EXPERIMENTAL AND CLINICAL TRANSPLANTATION

The cornerstone events of kidney and liver transplant history in Turkey are summarized herein. In 1975, we performed the first pediatric living-related renal transplant in Turkey. We followed this in 1978 with the first deceased donor kidney transplant, using an organ supplied by Eurotransplant. In 1979 the law on harvesting, storage, grafting, and transplant of organs and tissues was enacted; the first local deceased donor kidney transplant was performed by our team in 1979. In 1988, another ground-breaking event in Turkey, the Middle East, and North Africa was successfully achieved: the first successful deceased-donor liver transplant, and in 1990, the first pediatric living-related segmental liver transplant in Turkey, the region and Europe was performed by our team. One month later, an adult-to-adult living-related liver transplant (left lobe) in the World was successfully performed. On May 16, 1992, we performed the first combined liver-kidney transplant from a living-related donor, which was the first operation of its kind in the World. Between November 1975 and January 2022, we have performed 3288 kidney (380 pediatric) at the Hacettepe University Hospitals and later on at Baskent University; since 1988, 701 (334 pediatric) liver transplants have been performed. In over 40 years of kidney and liver transplants history in Turkey, 46876 kidney (2502 pediatric patients) and 18203 liver (2612 pediatric patients) transplants have been performed nationwide. In 2001, the Ministry of Health established the National Coordination Center as an umbrella organization to promote transplant activities, especially for deceased donor organ procurement. Transplant activities are accelerating daily throughout the country, but deceased donors are still far below the desired rates.

Key words : Deceased donation, Education, Ethics, Legislation, Living-related donation, Organ transplantation

Organ transplant for children remains one of the most complex and challenging areas within current medical practice. The practice of transplant in the pediatric population has revolutionized the life of children with end-stage organ failure. Pediatric transplant as a subspecialty is growing around the world with the establishment of new transplant programs and prioritization of organs for children.

In 1953, the first temporarily successful transplant of a human kidney was performed by Jean Hamburger in Paris. A 16-year-old boy received the kidney of his mother as living donor transplant.¹ Then in 1954, a milestone was made with the first long-term successful kidney transplant by Joseph Murray. Joseph Murray, a plastic surgeon, performed the first successful kidney transplant on the Herrick brothers, adult identical twins.² In February 1967, 6-year-old Tommy Hoag became the firstChildren’s Hospital Los Angeles(CHLA) patient to undergo a kidney transplant with a kidney donated by his father.³

History of Pediatric Kidney Transplant in Turkey

A first attempt of a solid-organ transplant in Turkey began with two heart transplants in 1968. By the early 1970s, we started to conduct experimental studies on liver transplant and on November 3, 1975, we performed the first pediatric renal transplant in Turkey, with a kidney donated from mother to her 12-year-old son (Figure 1).⁴

In an attempt to start a deceased-donor program in Turkey, I contacted and worked in cooperation with international networks, including first the Eurotransplant Foundation (Leiden, The Netherlands) and then the South Eastern Organ Procurement Foundation (Richmond, VA, USA). Thus, we were able to perform the first deceased-donor kidney transplant, which was carried out at our center on October 10, 1978, using an organ supplied by the Eurotransplant Foundation (Figure 2A and 2B).⁵

Kidneys donated by these organizations were used with a high success rate even though they were anatomically problematic. Following these successful imported kidney transplants, we increased the cold ischemia time from 12 hours to more than 100 hours (Figure 3).⁶

It became apparent that it would be necessary to have legislation to govern transplant activities; as a result of our efforts, the law on harvesting, storage, grafting, and transplant of organs and tissues was enacted on ^{June 3, 1979. Later that year on July 27, 1979, we performed the first local deceased-donor kidney transplant} (Figure 4A and 4B).⁷

We also worked with the Turkish public to provide education about the benefits of and social responsibilities involved in organ donation. In addition, we founded The Turkish Organ Transplant and Burn Treatment Foundation in 1980 to advance these interests. Standardized “Organ Donation Cards” were printed as well, with the aim to promote donation and bring this concept to life in peoples’ minds. On January 21, 1982, some new articles were added to Law 2238, with the enactment of Law 2594, which allowed for deceased donation without consent from next-of-kin. We started performing liver transplants right after this (Figure 5).

History of Pediatric Liver Transplantation in Turkey

In 1963, Thomas Starzl undertook the world’s first human liver transplant. The recipient was a 3-year-old boy and the donor was another child. Unfortunately, the pediatric patient died intraoperatively. Four years later, in 1967, Starzl performed the first successful liver transplant, for a 19-month old girl withhepatoblastoma who was able to survive for over 1 year.⁸

This was followed by a period of many ground-breaking events; on December 8,1988, we performed the first successful deceased liver transplant in Turkey and the region (Figure 6).

In 1989, Raia and his associates reported the first 2 pediatric transplants using grafts taken from living donors in Brazil, but both recipients died of medical complications. Following this, Dr. Broelsch and associates were able to perfom living related liver transplant in Chicago.^9,10 At the same time, I started experimental studies on sheep. This was followed by the first pediatric (1-year-old child) living-related segmental liver transplant in Turkey, the Middle East, and Europe on March 15, 1990 (Figure 7); just 1 month later, we achieved success with the first adult living related liver transplant (left lobe) in the world, after grafting tissue from a father to his 22-year-old son (Figure 8).¹¹

In addition, we conducted heterotopic liver transplants. In 1998, we performed a heterotopic deceased-donor partial liver transplant to a 17-year-old girl, heterotopic living-related transplant to a 16-year-old boy, and a heterotopic living-related liver transplant to a 17-year-old boy from his mother in 1999.^12-20 These were followed by other heterotopic liver transplants either from deceased or living related donors in the following years (Figure 9).

On May 16, 1992, we performed the first combined liver-kidney transplant from a living-related donor, which was the first operation of its kind anywhere in the world (Figure 10).^21,22

In 2001, the Ministry of Health established the National Coordination Center as an umbrella organization to promote transplant activities, especially for deceased donor organ procurement. Transplant activities are accelerating day by day throughout the country, but deceased donors are still far below the desired rates. Efforts to increase awareness continue through the media, schools, and many public and private institutions. Improvements in legislation, education, and coordination are key factors for increasing the quality and the quantity of transplant activities in Turkey.

Since 3 November 1975 until 1 January 2022, our team has performed 3288 kidney transplants (380 pediatric and 2908 adult patients), and since 1988, 701 liver transplants (334 pediatric and 367 adult patients). In over 40 years of kidney and liver transplant history in Turkey, 46876 (2502 pediatric patients) kidney and 18203 (2612 pediatric patients) liver transplants have been performed nationwide.

In conclusion, transplant is currently the best option for children with chronic organ failure. Although pediatric organ transplant is active in some parts of many developing countries, it is still inactive in many others and mostly relying on living donors. The lack of deceased donor programs in most of these countries is one of the main issues to be addressed to adequately respond to organ shortages. Still, pediatric kidney transplant outcomes are markedly improved and younger children today experience better long-term graft survival and anticipate even more advances in the future of pediatric kidney transplant.

Volume: 20 Issue: 5 May 2022 - Supplement - 3

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