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Article Excerpt
Kidney transplantation was first used successfully as a means of treating renal failure during the middle of the 20th century. A small number of nurses in the few hospitals that experimented with transplant viewed the new treatment as an exciting work opportunity. In this review of published literature, interviews with early transplant nurses and reviews of other primary source material describe the early clinical practice of transplant nurses, focusing mainly from 1950 to 1970. I argue that transplant nursing practice was driven largely by the evolving methods of immunosuppression and its complications. Additionally, transplant nursing is discussed in the context of clinical specialization at mid-century.
Initial Experiments in Kidney Transplantation
The earliest reported successful kidney transplant resulted from a surgeon's interest in improving vascular suturing techniques (1). In 1902 in Vienna, Austria, Emerich Ullmann performed an autotransplant in which a dog's kidney was moved from the abdominal cavity to the neck. The kidney produced some urine and the dog lived a few days (Hamilton, 1988). Subsequent animal kidney transplants, including autografts, allografts (between animals of the same species), and xenografts (between animals of different species) were performed between 1902 and 1912 by Ullmann, Alfred von Decastello (also of Austria), and a French physician, Alexis Carrel. Carrel later immigrated to the United States and performed many successful autografts in cats and dogs (Hamilton, 1988) (2). These animal kidney transplants established the technical feasibility of resecting a kidney from one location and reattaching it in another part of the body.
Mathieu Jaboulay, a French surgeon, reported the first kidney transplants into humans in 1906. He performed two xenografts using organs from a pig and a goat; each transplanted kidney functioned for only an hour (Hamilton, 1988). Next, a Ukrainian surgeon, Yu. Yu. Voronoy, performed six human kidney allografts between 1933 and 1949. His first transplant was in a woman who had attempted suicide by ingesting a substance that led to acute renal failure. The donor kidney came from a patient who had sustained a fracture at the base of his skull and died upon arrival at the hospital. The kidney was placed in the woman's thigh with the renal arteries and veins anastomosed to the femoral arteries and veins. Skin flaps were used to cover the kidney and the ureter was pulled to the surface of the thigh and sutured in place. Although the woman lived two days after the transplant, the kidney showed no signs of function (Hamilton & Reid, 1984). Voronoy's later allograft attempts also were unsuccessful.
These earliest reports of human transplants provided considerable detail about the patients and surgical procedure; however, involvement of nurses was not described. One can speculate that due to the patients' short survival, nursing involvement, if any, would have been limited to assisting the surgeon as directed, preparing equipment, and cleaning up afterward because these were common nursing functions during that period.
Experiments with Human Kidney Transplantation after World War II
After World War II, scientific research on disease mechanisms and treatments grew rapidly and laid groundwork for surgeons to pursue research on kidney transplantation. Beginning in 1947, sustained efforts to achieve successful transplants were initiated at the Peter Bent Brigham Hospital ("the Brigham") in Boston (3). The first transplant at the hospital was performed by Doctors David Hume, Charles Hufnagel, and Ernest Landsteiner to treat a young woman who developed acute renal failure after obstetrical complications. A kidney from a recently deceased patient was transplanted into her thigh. The transplanted kidney produced urine immediately, and the woman began showing signs of recovery. Two days later, the kidney was removed because it was no longer producing urine. The patient recovered and was discharged. The transplanted organ had likely served as a temporary "bridge" while her native kidneys recovered (Tilney, 2003).
More transplants were performed over the next few years, but with minimal or no success. Dr. Joseph E. Murray joined the Brigham Hospital staff in 1949 and began working with Hume and others in the laboratory experimenting with transplant. When Hume left in 1953, Murray took over in the transplant research laboratory and became the lead kidney transplant surgeon (4). At that point, the Brigham's renal physicians were collaborating with Murray on kidney research and testing other treatments for kidney disease (Murray, 2001; Tilney, 2003). Their interest in transplant was encouraged by a 1951 report from Richard Lawler and colleagues in Chicago, who performed a transplant in a woman suffering from polycystic kidney disease. One of her diseased kidneys was removed and replaced with a kidney from a deceased donor. The new kidney produced urine, her condition improved, and she was discharged two months after the transplant (Lawler, West, McNulty, Clancy, & Murphy, 1951). Ten months later, the transplanted kidney had ceased functioning, yet the patient lived five more years. This transplanted organ, like that in the Brigham's 1947 case, had likely served as a bridge while her remaining native kidney recovered partial function (Tilney, 2003).
By 1954, 16 transplants had been performed at the Brigham. Of these, 10 patients died, 5 kidneys showed "measurable but short-term function," and 1 kidney functioned for 5 months (5). In October 1954, a development that presaged future successes occurred. The Brigham had a reputation for its research on kidney disease, and physicians at other hospitals often referred patients with renal failure (6). Richard Herrick (7), a 23-year old man with severe renal failure, was sent to the Brigham from a nearby Boston hospital. The referring physician suggested that because the patient had a healthy twin brother, Ronald, it might be possible to perform a kidney transplant (Merrill, Murray, Harrison, & Guild, 1956). By this time, physician researchers had observed that the body rejected grafted tissues except when the graft was between identical twins. Thus, if the Herrick twins were identical, a successful transplant might be possible.
On admission, Richard Herrick presented with hypertension, persistent nausea and vomiting, disorientation, erratic behavior, and biochemical indicators of uremia. Over a two-month period, the renal team treated his symptoms, including use of two dialysis treatments. Some symptoms were resolved, yet he continued to decline. During these two months, Ronald was evaluated to assure he was healthy and to assess his willingness to donate a kidney. The transplant team performed a number of procedures to verify that the brothers were identical twins. Most important were full thickness skin grafts between them. Murray explained in his autobiography that this two-month period was also used to weigh the moral and ethical ramifications of moving forward with the transplant. No one had ever removed a kidney from a healthy human for transplantation into another individual; the unknowns were great. The renal team sought consultation from other physicians and psychiatrists, clergy, and legal counsel. Subsequent to these consultations and team discussions, they presented what they knew about the procedure, the risks, and the probable benefits to Richard, Ronald, and their family so they could make a decision about whether or not to proceed. When the family asked about risks Ronald might encounter in living with only one kidney, the renal team even approached insurance companies to obtain actuarial data. They learned that people who had only one kidney had no increased risk of death. Ronald decided to donate his kidney (Murray, 2001).
The transplant was scheduled for December 23, 1954. A few days prior to this, Murray carried out a "test run" on a cadaver using surgical techniques he had perfected on dogs in the laboratory (8). The donated kidney was placed into Richard's abdominal cavity; the renal artery and vein were anastomosed to the external iliac artery and vein, respectively, and the end of the ureter implanted into the bladder. The kidney functioned immediately (9). Ronald's post-operative course was uneventful, and he was discharged on the 14th hospital day. Richard's post-operative course was also relatively uneventful, and he was discharged on the 37th postoperative day. He had gained 11 lbs, his blood urea nitrogen had dropped to 14 mg/100 cc, and his blood pressure was 120/60 mmHg (Merrill et al., 1956). Over the next few months, his blood pressure rose, despite otherwise good functioning of the transplanted kidney. The rise was attributed to his native kidneys so they were removed in two subsequent surgeries. The hypertension resolved, and Richard returned to full-time work, married, and became a father (Murray, 2001). He lived until 1963, when he died from renal failure. The disease that caused his initial kidney failure, chronic glomerulonephritis, had recurred in the transplanted kidney (10).
Clare Burta was one of the nurses involved in the care of Richard Herrick (11). She was a 1952 graduate of the Peter Bent Brigham Nursing School, and in 1954, she was working in the recovery room at the Brigham. She first took care of Richard in the recovery room, then was one of the nurses who worked private duty shifts to take care of him on the surgical floor. Due to a national shortage of nurses at that time, staffing on hospital floors was insufficient to care for patients who needed close monitoring. Other patients who were likely to have private duty nurses were those who underwent cardiac surgery. Burta recalls that the nursing care for Herrick was much the same as it was for other post-surgical patients: check vital signs frequently, check surgical site for bleeding, closely monitor intake and output, and keep him comfortable. Burta worked many years before retiring, but she never provided nursing care...
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