Monday, June 6, 2016

Transplantation interviews Dr Lloyd Ratner

It's gated, but here's a link.
Lloyd E. Ratner, MD, MPH: Professor of Surgery and Director of Renal & Pancreatic Transplantation at Columbia University, and Treasurer of the American Society of Transplant Surgeons

Some interesting bits:

Transplantation: Together with a team at Johns Hopkins, you have been the first to perform laparoscopic donor nephrectomies. Would you mind sharing aspects of your personal journey leading to this surgical success with us?

LR: When first introduced in 1995, laparoscopic live donor nephrectomy was a novel, radical, and controversial concept. However, there was an antecedent history of about 10 years, which I witnessed. When I was a general surgery resident at Long Island Jewish Hospital, the Chairman of Urology and pioneer of endourology, Dr. Arthur Smith, was the first person to propose a minimally invasive nephrectomy for disease. Smith’s idea was to place a percutaneous nephrostomy tube into the kidney and allow a tract to form. Then, when the tract was sufficiently fibrosed, he proposed that a Resect-o-scope (like that used for TURPs or TURBTs) be passed through the tract and the kidney be resected from the inside out. Jerry Weinberg, a GU resident who worked with Smith eventually published the first experimental series of minimally invasive nephrectomies in a large animal model. In that series, Weinberg and Smith thrombosed the renal vessels radiologically, then fragmented the kidney with ultrasound, and finally removed the fragments laparoscopically.

During my transplant fellowship at Washington University, Ralph Clayman, with the assistance of his fellow Lou Kavoussi, performed the first laparoscopic nephrectomy for disease. In that first case, Clayman had the renal vessels thrombosed by interventional radiology followed by a laparoscopic nephrectomy. This initial case took approximately 12 hours. However, within 1 year, Clayman had reduced the operating time to approximately 4 hours, no longer requiring radiologic thrombosis of the renal vessels.

As part of a faculty position that I took subsequently at Johns Hopkins University, I directed a satellite renal transplant program at Bayview Medical Center (formerly Baltimore City Hospital). Together with Lou Kavoussi, the newly recruited Chief of Urology, we decided to perform laparoscopic live donor nephrectomies. Our goal was to remove logistical and financial disincentives to living kidney donation by reducing pain, length of stay, and recovery while improving cosmesis. In the mean time, Clayman’s group demonstrated in a large animal model that laparoscopically procured kidneys could be successfully transplanted. Finally, after identifying the right patients, Kavoussi and I performed the first laparoscopic donor nephrectomy in February 1995. The donor went home on postoperative day 1 and was back to work as a welder within 2 weeks. The recipient was discharged after an uneventful hospitalization with a creatinine of 0.8 mg/dL. From there, dissemination and adoption of the laparoscopic donor nephrectomy operation was largely patient driven.

Transplantation: Donor nephrectomies were discussed controversially in the 1990s. Can you share early challenges of outcomes and responses of the public, health professionals, and patients with us?

LR: The first manuscript describing the initial case report and technical aspects of the operation was flat-out rejected. After a rebuttal, the manuscript was accepted without revisions. A large portion of the transplant community could not conceive how we could do this laparoscopic operation safely. When we presented our data, people angrily stood up and told us that we were “amoral and that we were going to kill people.” I had nightmares every night for 2 years.
Transplantation: You have been a pioneer in paired kidney exchanges. How do you envision a further expansion?

LR: I believe that kidney-paired donation has not yet reached its maximal potential. The most attention has been paid to optimizing allocation algorithms. However, logistical and financial issues remain important, under-addressed obstacles. These need to be dealt with before we can expect further expansion.

Additionally, compatible pair participation in KPD is the most effective way to increase the desperately needed blood group O donors. However, this represents a major paradigm shift, where living donors are converted from a private resource to a shared or public resource. This will take years to gain widespread acceptance. Finally, I think that consideration should be given to using deceased donor organs to kick off living donor chains."