so it’s great to be back.  I am not much of a historian but I thought you might be interested in some pioneers in medicine of Louisville.  Some pioneers that all of you may have heard of one way or another.  They are Medford Scott, Deiter Heime and Dudley Lahume, three outstanding individuals.  And, our story actually starts back in 1963 when three other lesser individuals arrived in Louisville.  One of them, Leonard “Big Kidney in the Sky” Berman, Don “God Damn Don the Dean from Denver” Smith, and Al “Big Al” Lansing from Canada.  This was the start of the renal program at the University of Louisville. We’ve had some fantastic experiences over the years, many of them very trying, many of them humorous, and I wanted to tell you a little bit of what has been going on so that you have some idea of the problems that have been faced and the unusual things, and the accomplishments, in this field.

     After Dr. Berman got here, peritoneal dialysis was started at the University and the first dialysis was done on 2-D in General Hospital and Bev. Towery will know all about this.  One room was started in the Spring of 1964.  There was one bed.  It was a hot room, no shelves around.  Dr. Berman finally managed to purchase one kidney machine.  There were no facilities for hooking the patient up to the dialysis machine, a cut-down tray has to be brought down from the operating room; there were no shunts, that was before the time of the shunts so a cut-down had to be performed, performed on the artery and vein every time that a dialysis was one.  Now this was in the Spring and early Summer in Louisville so you can understand that it was pretty hot and you had to have a window up in order to keep the room cool so that the soot was blowing in from the outdoors across the bed.  Of course, the people in Renal Service weren’t the most skilled surgeons in the world so there would be about six of them standing around watching this done underneath a gooseneck lamp.  There were no nurses available to run the dialysis so that one of the physicians had to supervise it.  No facilities for blood storage, and with the original dialysis equipment these coils for the dialysis were all stacked around the floor in heaps of boxes.  To run someone on dialysis you have to at least watch their blood pressure and there was no blood pressure cup so one was borrowed from 2-D but it didn’t work, and at night the patient was there getting peritoneal dialysis or anything, there was one overhead light up on the ceiling.  So that is how the Renal Service started in Louisville at Louisville General Hospital.  A month Later, by hook and crook, and probably by beating on Beverly, there was one nurse hired who was to work on the dialysis unit but she could only work five days a week for eight hours a day at the utmost, this was Civil Service of course.  So, anything that had to be done at nights or on weekends was just out of luck, it was too bad for the patient.  An air conditioner was borrowed, as a matter of fact it was borrowed from Mr. Margolis’ office, and I don’t think he ever knew where that air conditioner went to but it disappeared and was put into this room on 2-D, and the Unit was enlarged courtesy of Baptist Hospital.  They had a kidney machine which they had decided that they were not going to be in the business of doing dialysis any more and they sent it over as a gift to the University of Louisville Nephrology Center.  So, eventually, after two or three months there two machines in there and at times there were four patients on this little hot, dusty room, two getting peritoneal dialysis, lying there for 48 hours and two getting hemodialysis.  A Clinic was also started at Louisville General Hospital, one day a week, and the Renal Service would see about 50 patients in this clinic but there were no lab facilities available so the lab work would all be drawn and it would be done at leisure by the Pathology Department at Louisville General Hospital and when the results were available the patients would have to be called at home and brought back in for their treatment of response to treatment.

     The first pioneer I mentioned was Medford Scott.  Medford Scott was a 27 year old fellow who had lupus erythematosus, he had two children.  He had had all his blood vessels used up with renal failure for dialysis in this magnificent unit.  He had been tried on peritoneal dialysis and he now had a pseudomonas peritonitis so peritoneal dialysis was oped.  In a rather joking fashion Dr. Berman in talking to the wife and consoling her that all was lost, that the only possible hope was a kidney transplant whereupon the rest of the family immediately took it up and his mother became a volunteer for a donor which put Dr. Berman in a very bad spot because he had suggested this but he had nobody to do any transplants, and there was certainly nobody skilled or trained for this.  So, knowing that in order to perform a transplant you had to hook an artery and a vein up, he came over to me and asked, “Are you interested in doing a kidney transplant?” I said, “Well, I don’t know anything about it but I can read and I could certainly hook that up, but I would certainly like to have someone hook the ureter up because I am not really very skilled at that,” so we enlisted Lonnie Howerton, Jr. to do the urological aspect of this.  And, so, the three of us got together and the first kidney transplant was planned on this basis.  This patient was a terminal renal failure, a bad situation having had peritonitis, and everybody realized this; that the chances of his survival was very small but the family were very determined that they would do anything possible.  So, an operating room was set up, the donor, the mother in one room and the recipient would be in the next room.  This was on September 3, 1964.  we even had the closed circuit TV set up so that anybody who wanted to watch could be in the lecture room up on the fourth floor at General, the Dean was there, the reporters were there, the operation just went like a breeze, perfectly smooth; there was about a 22 minute ischemic time for the kidney, the kidney immediately functioned, the patient was immediately transferred.  We wrapped him I sterile sheets, put him on a sterile blanket and then we transported him through the halls of Louisville General Hospital, down the elevator to the second floor, along to 2-F and put him in his isolation room, which was the TB isolation room on 2-F.  This isolation room had been scrubbed down with soap and water as a means of sterilizing it so that this patient would be safe from the chance of infection.  The nursing coverage here was the nurses volunteered to look after this pioneering effort but 24 hours later there was no nurse available to look after the patient.  The 3 to 11 nurse was not available.  The Nursing Director was called, “I am sorry, we have nobody who can cover this transplant”.  The first one in the State, but no, there was no help available to look after the transplant.  So, his wife took his vital signs for the next shift and alternated with physicians working on the renal service and the physicians working on the cardiovascular surgery service.  Then days later things got pretty desperate and all the physicians and the wife and so on were getting pretty tired so the patient was transferred to Jewish Hospital.  Mr. Otis Wheeler, who has since died, was the administrator there, volunteered and said, “we’ll look after him, we’ll provide the nurses, we’ll provide the isolation room, we’ll pick up the cost”, and the patient was transferred to Jewish Hospital and all these things were provided by the hospital and, as might be expected, three weeks afterwards the patient died of a pseudomonous infection.  So this was the start of transplantation in Louisville.  The operation, however, was a success, the kidney was functioning normally but the patient died of septicemia.  Today, and any other day, one would say that he was not a candidate for transplantation and everybody realized it at the time.

     Between November and December of that year there were four other patients who were terminal renal patients, who were in the same kind of situation.  Now this stage is when the first shunts became available, the Scribner shunts.  At that time you had to make your own shunts, you had to make them out of plastic, you had to mold the shunts, you had to make the cannulae, you had to make all connectors, and we sent a volunteer off to Hines Hospital in Chicago to find out how to make these shunts so that we could put them in, you didn’t have to cut down on an artery and vein every time.  That volunteer is also someone who is known to you and who along with me and Lonnie Howerton are the only surviving members of this, and that’s Miss Mary Heisbrown, otherwise known as Cauley Brown.  She went up as a volunteer to Hines Hospital tofind out how to make the shunts.  In this period in November-December, these patients were being kept alive by peritoneal dialysis alone.  One of the four was a young girl who has post partum renal failure and she died.  The other three, everybody was trying desparately to keep them alive and they were kept alive by peritoneal dialysis and the names of those three were Deiter Heim, Joe Clark, and Marshall Mitchel.  They played a very prominent role in the development of the whole dialysis and transplantation program.  In order to get them home for Christmas, they were dialyzed for 48 hours on December 23rd and 24th by Sidney “The Kidney” Marcum and Miss Brown sitting with the patients all night in this room 2-D to get them in good enough shape that they could go home for Christmas and hopefully come back after Christmas for further treatment.

     They returned after Christmas and the first one back was Deiter Heim, the second pioneer on the list here.  Deiter Heim had chronic glomerulo nephritis and hypertension and congestive heart failure.  He had a brother who was a policeman on the Louisville Police Force who was the same blood type and who decided he would be a donor of a kidney.  The day before the projected transplant Deiter Heim was determined he was going to go home and he was forceably restrained in bed to keep him in the hospital the day before the transplant.  The night before the transplant he had continuous seizures and convulsions he wsa unconscious, he was in pulmonary edema and he actually became hemoplegic; however, again the same two, Sidney “The Kidney” and Miss Brown worked all night to try to control the blood pressure and the seizures and the next morning, January 21, 1965, our second transplant was performed.  In the first 24 hours after the operation Deiter Heim put out 14 liters of urine.  He was, as usual, returned to the isolation TB room.  About a week after the operation, as might be expected, in operations under those conditions in General Hospital, he was wound infection with staphylococcus.  I went around to see him and talk to him and he said, “Don’t worry about me Doc, I’m going to be all right”.  And, he was right because Deiter Heim is still around today with a staph wound infection that we opened and drained, but in spite of all the drug therapy and everything else, Deiter came through and he is still doing fine.  As a matter of fact, he really didn’t have a rejection, an acute rejection for about 2 years, at which time he was treated by radiation and cortisone.  About 3 years ago he came in and we did an arteriogram and the arteriogram looked terrible but he was treated with heparin, persantin and aspirin and all the rest of it and he is still doing fine.  He did so well that about three years after his transplant he married the nurse who had looked after him, he divorced his former wife first, and he is still alive and he will be ten years in this January after his kidney transplant.  He still visits and encourages patients who are on dialysis and waiting for transplants.

     The third one of that four that were waiting was Joe Clark, Joe Clark was on Dialysis and he required a very special diet which the Louisville General Hospital dietary was unable to provide.  He needed a low potassium, low protein, low sodium diet.  Well, it so happened that his wife was a dietician and she not only cooked and prepared his meals but she drew up a handbook or a manual that was used on the renal service for all the patients who required special diets.  Joe had a transplant finally on April 27, 1965.

     The fourth one was Marshall Mitchell.  Now Marshall Mitchell was a carpenter, and while he was waiting for this transplant he was put to work and he built all the shelves and all the cupboards that were in the room on 2-D and, eventually, the renal service in the room next to him metasticised and he built all the cupboards and shelves that were in the next room there.  So, at this time every patient and every physician that was involved in this was one big family group, all working together and anybody who contributed, whether it was a wife or a patient, they all worked to try to help everyone else on the Unit.  Marshall Mitchell had every problem in the book.  He didn’t get his transplant for about 4 years.  He had pericarditis, hypertension, seizures, and finally he had a cadaver transplant in September of 1968.

     The next girl I mention only because of how well she has done, that is Catherine Davis who is a 14 year old girl from New Albany.  She was a high school student and her mother was the donor.  She had her transplant in June of 1965.  Catherine Davis has done well.  I will show you a picture of her a little later, she has just recently been married.  So she is still alive and doing well.

     We had a rash of people with unusual names at that time; the next one who came along was Darrell “The Duke” Hauck.  The Duke was a character that you would never accept for any kind of treatment if you had any choice.  The Duke rode a motorcycle, the Duke was covered with tattoos, the Duke had greasy black hair.  You can’t imagine anybody caring for him but he had a mother who loved him and his mother acted as a donor and The Duke had his transplant on August 15, 1965.  The Duke eventually died, not of a motorcycle accident but the Duke never really took his medication.  He eventually died of rejection and renal failure as might be predicted.  But, again, for the psychiatrists who are here, you really can’t tell what a patient is going to be like when he is chronically ill and Dennis may comment on this, they look horrible at this time, they are miserable, hard to get along with, but if they get a functioning kidney they may turn completely around.  So, the Duke was operated on in spite of all of his adverse situations because you can’t tell what a patient is going to be like after he is reasonably healthy.

     Other names:  Duane Maggenheimer.  Can you imagine The Duke, Duke Hauck, Duane Maggenheimer, Deiter Heim; Duane Maggenheimer is from Indianapolis and, at this time, we were the center for transplantation and he came down from Indianapolis.  He had is transplant and again, his mother was the donor and this was on November 4, 1965 and Duane is also still alive and he is married also and he and Catherine Davis were the “kids”, Duane was about a year older than Catherine Davis at the time of his transplant.

     The last one I mention here is a pioneer, Dudley Lahugh, he was of importance because he was the first cadaver transplant that we did.  This cadaver transplant was done on Christmas Eve, 1965 at Louisville General Hospital. Now if you have ever tried to do anything on Christmas Eve at Louisville General Hospital, let alone a cadaver kidney transplant, you can imagine what went on that evening.  I was in recovery room with the donor who was a gunshot wound of the head, at that time we had to wait until the patient’s heart had arrested.  So the patient’s hear had arrested and I had given the heparin intravenously, there was an intratracheal tube there and I was blowing down the intratracheal tube every once in a while, I was going external massage and a strange figure appeared at the foot of the bed.  It was her son, nobody was around so he just meandered up and walked into the recovery room and said, “What’s going on?”  So I sort of had to usher him out into the hall and then rush back and beat on the chest, blow on the intratracheal tube and then a resident and I pushed the bed from the recovery room down into the operating room and loaded the cadaver onto the operating table; meantime, the recipient was sitting in a wheelchair outside the operating room.  Again there was nobody around so the recipient had to undress himself and prepare himself for the transplant.  We got the patient onto the table, it was a prep a little, massage a little, blow a little; prep a little, massage a little, blow a little, and that’s the way we got that donor kidney out.  We got the donor kidney out and transplanted it into the recipient in the next room.  Now, about this time, in flying colors, as expected, the administration of the hospital came through again.  There was nobody to look after the patient.  We had talked to the Nursing Director beforehand and she said, “I am sorry, but at Christmas time we can provide no help, we will not be responsible for the care of this patient.”  “And if you want to do a transplant, that’s your tough luck.”  So the patient was kept in the operating room and the physicians and the operating room nurses who were there on call stayed with the patient for the next 24 hours and looked after the patient, to keep him alive and 24 hours later he was transferred to the same TB room down on 2-F where it was utterly safe from the rest of the infection in the hospital and we had the same coverage:  The staff looking after the patient.  Well, things got a little better and a Federal Grant was achieved by Dr. Berman from the Health, Education, and Welfare section of the U.S. Public Health Service which ran from 1966 to 1969.  It was a grant of an enormous amount, $750,000, for chronic dialysis and 2-D the original room now became the acute dialysis room and all chronic patients were to be looked after and the renovated wing, I guess it would be 2-E, would it?  Yes, 2-E, now this was the central dialysis unit and so this was the start of the new era.  In the Spring of 1966, Dr. Berman, as he was wont to do, was touring the world.  He visited all his former residents and fellows in Japan, India, and South America, and on his way back he stopped in London, England.  And while he was in London, England, he met a Sheik from Lybia, a Senator, Senator Sussi, and he had a daughter Nadja, who was dying of chronic renal failure and Leonard, in his magnificient way said, “Send her to Louisville, we’ll look after her.”  Well, she was to come over to Louisville and have a transplant.  She was about 12 years old at the time.  I may be a little bit wrong on the age, and the mother was going to be the donor.  Well, about May Jajda arrived on the scene with her brother.  Now a step-brother, not a directly related brother, the mother didn’t appear.  Here she comes in uremia very, very ill but with no donor.  Here she booked into Childrens’ Hosiptal she had to have some dialysis so that was done at General Hospital.  So, the first problem was to get some kind of a hook up so we did a shunt on her.  We put a cannulae into the femoral artery and the femoral vein, in children the other vessels are too small and worried over whether she would lose the leg if we did this which, of course, she didn’t.  She was a very nervous girl and to try to do anything to her she would scream and holler and carry on, you would have thought she was Italian instead of Lybian when you tried to deal with her.  We got the dialysis in.  To be dialyzed, she had to be taken to General Hospital.  To go to General Hospital and be dialyzed, you have to sign a form to say who is going to be responsible for this.  Who is going to be financially responsible for paying for this patient.  So her brother had to go to the Central Desk in the main lobby there and fill out all of this form.  He didn’t speak very good English, but the clerk said to him, “Who is responsible?” He said, “I’ll be responsible.” “Who are you?”.  I’m her brother.” She said, “How much do you make?” he thought a bit and he said, “Mmm, about one quarter million about every three months.”  This utterly ruined the statistics for General Hospital thereafter.  In any case, in about two weeks later she developed pericarditis then she developed a tremendous ephusion, then she developed a tamponade and Kareem may remember trying to tap her one time but she got worse again.  Patients with renal failure develop a bloody effusion that clots in a hurry and you really can’t relieve them by tapping.  So one Friday noon, the next stage in this adventure, she was rushed to the operating room at Childrens’ Hospital right after one of her open heart and we had to do a pericardectomy, she practically arrested on the table, Don Thomas gave the anesthetic for this and we slashed open her chest with no pulse or pressure, slashed open the pericardium, the blood gushed out and she immediately got better, removed the pericardium and then went back to the situation of dialysis.  Still, just her step-brother here is Nadja Sussi on dialysis waiting for a transplant were the mother didn’t come.  Nobody else was going to come so eventually we got a cadaver donor who was an American Negro male who was shot in a Saturday night fight downtown and Jadja Sussi got his kidney, it functioned immediately, she did extremely well and immediately family started coming out of the walls.  They arrived from Lybia, they arrived from Washington, the mother came, the cousins came the brothers came, we got letters from the Lybian Ambassador, telegrams saying how great it was; relations with Lybia and the United States are at a new high because of what you have done for our Senator’s daughter and so on.  They took over the top floor of the 800 Building and lived there while their daughter was being taken care of at General Hospital.  Let me tell you, to this day they never got a bill for any of the physicians services because Dr. Berman figured he was going to get a big grant or a big donation from them.  Well, They never got anything, none of us ever got a penny and they took the daughter back off and that was the end.  I think the war with Israel broke out and that was the end of relationships with Lybia.  Sadly enough she did extremely well but she insisted on going home.  Well, we finally let her leave about a month after the transplant.  She was supposed to go to London, England to be looked after at the London Hospital.  She stayed there about two days and then went back to Lybia.  She was looked after by a fellow who eventually came back here as an orthopedic resident and she eventually died of a low white count from an overdose of immuran because she was never back for any follow up and had nobody there to look after her.

     The next striking figure was Calvin Johnson.  Now Calvin Johnson was an individual, a negro male who was being looked after at the University of Kentucky.  He was started on peritoneal dialysis down there.  He developed a peritonitis, he developed a bacteruremia, then when he arrived here, recovering from his peritonitis but he bacterial endocarditis leading off the aortic insufficiency.  We put a shunt in him.  He started on dialysis, he went into more and more heart failure, he developed gross heart failure with severe pulmonary hypertension and severe aortic insufficiency and in November of 1966 we did an aortic valve replacement on him.  This was the first in the world, as for as I know, on any patient who had a valve replacement who was on chronic dialysis.  I think the tribute here goes to the teamwork involved for we had an unique situation.  The fellow who was doing the transplants was doing heart surgery which you don’t see anyplace else really.  The teamwork between the renal team, the transplant team, and the cardiovascular team was very unusual and Calvin lived for two years after this.  Returned to school, was going to school in Lexington, was on dialysis, never had a recurrence of his bacterial endocarditis which was startling because he was dialyzed about three times a week and you know what the chances of getting infection through this area.  He finally died while waiting for a transplant.

     Our only indentical twin was Maurice Hartke.  We were guite concerned; was he an identical twin or not?  with his brother.  There was something about two different placentae was all we could find out in the records which has all been lost, he was born some place in California, and we had all their blood types and everything else done and finally, in order to be sure we thought or, we thought be sure about this, we did skin grafts.  We took them from the donor to the recipient, we took a piece of skin out of the arm of one, took a piece of skin off the donor, plunked it on here and waited to see.  Three weeks later we put another one on there and they survived and were not rejected so we went ahead with the transplant and Maurice Hartke is still doing well.  However, Dr. Berman because of this story and worrying about it had to put the fellow on small doses of suppressive drugs even though the skin grafts were doing well, and everything else he just felt he couldn’t afford not to treat him.

     So the transplants continued.  In spite of the fantastically poor nursing coverage, there was; however, a volunteer team of nurses set up Jewish Hospital Intensive Care Unit, from Louisville General Hospital and one from Children’s Hospital, and there was one private duty nurse who volunteered and they would come on call and they would cover the transplants for the first three days whenever they were done, either living, related, or cadaver transplants.  It was makeshift arrangement, it was unreliable and it was a tremendous hardship on these girls for they would have to work their regular shift and then come over on a volunteer basis and work another 8 hours on the transplants.  We were still in the same private room which was still being used as the isolation room for TB patients at Louisville General Hospital and finally the first dialyses were being done at Jewish Hospital in 1967 and finally the living related donor transplants were moved over because of the fact that we could have reasonable coverage of the patients in a little better facility.  The first cadaver transplant was done over there on April 2, 1968 and it was a pair, George Gibson and Sadie Twyman.  George Gibson was the worst character you could ever imagine.  The first time I ever ran into George Gibson was on a four-bed ward in Jewish Hospital.  Here is this tall, thin fellow, he looked jaundice, the pallor and sort of a lemony color, skin flaking off, standing there-no clothes on, feces all over his hands and the bed, sort of-about the worst possible candidate for a transplant.  Unbelievable looking individual, completely out of contact with reality and utterly miserable.  Well, he was one of the two and to show you how wrong we were, he lost that graft but he had a second transplant later and George Gibson is still around and his whole personality and everything else is completely changed.  He became cooperative individual, who was relatively easy to deal with and there was lesson to me when I looked at this fellow and I said, “What are we wasting our time and effort on?, on a patient who looks like this.”  These double transplants were done:  the donor died at Louisville General Hospital and after death and this was literally in these days after the heart had to stop before you took anything out.  The kidneys were removed, flushed, dropped in a basin and carried across the parking lot over to Jewish Hospital where they were transplanted into the recipients there.  They went to the Intensive Care Unit where they had isolation and then after they finished there, they went back to a private room on the floor where again they were isolated, at least as far as respiratory infections were concerned.

     Okay, Well, about this time Dr. Berman began to have some problems as you will remember.  He had difficulties with the, his eyes, he had some retinal detachment;  actually involving both eyes and there were a lot of problems, I am sure, with his relationships with “God Damn Don” at that time, and he was disappointed in the future support of the dialysis program and he resigned about the middle of 1968.  I would say that that is about the end of the first era of the dialysis and transplantation program.  Dan Leb who was sort of second in command at that time was then appointed the Director.

     The next outstanding patient I want to mention is Debbie Jefferies.  Now Debbie Jeffries was a little girl, I think she was about four at the time, she had chronic pyelonephritis with reflux and hydronephrosis and she had a cadaver kidney transplant on August 8, 1968, an adult kidney.  Now this little soul was about “this” big.  To do the transplant we had to do an extraperitoneal incision here, we sneaked up and took out her own kidney and the ureter, her bladder, however, was so badly damaged it couldn’t be used.  We hooked up the artery and vein and literally didn’t think we were going to get the kidney into her.  We had a heck of a hard time trying to stuff this adult kidne into this little child, like into a doll.  We couln’t hook it up to the bladder, and Lonnie Howerton did a skin ureterostomy.  In other words, instead of like an ileostomy or a colostomy the ureter was brought out and he hooked it to the skn.  Now this is reported as NEVER being successful.  As far as I know, it may be the only one that’s ever been done but Debbie Jeffries is still around, the uererostomy is still functioning, and that’s another first for Louisville, as far as the transplant program is concerned.  It’s such a first that it’s been reported but not by the group from Louisville.  It was reported by Dr. Dominic Gentile who was a fellow here at that time, is now out in California and at a National meeting he reported about the use of a skin ureterostomy for transplant patients but he didn’t tell anybody that it was done here in Louisville.  It was reported as though it was done in the unit in California.  Typical—right.

     Another first:  Ronald Soch.  Ronald had a carcinoma of the kidney.  Dr. Sivak, locally, went in to try and remove this, he thought it was a cyst or something, it was a mass of lesions.  He biopsied it, blood all over the place and he just quit and closed, and it turned out it was a carcinoma of the kidney.  The only thing was, it was the only kidney the fellow had, he didn’t have the other kidney.  So I was called because we did an arteriogram afterwards and it looked like maybe it was upper pole, maybe we could do a Hemenophrectomy but since the previous one was so bloody, he figured he better have someone else there that was used to dealing with blood.  Nowadays they would refer him to Mack Brewer because I have seen Mack do an appendix the other day and lost more blood than we did doing the aneurysm in the next room.  But George didn’t know any better, he called me.  So we went in and this thing was invading the muscle of the abdominal wall right through the peritoneum and everything else.  However, we went ahead and we resected the kidney; I took a part of the abdominal wall as well, I took out everything within reach and, and then we put him on dialysis and this was on November 7, 1969.  He was put on dialysis but he did very poorly on dialysis and he really wanted a transplant.  Well, another absolute contraindication to transplantation is the presence of carcinoma either in the donor or the recipient.  But he followed for 9 months and there was no sign of any recurrence.  He was started on immuran and prednisone for about 6 weeks to see if we could flare up any metastases and none showed up so, finally, his son was enlisted as the donor.  Well, the night before the transplant I was making rounds and I went around to check all the lab work on the donor and the recipient and I looked down and here is the urinalysis on the son’s and he’s got a lot of white cells in the urine.  So he’s got a urinary tract infection, he really didn’t expect to survive from being the donor of the kidney for his father so he had gone out to have a big time on the town and had been to a house of ill repute and arrived in the hospital as a transplant donor with gonorrheal infection.  Well, his father was a pretty husky fellow and I guess he ruled the roost, and he got treated and 6 weeks later was back in the hospital to give this kidney anyway.  So he had the transplant.  That was on October 5, 1970.  As far as I know he is still the only patient in the world who has had a transplant after a rephrectomy for carcinoma, and Mr. Sosh is still alive and doing well with no evidence of recurrence of his tumor.  His kidney is functioning beautifully.

     That was the last transplant for a whole year.  Dr. Leb resigned at the end of 1970 and there was no director of Renal Unit.  The Renal Unit was sort of held together by Glenn Marcum for a year, who was acting as a part-time volunteer to, at least, keep the dialysis going but there were no transplants at all and in the meantime any patients who were waiting for transplants and couldn’t get it had to just die.  There had been 986 dialysis done the year before and they dropped to 576 that year but there would have been none without Dr. Marcum.  Finally, in September, 1971 a new Director was appointed, Dennis Martin.  By the time Dennis arrived on the scene, the Unit had a debt of $130,000, Governor Nunn, bless his heart, had vetoed a $250,000 bill for support of the program but of the kindness of his heart he dipped into his Emergency Fund and turned over $50,000 to sort of bail the program out when Dennis came here.  Dennis then had to go and beat on the doors of the Vocational Rehabilitation, Ohio Valley Regional Medical Programs, Medicare, Blue Cross and Blue Shield, to try to raise the costs to try to support dialysis.  The Jewish Hospital; again, I have to pay tribute to because I don’t think the people in the University and people in the community really know what the hospital has done.  They completely picked up the bill for all the transplants patients that were done over there. You arrived in the hospital, you had your transplant, you had no money, they picked up the total bill for every transplant that was done over there, no questions asked.  And, they also would pick up the bill for any dialysis for patients who arrived on that program.  The nephrologists worked for no fee and the surgeons worked for no fee through this total period.  I must say, the support from the University of Louisville itself was extremely sparse.  At that time also I had my own problems, as you know, and there is a new Chairman in the Department of Surgery and who was very much opposed to the program and said there would be no more transplants biologists; who, however, has not yet been found so the program had to go on anyway.  About the same time tissue typing was started and here Bob Howell was involved.  The tissue typing was no started in the University but was started in the laboratory at Jewish Hospital under Dr. Howell.  A microscope and a deep freeze were loaned by Dr. Charles Fischel who was the Chairman of the Department of Microbiology, and was very interested in immunology and transplantation and was a great help to us when our program was first getting started.  The funds to train the technicians who were involved in tissue typing or lymphocyte typing really came from the Kentucky Kidney Foundation, no Bob I think, happens to be the President of the Kentucky Kidney Foundation.  The technicians were sent out to Pual Tersaki in California to learn how to do this, s setup was arranged in the Department of Pathology, the possible recipients were typed when it became decided that they were going to be possible recipients; when a donor became available, however, it became an emergency situation where the typing had to be done on the spur of the moment.  So we soon put them to work.  They hadn’t been trained very long when on December 24, 1971, Christmas Eve, we put Bob and his technicians to work all night typing a possible donor and a double transplant was done on Christmas Eve of 1971.  Two weeks later, on New Year’s Day, we did another double transplant and four days after that we did another double transplant, on January 5, 1972, so we had six transplants in a little over a week, all of them over the Holiday season, all of these patients were operated on at Jewish Hospital and looked after in their intensive Care Unit and, again, all the anesthesia:  I mention this because of problems that Dr. Gray may be associated with, anesthesiologists worked for nothing, Christmas Eve, New Year’s Day, and 4 days after on a working day, and physicians and surgeons all worked for nothing and all the costs were picked up by Jewish Hospital.  I think the whole program would have been impossible without this kind of support and the only reason I am here tonight is to tell you about some of the things that nobody know about in this whole program.

     However, political problems engendered by the publicity associated with this led to the fact that we didn’t get any more transplants from Louisville General Hospital, nor donors for another year.  We were refused any more donors and in the meantime, again, the patients just sort of waited around or died but the living donor program continued.  One of the six that was operated on in this group was a girl by the name of Patricia Pulliam who was also unusual and again something unique.  About two or three months afterward she came in with renal failure and we thought she had a rejection, I quess it was maybe a little longer than that, maybe closer to six months.  An arteriogram was done and it showed a severe stenosis of the renal artery just beyond the cite of an anastomsis.  So---We operated on her, found the area, resected it, and put in a vein graft and the kidney then responded immediately by functioning well and is still functioning well; and the fascinating thing, which I have never gotten anybody to be enthused about is the changes in this kidney were those of atherosclerosis in the renal artery.  Local segmented thing.  It was not any place else, but just beyond the cite of an anastomosis with an atherosclerotic plaque, thick, cholesterol deposit.  To me it seems fascinating that here is a situation where there was an immune response involved or being suppressed, there is local trauma as well, and anastomosis and yet this normal renal artery ahead of time now shows severe localized atherosclerosis.

     The last unusual patient I want to mention was operated on this year (1974) and, again, this one also has never been done any place else in the world, a sixty-year old fellow who was on dialysis.  Started on about Christmas time of last year and ended up with a history of hypertension and some angins, came back into the hospital in January with heart failure and then his angina got worse and worse and worse, he was having pain at night and at rest, he couldn’t go on dialysis, because he had severe chest pain, he finally had coronary arteriograms which showed that he had marked EKG changes with these episodes of chest pains so he had coronary arteriograms and he had coronary arteriosclerosis and underwent a double by-pass graft in February while he was still on chronic dialysis.  He is still doing well, he has no angina, he has gone back to efficient and active work, is dialyszed regularly, has no angina on dialysis.  And, again, as far as I know, that’s the first one of those that’s ever been done.

     Since Dr. Martin came, the program has steadily grown and dialyses I mentioned originally were about 1,000/year dropped to about 500 or 600 before he came were 1800 the year after he came then to 3,000 and last year there were 4,100 dialyses performed on the renal service.  There are now about 50 patients who are on Center dialysis and there are about 80 patients who have been trained and are on Home dialysis.  These are in addition to about 300 acute dialyses each year.  Transplants from 1964 to 1971, there were 40 transplants; 15 out of 24 living related donors, are still alive and 6 out of 16 cadavers are still alive.  That’s a span of over ten years, a minimum of 4 years with over half the patients still alive and doing well.  Since ’72 to ’74, less than 3 years up until September, of this year there were 46 transplants 21 out of 24 living related;  are alive 18 of them with functioning transplants and 11 of the 22 with cadaver transplants.  Again, about 30 out of 46 living with functioning kidneys.

     I must pay tribute there to the excellent early results that I think we have to attribute primarily to Dr. Howerton.  The biggest complication that anybody sees with transplants any place in the country is with urological transplants.  There will be 50% to 60% of the cases would have some complication with the ureter, bleeding, stricture, leak, and yet we almost never saw anything.  About the only time we had a complication were a couple of cases that he didn’t do, a couple of patients that someone else did as an emergency and I would say that when Dr. Howerton was doing them we would say that the incidences of urological complications were practically zero and when I think of our early excellent results, we really have to pay great credit to Lonnie for that.

     Now we have two other people involved in doing the transplants, Dr. Amin who is in the Department of Surgery and also working with Dr. Howerton in private practice, and Dr. Mazree who is working with me so we have a little backup as far as emergency procedures are concerned.

     The Belzer apparatus:  This is an apparatus which is used to perfuse the kidney.  When you take the kidney out of someone you hook it to a machine and keep it going by running some oxygen and nutritious solution through it.  One of these became available in 1973 by the Brown Foundation who put up $14,000 to buy one and it was fantastic because the kidney could be taken out any time, hooked to the machine, we’d say well, we’ll do the transplant tomorrow at 3 o’clock when we have finished our schedule.  It was just great.  Instead of working all day, doing a transplant that night, and then getting up and doing another day’s work the next day, we could schedule the transplants.  We also had time to arrange to check the tissue types to see whether the patients were a good match or not.  The only problem was that it just didn’t work out very well.  Partly we don’t know how to use it, partly we never had a technician who was really well trained, but I would say that our results with using that apparatus were disappointing and really no better probably not as good as when we just took the kidney out and flushed it and stored it saline slush and put it in 8 to 10 hours later so that at the present time that piece of apparatus is sort of sitting and not being used.

     Another area of development is that of training people, not only medical students, fellows, six a year who are being trained in nephrology, but nurses are being trained to work in sattelite units beside the main center, these sattelite units are in Elizabethtown, Owensboro, and Greenville now and there will probably be future units at the Trover Clinic in Madisonville and there will probably be private units set up here in Louisville.  The costs have gone down enormously.  In 1971 the cost of being dialyzed at the Center was $35,000 a year per patient, it is now down to $18,000 a year.  That’s a fantastic amount of money.  As opposed to this, home dialysis originally was $10,000 a year and is now down to $3,000.  So you can understand that when the Federal Government is going to support any program, they are going to say you are going to be dialyzed at home, they are going to support home training of $3,000 a year as opposed to $18,000 to $20,000 a year.  The Medicare support has come in.  Anybody who has chronic renal disease has become eligible for Medicare—that sound fantastic.  Eight percent of the costs are borne, so there is great enthusiasm for this but I would say that with the fantastic amount of paper work and red tape, the enthusiasm of the physicians for the program has been somewhat tempered and it has not yet worked out as well as one might expect.

     Despite all this, the renal unit has been self-supporting and only two out of the forty people who worked full-time in the unit are supported by the University and the other 38 are paid for by funds generated either by grants, or funds generated by the care of the patients there.  So you can imagine the fantastic problems, financial, personnel and facilities, and we have had severe political problems between the University, General Hospital, The Board of Health, the State, and the Federal Governments.  They are pretty big group to take on.  In spite of this we have had some great triumphs, we have operated on practically every holiday, we’ve done one on Christmas, we have done 2 on Christmas Eve, done 2 of them on New Year’s day, we have done them on Easter, Thanksgiving and Labor Day;  the only day we haven’t operated is Derby Day.  And I must tell you—I did have an offer of a transplant on Derby Day.  It was a call from Norton Hospital at 23 minutes after 5 on Derby Day and I was at home, it was a possible heart transplant donor.  I said, “There’s no way that we are going to be able to do a heart transplant on Derby Day in Louisville.”  So, fortunately, fifteen minutes after the Derby was run the patient died at Norton Hospital.  But that’s the only holiday that we haven’t worked on and we have in addition, several other accomplishments.  Several world “Firsts”.  We were the first to do valve replacements with patients on chronic dialysis, first skin ureterostomy, one of the first to do resection of the renal artery stenosis, and the first to do the coronary by-pass graft and so on, on chronic dialysis.  So, in spite of the fantastic problems of a great increase in dialysis and transplant, State and Federal support has come about and it looked like we were in a golden era and, again, tragedy has intervened and I know Dennis would not want me to involve him personally in anything like this but again, because of political reasons, now we are without a Director in the Renal Unit.  Again, we are floating, no Director, the transplant program will have to stop, the dialysis program will limp along, we eventually hope that we will get back into the swing of things again.   

     That’s my story.  I was going to show some slides, I think I have talked longer than I wanted to and I will stop here and answer any questions.