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Reflecting on the Past and Looking Toward the Future: A Brief History of University of Wisconsin Transplant Program

Isabel Breyer, MD; Didier Mandelbrot, MD; Sharon M. Bartosh, MD; Sandesh Parajuli, MD

WMJ. 2024;123(4):256-258.

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The history of the University of Wisconsin (UW) solid organ transplant programs began with the first deceased donor kidney transplant in March 1966. Shortly after, pancreas and liver programs were started and began to grow as many influential individuals were recruited to the university.1 In 2005 and 2006, the kidney program became the largest in the United States in terms of volume, and in November 2022, a program milestone was reached: 12 000 kidney transplants. Today, the University has 19 adult and 15 pediatric transplant programs, which together have performed over 17 216 adult and 574 pediatric transplants. In addition, major innovations to the field of solid organ transplantation, including the development of University of Wisconsin solution by Folkert Belzer, MD, and colleagues, took place at UW and are now used worldwide.1

This commentary reflects on the history and success of these programs with an eye toward the future.

EARLY DAYS

The history of the UW Health Transplant Center was not without obstacles. Early programs experienced periods of slow growth as they worked to recruit faculty and improve operative techniques. The first two pancreas transplants at the center failed; programs such as the pediatric liver transplant program faced initial challenges in gaining support; and the first pediatric intestinal transplants were complicated by rejection and mortality.1 These challenges, among others, helped push the center forward as faculty worked to remedy them.

ADULT KIDNEY TRANSPLANT PROGRAM

For over 800 000 adults living with end-stage kidney disease (ESKD) in the US,2 kidney transplantation is life-altering and offers many advantages compared to dialysis: greater long-term (≥ 1 year) survival,3 improved productivity and employment rates,4 and better quality of life.5 The most common conditions leading to ESKD in order of decreasing prevalence in the US are diabetes, hypertension, glomerulonephritis, and polycystic kidney disease.6 Based on Organ Procurement and Transplantation Network (OPTN) data, almost 90 000 patients are currently on the kidney waiting list.7

In 1966, surgeons at UW began performing solid organ transplants with the first deceased donor and, later that year, the first living donor kidney transplant. At the end of 2022, 6477 deceased donor and 3875 living donor transplants had been performed at UW, with 3007 patients actively followed in the kidney transplant clinic (See Table 1 in full-text pdf).

PEDIATRIC KIDNEY TRANSPLANT PROGRAM

Among the US pediatric population, ESKD most often occurs secondary to congenital anomalies of the urinary tract, glomerular disease, or secondary glomerulonephritis.6 Preemptive kidney transplantation is the preferred mode of renal replacement therapy (RRT), yet hemodialysis remains the most commonly used initial RRT (23% vs 43%, respectively),2 likely reflecting the mismatch between the number of patients with ESKD and available organs. Amaral et al compared outcomes among pediatric patients with ESKD who underwent preemptive kidney transplantation versus those exposed to dialysis and found dialysis exposure to be associated with a higher risk of both graft failure and death.8

In 1967, a year after the center’s first adult kidney transplants, the first pediatric living and deceased donor kidney transplants were completed successfully. Since then, over 88 living donor and 175 deceased donor pediatric kidney transplants have been performed at the transplant center, with 99 patients actively followed in the clinic. (See Table 2 in full-text pdf.)

ADULT SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANTS

For patients with ESKD secondary to type 1 diabetes or insulin-dependent type 2 diabetes, simultaneous pancreas-kidney transplant is a life-changing treatment that can significantly improve quality of life by replacing the need for daily insulin and regular dialysis. Currently, 83% of all pancreas transplants performed are simultaneous pancreas-kidney transplants, 12% are performed in patients who have previously received a kidney, and 5% of pancreas transplants alone are performed for patients with brittle type 1 diabetes without concurrent kidney disease.9

The first adult simultaneous pancreas-kidney transplant was performed at UW in 1982. This is one of the institution’s larger programs, with 1454 transplants performed through 2022 and 537 patients actively followed in the clinic. (See Table 1 in full-text pdf.)

ADULT LIVER TRANSPLANT PROGRAM

Among patients with end-stage liver disease (ESLD) listed for transplant, common primary diagnoses include alcohol-related liver disease, hepatocellular carcinoma, hepatitis C, and non-alcoholic steatohepatitis (NASH).10 In recent years, NASH has become the most rapidly increasing indication for liver transplantation, reflecting the obesity epidemic in the US, while transplants due to chronic hepatitis C have declined due to the development of highly effective direct-acting antivirals.11 Regardless of etiology, liver transplantation is the gold standard treatment for ESLD and can significantly improve life expectancy.

This is UW’s third largest transplant program, surpassed only by the adult kidney programs. The program’s first transplant was performed in 1984, and 2759 transplants had been performed by the end of 2022. At that time, 1095 patients, including some of the 47 living donor liver recipients, were followed in the transplant clinics. (See Table 1 in full-text pdf.)

In 1999, 15 years after the first deceased donor adult liver transplant at UW, the first living donor adult liver transplant was performed at UW, marking the beginning of an exciting new era. For patients with liver failure, waiting for a deceased donor organ was no longer the only option. Instead, they could receive a partial liver from a living donor, and by the end of 2022, 47 living donor adult liver transplants had been performed at UW. (See Table 1 in full-text pdf.)

Across the US, living donor liver programs have experienced slow growth due to challenges such as widespread media coverage of donor deaths in the 2000s and graft size issues leading to exclusion of potential living donor-recipient pairs.12 Growth of these programs is needed to better serve over 10 000 patients currently waitlisted for a liver.7 Increasing the donor pool via living donors is an important goal as nearly 20% of waitlisted patients either die or become too ill for transplant each year.10

OTHER SOLID ORGAN TRANSPLANT PROGRAMS

Besides the aforementioned programs, there are various active thoracic and abdominal solid organ transplant programs at UW, including simultaneous multiorgan transplant programs. (See Tables 1 and 2 in full-text pdf.) Most patients continue to follow up in the transplant clinic.

From 1966 to 2023, UW’s solid organ transplant programs have affected thousands of lives, advanced the field of transplantation through research and innovation, and recruited teams of dedicated individuals. The large proportion of transplanted patients actively followed at our transplant clinics is one of the many strengths of these programs, as they ensure high quality care and provide extensive data for research. Some patients return to the clinics for decades of follow-up care, and we can gather invaluable longitudinal data from the successes and setbacks of their clinical courses.13,14

The successes of the UW Health Transplant Center would not be possible without its patients and the gifts of life from organ donors throughout Wisconsin and nationwide. It is only through their donations that the center has and will continue to serve patients for years to come.

REFERENCES
  1. Sollinger HW, Becker YT, Burlingham W, et al. The history of the University of Wisconsin transplant program. Clin Transpl. 2007;271-287.
  2. The United States Renal Data System 2022 Annual Data Report. United States Renal Data System. Published 2022. Accessed date February 22, 2023. https://adr.usrds.org/2022
  3. Chaudhry D, Chaudhry A, Peracha J, Sharif A. Survival for waitlisted kidney failure patients receiving transplantation versus remaining on waiting list: systematic review and meta-analysis. BMJ. 2022;376:e068769. doi:10.1136/bmj-2021-068769
  4. Kirkeskov L, Carlsen RK, Lund T, Buus NH. Employment of patients with kidney failure treated with dialysis or kidney transplantation-a systematic review and meta-analysis. BMC Nephrol. 2021;22(1):348. doi:10.1186/s12882-021-02552-2
  5. Tonelli M, Wiebe N, Knoll G, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant. 2011;11(10):2093-2109. doi:10.1111/j.1600-6143.2011.03686.x
  6. Gupta R, Woo K, Yi JA. Epidemiology of end-stage kidney disease. Semin Vasc Surg. 2021;34(1):71-78. doi:10.1053/j.semvascsurg.2021.02.010
  7. Data and Trends. United Network for Organ Sharing. NOS. Accessed September 9, 2024. https://unos.org/data
  8. Amaral S, Sayed BA, Kutner N, Patzer RE. Preemptive kidney transplantation is associated with survival benefits among pediatric patients with end-stage renal disease. Kidney Int. 2016;90(5):1100-1108. doi:10.1016/j.kint.2016.07.028
  9. Jiang AT, BHSc, Rowe N, Sener A, Luke P. Simultaneous pancreas-kidney transplantation: the role in the treatment of type 1 diabetes and end-stage renal disease. Can Urol Assoc J. 2014;8(3-4):135-138. doi:10.5489/cuaj.1597
  10. Kwong AJ, Ebel NH, Kim WR, et al. OPTN/SRTR 2021 annual data report: liver. Am J Transplant. 2023;23(2 Suppl 1):S178-S263. doi:10.1016/j.ajt.2023.02.006
  11. Younossi ZM, Stepanova M, Ong J, et al. Nonalcoholic steatohepatitis is the most rapidly increasing indication for liver transplantation in the United States. Clin Gastroenterol Hepatol. 2021;19(3):580-589.e5. doi:10.1016/j.cgh.2020.05.064
  12. Sturdevant M, Ganesh S, Samstein B, et al. Advances and innovations in living donor liver transplant techniques, matching and surgical training: meeting report from the living donor liver transplant consensus conference. Clin Transplant. 2023;37(7):e14968. doi:10.1111/ctr.14968
  13. Parajuli S, Mandelbrot DA, Aziz F, et al. Characteristics and outcomes of kidney transplant recipients with a functioning graft for more than 25 years. Kidney Dis (Basel). 2018;4(4):255-261. doi:10.1159/000491575
  14. Parajuli S, Bath NM, Aziz F, et al. More than 25 years of pancreas graft survival after simultaneous pancreas and kidney transplantation: experience from the world’s largest series of long-term survivors. Transplantation. 2020;104(6):1287-1293. doi:10.1097/TP.0000000000002960
Author Affiliations: University of Wisconsin Transplant Center, University of Wisconsin School of Medicine and Public Health (UWSMPH), Madison, Wisconsin (Breyer, Mandelbrot, Parajuli); Department of Pediatrics, UWSMPH, Madison, Wisconsin (Bartosh).
Corresponding Author: Isabel Breyer, MD, email ibreyer@wisc.edu; ORCID ID 0009-0002-9274-6549
Funding/Support: None declared.
Financial Disclosures: None declared.
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