Organ transplantation : The journey so far

Attempts at organ transplantation have been recorded over the centuries, often in graphic detail. The earliest reports of transplantation in humans included several miracles. One of the best known examples is the thirteenth century story of Cosroas and Damian. They were Christian Arab saints who were martyred around AD300 and were reputed to have successfully replaced the diseased leg of a sexton with that from a Moor who had died several days earlier. The use of autologous tissue transplants as a method for restoring mutilation of the nose dates back to an even earlier period. The practice originated in India and was modified to greal effect in Europe by, amongst others, the sixteenth century plastic surgeon Gaspare Tagliacozzi. Other early transplanters had more unrealistic achievements in mind such as the Frenchman Serge Voronoff who at the beginning of the century popularised the transplantation of monkey testis into man, in the mistaken belief that the procedure would stave off age~
-related deterioration in physical and mental agility. Organ transplantation is,in historical terms, a relatively recent phenomenon.

Renal transplantation only became widely available in the 1970s and transplantation of the liver and thoracic organs did not become a clinically acceptable treatment until the 1980s. By any standard,the events accompanying the evolution of transplantation are remarkable.

Progress was frequently interspersed with failure and major advances had their basis in both empiricism and the application of rational scientific method. There was intense publie interest in transplantation as the story unfolded and difficult ethical and social dilemmas arose frequently. Contemporary medical opinion was not always supportive of attempts to advance the field of transplantation and the activities of transplant clinicians were often met with indifference and sometimes overt hostility .

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To a large extent, the history of organ transplantation is synonymous with that of kidney transplantation. The development of effective immunosuppressive agents,the principles of organ prcservation and the role of HLA matching and allo-sensitisation on graft outcome were all first defined in the context of kidney transplantation. The reasons why transplantation of the kidney became a clinical reality well before transplantation of the other abdominal and thoracic organs are
self-evident. During the 1950s, when the first successes with kidney transplantation were described, the prospect of successful liver or cardiac transplantation was inconceivable in
humans.

Cardiac surgery was then in its infancy and the technical complexities of undertaking liver transplantation were far too great to risk. The concept of heart-beating donors had not yet been established and although kidneys obtained from a non heart-beating cadaver inevitably incurred ischaemic injury, this was less of a problem than for the heart or liver. In the case of kidney transplantation, the opportunity also existed for living donation. This allowed optimal timing of the operation, guaranteed a healthy donor organ and, in the case of a related donor, the chance of a good tissue match.

Finally, successful kidney transplantation coincided with the introduction of the patients who might benefit from transplantation to specialist centres but proved invaluable in providing temporary support in the early post-transplant period before graft function was optimal. At present, the most common organ transplanted is the kidney followed by the liver and heart.

Adapted from the Principles and Practice of Surgery by Badoe.

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