375Focus: Illuminating Science Years of Science at Harvard

A Tale of Two Kidneys Overcoming the Immunological Barrier in Organ Transplantation By Roxanna Haghighat

rgan transplantation becomes from one person and implant it into Harvard Medical School (now known Oa pesonal rather than scien- a separate human being at the outset as Brigham and Women’s Hospital), WLÀFPDWWHUDWWKH'09·VRIÀFHZKHUH seemed overwhelmingly complicated 'U0XUUD\SHUIRUPHGWKHÀUVWVXF- newly-licensed drivers are faced with DQGDOPRVWOLNHVFLHQFHÀFWLRQ³DPRUH cessful transplant of a major organ, for the crucial choice of whether or not humanistic Frankenstein, perhaps. Yet, which he received the Nobel Prize in to be an organ donor. Organ dona- decades of research later and count- Physiology in Medicine in 1990. More tion carries two seemingly polarized less obstacles overcome, organ trans- VSHFLÀFDOO\LQKHSHUIRUPHGWKH LPDJHV³RQHRI DJULHYLQJIDPLO\ plantation stands as the gold standard ÀUVWUHQDOWUDQVSODQWEHWZHHQLGHQWLFDO choosing to give life to sick patients therapeutic approach for patients with twins without organ rejection result- sitting at the top of the transplant list failing organs. ing in recipient mortality. Beyond this with no other treatment options and the While transplantation remains con- successful demonstration, Dr. Murray other of the global organ black market troversial in some cultures, as it is seen sought further to link his medical ac- by which scarce tissue resources are DVFRPPRGLÀFDWLRQRI KXPDQEHLQJV FRPSOLVKPHQWWRWKHEDVLFVFLHQWLÀF smuggled across borders. Perceptions the ability to perform organ transplants principles underlying it, investigating DVLGHWUDQVSODQWDWLRQ³ZKLOHWRGD\D LVDUHPDUNDEOHVFLHQWLÀFDFKLHYHPHQW genetics, the immune system, and organ VHWRI URXWLQHVXUJLFDOSURFHGXUHV³ that is due largely to the efforts of Dr. rejection. His discoveries, both in the UHPDLQVDQLQFUHGLEOHVFLHQWLÀFIHDW Joseph E. Murray. During his time at operating room and at the bench, have The capacity to remove a live organ the Peter Bent Brigham Hospital of the forever opened up the possibility of a credit:The National Archives of Plastic Surgery, Francis A. Countway LIbrary of Medicine Francis Archives of Plastic Surgery, credit:The National

8 Harvard Science Review ‡ fall 2011 375Focus: Illuminating Science Years of Science at Harvard curative therapy for end-stage disease. use of the transplantation of organs for therapeutic purposes.” (3). Given the The Immunological Barrier The History of Transplantation limited understanding of the immune Yet, following a common thread 7KHILUVWVXFFHVVIXODOORJUDIW³D system at the time, in the history of transplant between individuals of the this conclusion, at- medical advances, VDPHVSHFLHV³ZDVSHUIRUPHGLQ tained through his physician scientists (1). This crude operation, however, was extensive experi- refused to accept limited to bone transplantation. Nearly ence with grafts WKLVXOWLPDWXPLQ- WZRFHQWXULHVODWHUWKHÀUVWKXPDQWLV- and transplants, is VWHDGLQWKHV sue graft was performed in Switzerland, especially remark- DQGVUHVHDUFK but advancements to full, solid organ able. Carrel him- uncovered the transplants consistently failed through- self had pioneered source of immune RXWWKHHDUO\thFHQWXU\  7KHÀUVW the first vascular rejection, known meaningful step toward a successful suturing technique, as HLA antigens organ transplant was the allograft of a known as “trian- (Human Leukocyte FRUQHDLQ$XVWULDLQLQVSLUHGE\ gulation,” which Antigens). In par- this success, surgeons in France began entails connecting ticular, after clini- credit:(7) attempting kidney transplants begin- blood vessels from cal experience in QLQJLQ2I DWRWDOIRUW\SDWLHQWV the living recipi- France with hema- all passed away due to organ rejection, ent and deceased tology and research XVXDOO\ZLWKLQWKHÀUVW\HDUZKLFKVW\- donor (3). This Figure 1. Dr. Joseph E. Murray at Harvard Medi- mied physician willingness to perform method, inspired cal School, French and patient willingness to receive such and perfected by his work with a immunologist Jean Dusset attempted DQRSHUDWLRQ   seamstress, enabled the short-term suc- to transfer techniques in immunohae- Given the repeated failures of these cess of organ transplants. By the late matology, or blood banking, to white WUDQVSODQWVLQ)UHQFKVXUJHRQ VIHOORZ1REHO/DXUHDWH6LU3HWHU EORRGFHOOVDQGSODWHOHWV  $IWHURE- and Nobel Prize Laureate in Physiology Medawar expressed the frustration of serving the agglutination of leukocytes or Medicine Alexis Carrel realized that physicians towards the seemingly in- and thrombocytes, he eventually identi- there must be some “biological force” surmountable challenge of transplanta- ÀHGWKHÀUVWOHXNRF\WHDQWLJHQLQ inhibiting a successful operation be- tion, declaring that the biological force NQRZQDV+/$$ +XPDQ/HXNRF\WH tween individuals of the same species: described by Carrel would “forever… Antigen), for which he received the ´&HOOVDUHVSHFLÀFRI WKHLQGLYLGXDOWR inhibit transplantation from one indi- 1REHO3UL]HLQ  7KHUHFLSLHQW·V whom they belong. This peculiarity of YLGXDOWRDQRWKHUµ   immune system recognizes the HLA our body has so far prevented the wide antigens on the cell surfaces of the donor’s organ, which induces the host cells’ immunological response to reject the foreign cells. This process, known as the “graft-versus-host” reaction *9+ XQGHUOD\WKHIDLOXUHRISUHYLRXV transplantation attempts. The discovery of Carrel’s infamous “biological factor” immediately sparked renewed interest in transplantation, HVSHFLDOO\LQWKHÀHOGRIQHSKURORJ\ With the help of Dr. Carl W. Walter, Dutch physician Willem Kolff devel- oped the first “artificial kidney,” or GLDO\VLVPDFKLQHLQKRZHYHU dialysis treatment was not only tem- porary but also expensive and painful  7KHODFNRISHUPDQHQWWKHUDS\IRU patients with renal disease beckoned plastic surgeon Dr. Joseph Murray to Figure 2. A basic overview of the immune system response to an antigen credit:http://pathmicro.med.sc.edu/book/immunol-sta.htm fall 2011 ‡ Harvard Science Review 9 375Focus: Illuminating Science Years of Science at Harvard

Figure 3. A ureteroneocystostomy

Chief of Plastic Surgery, Dr. Murray was inspired by his men- tor’s breakthrough operation. 7KHVLJQLÀFDQFHRI DJHQHWLFUH- lationship between the donor and host implicated a genetic factor in the immunological response to organ transplantation. Two IXUWKHUH[SHULPHQWVFRQÀUPHG WKLVSRVWXODWLRQ)LUVWLQ Drs. Billingham and Medawar of the University of Birmingham induced acquired immunological tolerance in various mammals, including cows, through a neo- natal injection of donor cells into a future allograft host (10). Second, Sir Michael Woodruff of the University of Edinburgh successfully skin grafted between dizygotic, or fraternal, twins who had shared placental blood, explore the increasingly realistic pos- allow the transplanted organ to survive. which led to a protection against sibility of a successful renal transplant. Drs. Merrill and Hume attempted to immune response (11). Armed with After graduating from Harvard Medical use corticosteroids as post-operative knowledge of these results, Dr. Murray 6FKRROLQKHWUDLQHGLQSODVWLF treatment to decrease inflammation sought to overcome the immunological VXUJHU\WKURXJKWKH86$UP\DW9DO- and downregulate the immune response barrier in humans that now seemed to ley Forge General Hospital, where he following surgery, but supplies lasted be manipulable. gained extensive experience with skin for only a few days (9). First, however, Dr. Murray had to autographs and allografts (7). Given Meanwhile, Dr. Murray had wit- prove that the transplantation itself of WKLVEDFNJURXQGKHLGHQWLÀHGWKURXJK nessed the outcomes of skin allografts, a kidney would not be fatal to the re- his training the potential to cross-apply which rarely survived permanently, but cipient. An autograft, the transfer of a ongoing research in skin grafts between exhibited patient’s own tis- identical twins with surgical attempts at g r e a t e r ´7KHVLJQLÀFDQFHRIDJHQHWLF sue or organ to human renal transplants. s u c c e s s UHODWLRQVKLSEHWZHHQWKHGRQRUDQG another part of w h e n KRVWLPSOLFDWHGDJHQHWLFIDFWRU his body, would function as a Revival of Interest g r a f t e d LQWKHLPPXQRORJLFDOUHVSRQVHWR At the Brigham Hospital, encour- between negative control. aged by success in the canine model, family RUJDQWUDQVSODQWDWLRQµ After repeated Drs. John Merrill and David Hume members, experiments in had begun experimenting with cadav- rather than between an unrelated donor the canine model, at Brigham Hospital, HULFGRQRUNLGQH\V%HWZHHQDQG and recipient. In 1937, Dr. J.B. Brown Dr. Murray mastered the technique WKHWZRFRQGXFWHGQLQHVXFK at Barnes Hospital in St. Louis took this of grafting the kidney into the lower operations, whereby the cadaveric kid- observation one step further by grafting abdomen, internally connecting the neys were grafted into the recipients’ skin between monozygotic, or identical, donor kidney blood vessels to those IHPRUDOYHVVHOV  +RZHYHUGHVSLWH WZLQVDV'U%URZQKDGK\SRWKHVL]HG of the recipient’s abdomen. Also, a technical achievement in four of the this operation resulted in permanent ureteroneocystostomy, by which he surgeries, the most successful host died graft survival. Having worked closely placed the upper end of the ureter within six months of the transplant due with Dr. Brown during his time at into the bladder, enabled urine drain- age (11). To date, this technique is

credit: http://www.cpmc.org/learning/documents/kidney-ws.html WRLQVXIÀFLHQWLPPXQRVXSSUHVVLRQWR 9)*+ZKHUH'U%URZQZDVWKH

10 Harvard Science Review ‡ fall 2011 375Focus: Illuminating Science Years of Science at Harvard used in standard renal transplants, and my brother, but the only operation I’d ionizing radiation and cytotoxic drugs these kidneys were shown to function ever had before was an appendectomy, like azathioprine to prevent immune completely normally up to two years and I hadn’t much liked that” (13). cell proliferation (13). After the opera- DIWHUVXUJHU\   Dr. Murray and his surgical team took tion, Richard’s new kidney immediately care to avoid pressuring the Herricks to functioned properly, nearly restoring his The Case of Richard Herrick make a decision and instead counseled renal health. He lived for eight years 7KXVLQZKHQ'U0XUUD\ZDV the brothers to ask as many questions as after the operation until renal failure offered the chance to operate on a pa- they felt necessary. Insurance compa- destroyed his new kidney as well (13). tient diagnosed with critical renal failure nies assured them that there was no de- ,Q'U0XUUD\UHSHDWHGWKHSUR- who had a healthy identical twin broth- creased life expectancy associated with cedure, transplanting a kidney between er, he only IHPDOHWZLQVWKHUHFLSLHQWJDYHELUWK leapt at ´'U0XUUD\SURYHGWKDWDWUDQVSODQWDWLRQ one kid- to a healthy child two years after the the op- GLGQRWQHHGWRRFFXUEHWZHHQJHQHWLFDOO\ ney and surgery and lived through the 1990s, portuni- LGHQWLFDOWZLQVDQGWKDWWKHNH\WR chances FRQÀUPLQJWKHUHSURGXFLELOLW\RI WKH ty. Un- DVXFFHVVIXOWUDQVSODQWZDVLQGHHG for dis- experiment. The immense success der the LPPXQRVXSSUHVLRQµ ease af- of this operation not only proved the leader- fecting viability of life-saving organ trans- ship of Dr. Merrill, who was Head of the remaining kidney remained un- plantation but also encouraged further Nephrology at the time, the Brigham changed. Finally, the Herricks decided laboratory research into overcoming Hospital renal transplant team accepted WRSURFHHGZLWKWKHVXUJHU\'U- the immunological barrier. the patient, Richard Herrick, referred by Hartwell Harrison was charged with Dr. Donald Miller of the U.S. Public the removal of Ronald’s kidney while Beyond the Operation Health Service. Dr. Miller had heard Dr. Murray performed the transplant Dr. Murray himself pursued a means about the Brigham team’s ongoing itself (13). of immune suppression through UHVHDUFKLQWKHÀHOGDQGUHFRPPHQGHG to Richard’s twin, Ronald, to seriously consider donating his kidney to save his brother’s life. Prior to renal transplan- WDWLRQJHQHWLFFRPSDWLELOLW\ZDVÀUVW established by a reciprocal skin graft, ZKLFKFRQÀUPHGDJHQHWLFPDWFKDIWHU four weeks without rejection (13). 7KHÀQDOKXUGOHWKHQZDVWKHHWKLFDO problem of asking a perfectly healthy person to willingly give up an organ for another’s survival. Issues arose as to whether the surgeons would be violating their Hippocratic oath to “do no harm” to a patient by excising an organ without conferring any medical EHQHÀWWRWKHGRQRU8OWLPDWHO\WKH RSHUDWLRQZDVMXVWLÀHGE\WKHEHQHÀWV for his twin brother. Still, Ronald faced an ostensibly burdensome decision: “When it became clear that Richard Figure 4. Brothers Ronald Herrick (left) and Richard Herrick (right) would die without one of my kidneys, I did some serious soul-searching. I Based on the clinical and lab research laboratory experiments on murine and PHDQKHUH,ZDV\HDUVROG\RXQJ until this point, Dr. Murray realized the canine models as well as clinical trials and healthy, and they were going to SULPDU\FRQFHUQVZHUHWRÀUVWVXUJLFDOO\ with skin allografts. Different methods %RVWRQ*OREH cut me open and take out one of my insert the kidney and induce function, he tested included immunoparalysis by organs. It was shocking even to con- and then to suppress the immune reac- repeated grafts, inducing tolerogenecity VLGHUWKHLGHD,IHOWDUHDOFRQÁLFWRI  tion. Having perfected his technique by exposing the host to donor anti- emotions. Of course I wanted to help IRUWKHÀUVWWDVN'U0XUUD\WXUQHGWR gen before operation, and drugs like credit: Jack Sheahan,

fall 2011 ‡ Harvard Science Review 11 375Focus: Illuminating Science Years of Science at Harvard toluene (11). Ultimately, though, Dr. Drs. Robert Schwartz and William especially among surgeons interested in Murray pursued what he thought to Dameshek of the New England Center cardiac transplants. If a kidney could be the most promising approach: total Hospital inhibited rabbits from pro- be successfully rescued, then what of body X-ray treatment coupled with ducing antigens against human serum WKHKHDUW³DQRVWHQVLEO\PRUHYLWDORU- PDUURZLQIXVLRQÀUVWWHVWHGRQPLFH albumin, and this tolerance endured JDQ",QVXUJHRQVDWWKH8QLYHUVLW\ and rabbits, then with skin allografts. even beyond the period of drug treat- of Mississippi developed a method of However, only one out of the twelve PHQW%\DPRUHWKHUDSHXWLFDOO\ such transplantation that involved the patients on whom Dr. Murray used this effective drug, known as azathioprine, replacement of the heart and one lung technique lived beyond three months was discovered and used for twenty  8VLQJWKLVWHFKQLTXHWZHOYHWUDQV- SRVWRSHUDWLRQ,QWKLVSDUWLFXODU years after its introduction. Soon after, plant recipients were able to survive patient had received a kidney from his cadaveric allografts were used, and by IRUKRXUVDIWHUVXUJHU\KRZHYHU fraternal twin after being exposed to RQH\HDUVXUYLYDOUDWHVIRUKRVWV the technique was overly complicated, DQRQOHWKDOGRVHRI WRWDOERG\;UD\ receiving kidneys from living related requiring the surgeons to connect the after the surgery, he led a fully normal GRQRUVZHUHQHDUSHUFHQW7KH pulmonary veins with the left atrium. OLIHSDVVLQJDZD\WZHQW\ÀYH\HDUVODWHU same principles that drove Dr. Mur- Determined to simplify the surgery due to cardiac disease (11). Thus, Dr. ray’s experiments encouraged other while achieving a better success rate, Dr. Murray proved that a transplantation physicians to expand transplantation Norman Shumway of Stanford Univer- did not need to occur between geneti- attempts to other organs like the liver, sity experimented in canine models with cally identical twins and that the key to SDQFUHDVDQGKHDUW,QDURXQG orthotopic homotransplants combined a successful transplant was indeed 17,000 kidney transplants were per- ZLWKR[\JHQDWRUV  7KLVWHFKQLTXH immunosuppression, though protocol IRUPHGLQWKH86)URPWR adapted from that of the British sur- optimization was still on the horizon. over 90 percent of living donor kidney geons Dr. Cass and Dr. Brock, left the Since the X-ray and marrow infusion recipients lived at least four years after left and right atriums partially intact. approach exhibited a very low success WKHLURSHUDWLRQ )LJXUH  Altogether, Dr. Shumway did see an rate, the next largest advancement was The success of Murray’s experiments improvement in success rates: five the introduction of immunosuppres- certainly were not limited to renal trans- of the eight dogs survived between VLYHGUXJVLQ  8VLQJWKH SODQWDWLRQH[FLWHPHQWLQWKHÀHOGRI  VL[WRGD\VDIWHUVXUJHU\7RGDWH DQWLPHWDEROLWH0HUFDSWRSXULQH organ transplantation quickly spread, Shumway’s method is used in cardiac WUDQVSODQWV   To prolong post-oper- ative life, Dr. Reemstma of Tulane University used methotrexate as a chemical form of immunosuppres- sion, encouraged by the successful use of such treatments in renal trans- SODQWV  :KHQWKLV drug was used in hetero- tropic canine transplants, rejection was delayed up WRGD\V8VLQJWKLV NQRZOHGJHLQ'U Christiaan Barnard fa- mously performed the first successful human heart transplant in Cape Town, South Africa, with a cocktail of local irradia- tion, azathioprine, pred- nisone, and actinomycin C as immunosuppres-

credit:(14) Figure 5. Five-year survival rates for heart, lung, or kidney recipients from 2001-2007 VDQWV  )URPWKDW

12 Harvard Science Review ‡ fall 2011 375Focus: Illuminating Science Years of Science at Harvard neers such as Dr. Murray has revo- to both suppress the immune response lutionized modern medicine. Organ in cardiac transplants and attenuate transplantation today is a viable and P\RFDUGLDOK\SHUWURSK\/LNHDOOÀHOGV valuable therapeutic intervention. of medicine, transplantation surgery There remain, however, major ob- will continue to move forward in the stacles to be overcome from medical, years to come, as knowledge of basic ethical, and policy perspectives. One science and the restructuring of the major debate surrounds whether or healthcare system open treatment op- not governments should incentivize tions for a larger number of patients. organ donation. A successful trans- —Roxanna Haghighat ‘15 is a prospective plant does indeed ensure a longer, Molecular and Cellular Biology concentrator healthier life for the donor, and due in Lionel Hall. to other medical advances that allow patients to live longer with chronic diseases, demand for these organs is References 1.”Tissue Transplant History” New York Organ Donor ever-growing. This supply-demand Network (2011). 2.Edgar, P., Bullock, R., Bonner, S. (2004). Manage- one from which most patients do not ment of the potential heart-beating organ donor. Figure 6. Dr. Norman Shumway &RQWLQXLQJ(GXFDWLRQLQ$QDHVWKHVLD&ULWLFDO&DUH live to be removed. Countries like Iran DQG3DLQ 4(3): 86-90. point on, multiple surgeons repeat- have resolved this issue by creating a na- 3.Simmons, J. “Alexis Carrel.” 'RFWRUVDQG'LVFRYHU- edly improved surgical techniques, LHV/LYHVWKDW&UHDWHG7RGD\·V0HGLFLQH. Boston: tional program to incentivize organ do- +RXJKWRQ0LIÁLQ culminating in the Shumway team’s nation, particularly by providing health 4. “Physiology or Medicine 1990 - Press Release” development of a percutaneous trans- Nobelprize.org (1990). 5. “Jean Dausset - Biography” Nobelprize.org method enabled them to obtain a small DÀQDQFLDOLQFHQWLYHRQRUJDQGRQDWLRQ (2005). would systematically target the poor and 6. Murray, J.E. “Nobel Prize Lecutre: The First via catheter to determine the chances OHDGWRWKHFRPPRGLÀFDWLRQRIKXPDQ Successful Transplants in Man” Stanford Program in RI UHMHFWLRQ%\6WDQIRUGKDG History and Philosophy of Science and Technology beings (17). Other ethical debates sur- (2011) . ZLWKDVXUYLYDOUDWHRI SHUFHQWDIWHU 7. “Joseph E. Murray - Autobiography” Nobelprize. IDUVFLHQWLÀFSURJUHVVVKRXOGEHWUDQV- org (1990). The final cornerstone in cardiac example, regarding whether facial trans- 8. “Joseph E. Murray Biography” faqs.org (2011). rather, it was the use of cyclosporine in France and Brigham and Women’s 9. “About Dr. Hume” United Network for Organ A as a superior immunosuppressive Sharing (2011). DJHQW,GHQWLÀHGDVDQLPPXQRVXS- Transplantation, pioneered and revo- 10. Billingham, R.E., Medawar, P.B. (1951). The pressant by Swiss Dr. Jean-François technique of free skin grafting in mammals. -([S lutionized by Dr. Murray at the Harvard %LRO 28: 385-402. %RUHO LQ  hospitals, 11. “Joseph E. Murray - Nobel Lecture” Nobelprize. ´7KHSHUVHYHUDQFHRI'U org was found to 0XUUD\KDVUHYROXWLRQL]HGPRGHUQ (1990). the lives of 12. Murray, J.E., Lang, S., Miller, B.J., Dammin , be not only the PHGLFLQHµ countless G.J. (1956). Prolonged Functional Survival of Renal most effective Autografts in the Dog. 6*2 103: 15. around the 13. Murray, J.E. “Richard and Ronald Herrick.” 6XU- immunosup- world and has improved the lives of JHU\RIWKH6RXO5HÁHFWLRQVRQD&XULRXV&DUHHU. pressant in porcine cardiac allografts Science History Pubns, 2004. 74-76. millions more. However, the impact 14. “Fast Facts” ustransplant.org (2011). 15. DiBardino, D.J. (1999) The History and Devel- FDWLRQRIWKHVHÀQGLQJV6KXPZD\XVHG not simply to develop a standard for opment of Cardiac Transplantation. 7H[DV +HDUW cyclosporine A in three different dos- ,QVWLWXWH-RXUQDO26(3): 198-205. transplants but also to enhance under- 16. Ghods, A.J., Shekoufeh, S. (2006). Iranian Model DJHVLQLQFUHDVLQJWKHRQH\HDU standing of the immune system in the of Paid and Regulated Living-Unrelated Kidney Dona- VXUYLYDOUDWHWRSHUFHQWE\   tion. &-$611(6): 1137-1138. context of the whole human body. As 17. Scheper-Hughes, N. (2004) Parts unknown: evidenced by the work of Drs. Barnard 8QGHUFRYHU HWKQRJUDSK\ RI WKH RUJDQVWUDIÀFNLQJ The Future of Organ Transplanta- underworld. (WKQRJUDSK\(1): 29-73. DQG6KXPZD\RWKHUÀHOGVRI PHGLFLQH 18. Powell, A. (2009) “Brigham face transplant re- tion expanded consequently, including phar- cipient goes home” +DUYDUG*D]HWWH .

macology. Cyclosporine A is now used FUHGLW2IÀFHRI&RPPXQLFDWLRQDQG3XEOLF$IIDLUV6WDQIRUG8QLYHUVLW\

fall 2011 ‡ Harvard Science Review 13