ABSTRACT
In the past 50 years, organ transplantation has developed from an improbable laboratory exercise to a major therapeutic success. The surgical problems of organ grafting have, for the most part, been solved. Rejection of grafts is now partially understood and usually controllable by powerful immunosuppressive drugs. A steady improvement in patient outcome, especially following the introduction of cyclosporin as an immunosuppressive agent has resulted in a worldwide shortage of organs for transplantation. This has provoked serious ethical dilemmas in every country. These matters are summarised in the following text.
Organ and bone marrow transplantation have been extraordinary success stories in medicine during the past 50 years. A large and important clinical service has been developed in both these subjects and there has been a staggering improvement in the overall results of transplantation of patients who previously were offered no treatment for a variety of fatal diseases. Long-term good functional survival of the transplant has been observed in an increasing number of patients; some are more than 40 years after the transplant procedure. Transplantation would not exist in the clinic without a powerful backing of basic and transitional research, progress being manifest in a partial understanding of the rejection process, the immune system and how to circumvent rejection. In the 1950s, there appeared to be 2 problems, namely surgery and biology. It was not clear until the first identical twin kidney transplant in 1954 that the human kidney could withstand the procedure which involved removal from 1 individual, a period of ischaemia during the implantation and the actual surgery in the recipient to provide new arterial and venous access and uretic drainage.1 There were sporadic attempts at kidney transplantation during the 20th century and important observations were made by Alexis Carrel who had introduced a method of joining blood vessels together and had used this in experimental kidney grafting in animals. Carrel himself pointed out that “autografts” could be successful with long-term function but grafts between unrelated individuals, later called allografts, might function initially but were doomed to failure by mechanisms not understood then. Gradually surgical techniques were developed for experimental transplantation of the liver, heart, lungs, pancreas and spleen. The early literature was dominated by discussions of different technical procedures and it became clear that in all the organs mentioned above, depriving the tissue of a blood supply should be reduced to a minimum. Cooling gave additional time so that the organs remained alive, just as in the principal of the refrigerator, and the main blood vessels required full restoration of blood flow but the lymphatic system and autonomic nerves were not vital to initial function and regeneration was to be expected with time.
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