Michael Ramsay, MD, FRCAdocram@baylorhealth.edu,     Department of Anesthesiology and Pain Management, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA

The history of medicine is that what was inconceivable yesterday and barely achievable today often becomes routine tomorrow. Liver transplantation began with almost no resources at the same time as the tentative first steps were taken to land a man on the moon. Because human lives would be at stake, both objectives had a sacramental element from the outset: a solemnly binding commitment to perfection. The gift of an organ is really a gift of life, and something as valuable as a life-saving organ is more important to a suffering patient than wealth or power. The concept of a team approach to the care of the transplant patient is an important factor in the development of a successful program. This has resulted in recipient survival rates reaching 90% at one year.

Keywords

History

Transplantation

Liver

Kidney

Pancreas

Intestinal

Key points

Introduction

“At the present state of our knowledge, renal homotransplants do not appear to be justified in the treatment of human disease.”1–5 The 1950s and 1960s shaped the future of major organ transplantation. The major advances were associated with the understanding and development of immunosuppressive agents, and the success of techniques for organ preservation. Experimental transplantation of kidneys between animals and between animals and humans had been performed without success. Alexis Carrel described the technique of vascular anastomosis but realized that unless some method of preventing the recipient from reacting against this foreign tissue was developed, there would be no future for organ transplantation.

In working with skin grafts, Peter Medawar was able to show that failure of a graft was an immunologic response.6 In 1953, Medawar also described acquired tolerance, offering an opportunity that organs might be accepted if the immune system was manipulated appropriately.7 The initial strategies to combat rejection included total body irradiation and adrenal cortical steroids. These approaches had minimal effect, but the antileukemia drug 6-mercaptopurine prolonged renal allograft survival in dogs.8 This development resulted in the discovery that azathioprine had immunosuppression properties.9 However, the results were not impressive, until Starzl combined it with prednisone and showed that rejection could be prevented and, if present, reversed.10 This advance allowed the success and future of major organ transplantation.

Kidney transplantation

In 1936, Russian surgeon Yu Yu Voronoy transplanted a kidney into the groin of a patient suffering from mercury poisoning. This was an attempt to tide the patient over an acute episode of anuria. This attempt failed, but in 1945, Landsteiner and Hufnagel did transplant a kidney from a cadaver to the brachial artery and cephalic vein of a young woman in acute renal failure. The patient’s own kidneys resumed function a few hours later and the transplant was excised. No details of the anesthesia are given for these procedures or any later attempts until the first successful renal transplant in 1954.5

On December 23, 1954, the first successful kidney transplant was performed by surgeons Joseph Murray and Hartwell Harrison, together with nephrologist John Merrill (Fig. 1). The donor and recipient were identical twins, 1 twin healthy and the other dying of renal disease. The operation was successful and the recipient survived for more than 2 decades. He did have to go back to surgery to have his native kidneys removed because of continuing hypertension. The donated kidney underwent 82 minutes of warm ischemia time and yet functioned promptly on reperfusion.11

The management of anesthesia presented much concern.12 First, consenting the living donor to undergo a procedure that had no potential benefit to him at all was carefully evaluated. The hospital medical staff and Board of Trustees approved it and the Supreme Court of Massachusetts passed a declaratory judgment allowing the operations to proceed. The anesthetic plan for the donor was to give the most near-perfect anesthetic. This plan required the assignment of an experienced anesthetist, and giving him rein to choose the anesthetic safest in his hands. General anesthesia was used, and in the first donor, brisk hemorrhage occurred when the entire renal artery was taken, not leaving a cuff on the aorta that could be clamped, so digital control was necessary. The anesthetic choice made was nitrous oxide, oxygen, and ether, together with tracheal intubation. The use of ether was determined to be safe in the presence of cautery if the cautery was at least 0.6 m (2 feet) away from the face and the ether was administered via a tight seal around the airway.

The recipient presented in renal failure together with hypertension, congestive heart failure, and encephalopathy. Concern for potassium intoxication required monitoring of the electrocardiogram and care with transfusion of banked blood, because this would add excess potassium. Further concerns about the recipient being particularly prone to infection called for strict reverse isolation precautions. The anesthetic equipment was sterilized, and the anesthetist was gowned and gloved. The anesthetic used for the recipient was a continuous spinal technique. This decision appeared to be logical because this was a lower abdominal extraperitoneal surgical procedure, requiring little or no muscle relaxation. The development of hypotension was not a problem with the spinal anesthetic, because these patients were hypertensive as a result of their kidney disease. Occasional small amounts of intravenous thiopental were administered if the patient became anxious. The report of the initial anesthetic technique by Vandam was followed by a conclusion that anesthesiologists would contribute to the care of transplant recipients, as part of a multidisciplinary approach, as transplants become more frequent, when the immune response is solved.

As experience with kidney transplantation increased, further reports of anesthesia management were described. In 1964, Levine and Virtue13 described the experience of the first 50 renal transplants at the University of Colorado. These investigators noted that the surgeon required a quiet and well-relaxed patient and that the recipient required analgesia. The living donor procedures required more time than a standard nephrectomy, approximately 5 hours 45 minutes, and organ hypothermia was being used to protect the graft. The investigators also described that recipients who underwent pretransplant dialysis on the artificial kidney experienced a decrease in cholinesterase concentration, making them susceptible to prolonged paralysis if succinylcholine was administered. The investigators also raised the question of cardiac arrhythmias as a result of potassium changes if succinylcholine was administered to a patient in renal failure.

Strunin14 reported on some aspects of anesthesia for renal homotransplantation, describing the first 36 patients receiving cadaveric (the term cadaveric is no longer in use and has been replaced by deceased donor) kidneys at St Mary’s Hospital in London, United Kingdom. When cadaveric donors are used, the importance of keeping the total ischemia time short was recognized, and this placed the transplant team on 24-hour response availability.15 The added protection of the homograft by ice-cooling was described by Calne,16 and this proved that a more prolonged ischemia could be withstood. At the time, this period could be experimentally as much as 12 hours and this and longer times are now...