Portal de Periódicos da CAPES

Interview with Dr Paul Terasaki

2003; Elsevier BV; Volume: 3; Issue: 9 Linguagem: Inglês

10.1034/j.1600-6143.2003.00194.x

1600-6143

J. Michael Cecka,

Organ Transplantation Techniques and Outcomes

In 1964, Paul Terasaki developed the microcytotoxicity test, a test that required only 1 μL each of the scarce antisera used to identify human leukocyte antigens (HLA) (1Terasaki PI McClelland JD Microdroplet assay of human serum cytotoxins.Nature. 1964; 204: 998-1000Crossref PubMed Scopus (1743) Google Scholar). This significant development allowed tissue typing to be standardized around the world and led to advances in a number of peripheral fields – a new way to resolve disputed paternity cases (2Terasaki PI Resolution by HLA testing of 1000 paternity cases not excluded by ABO testing.J Family Law. 1977; 16: 543-557Google Scholar), links between HLA and a variety of diseases (3Scholsstein L Terasaki PI Bluestone R Pearson CM High association of an HLA antigen, w27, with ankylosing spondylitis.N Engl J Med. 1973; 228: 704-706Crossref Scopus (1058) Google Scholar) and, of course, the important and persistent association between HLA and transplantation. As a result of Paul Terasaki's research (as well as that of his many students around the world) showing better kidney graft survival rates for recipients of HLA‐matched deceased donor kidneys, and his development of a simple cold storage solution for shipping of kidneys (4Collins GM Bravo‐Shugarman M Terasaki PI Kidney preservation for transportation. Initial perfusion and 30 hour ice storage.Lancet. 1969; ii: 1219Abstract Google Scholar), the United Network for Organ Sharing currently facilitates the shipment of approximately 100 kidneys each month between US transplant centers for transplantation to HLA‐matched recipients with high success rates (5Takemoto SK Terasaki PI Gjertson DW Cecka JM Twelve years' experience with national sharing of HLA matched cadaveric kidneys for transplantation.New Engl J Med. 2000; 343: 1078-1084Crossref PubMed Scopus (206) Google Scholar). Concomitantly with the development of the microcytotoxicity test, Dr Terasaki recognized that patients who had preformed antibodies against donor HLA antigens would reject the graft in a hyperacute fashion (6Terasaki PI Marchioro TL Starzl TE Serotyping of human lymphocyte antigens. Preliminary trials on long‐term kidney homograft survivors.Nat Acad Sci Monograph. 1965; : 83-96Google Scholar). As a result, all patients waiting for a kidney transplant are screened for the presence of these antibodies and a lymphocyte cross‐match test is routinely performed to prevent hyperacute rejection. These seminal contributions and an unwavering commitment to improve kidney transplant results established Dr Terasaki's position among the pioneers of transplantation. But these contributions represent only a small part of a larger interest in the importance of humoral immunity in transplantation. Paul Terasaki's retirement from the UCLA Department of Surgery and the UCLA Tissue Typing Laboratory in 1998 lasted less than a year. He has since established the Terasaki Foundation, an independent laboratory dedicated to cancer immunotherapy and the study of humoral immunity and transplantation. Since his retirement, his continuing research has raised awareness and interest in the role of antibodies in transplantation. Recently, I met with Paul Terasaki at his foundation to discuss the humoral theory of transplantation and his current work. Question: Your earliest work, and perhaps the work that initially placed you in transplantation, was at University College with Sir Peter Medawar, who is remembered for demonstrating that transplantation immunity was mediated by cells. What drew you to study antibodies instead of cells? I was 28 years old at that time, and perhaps it was some sort of youthful rebellion that made me go in the opposite direction. When leaving London, I chose to go to Paris to study with Jean Dausset, which indicates that while still in England, I had decided to change to human studies, and to work on antibodies. Actually, I did not work in Dausset's lab. The story, recounted in our History of HLA book (7Terasaki PI, ed. History of HLA. Ten Recollections. Los Angeles: UCLA Tissue Typing Laboratory; 1990.Google Scholar), is that while in London, I prepared to go to France by taking French lessons, and communicated with Dausset in French (with the aid of my French teacher). Dausset was surprised that despite our correspondence by mail, I was actually hardly able to speak French. He promptly shipped me off to the Institute Pasteur, where I worked for 2 months. I became discouraged, and returned home to Los Angeles, not having mastered French. In the many years since, Dausset and I have become good friends, and he recommended me for an honorary doctorate degree from the University of Paris, Sorbonne. Question: The microcytotoxicity test really created the field of histocompatibility as we know it today. How did you come up with such an unusual method? Necessity is really the mother of invention. Both my technician, John McClelland, and I were unable to venipuncture each other, so we finger poked each other for blood. We had to make enough lymphocytes from capillary tubes of blood for the test. Moreover, not being in the blood bank, we had no source of antibodies except left over serum from Rh testing of pregnant women. The microtest permitted 1000 tests to be done with 1 mL of serum (Figure 1). We were able to read 60 tests on one plate within 1 min by attaching buttons on the base of the microscope to an electric typewriter (before the days of computers). Every drop was extremely valuable to us. I can still remember Jon van Rood asking why I was so stingy. Four years after its introduction, the microtest was adopted as a standard by the NIH (so is sometimes referred to as the NIH test), and 6 years later at the 1970 Workshop, it was adopted as an international standard. Question: The recognition that hyperacute rejection was mediated by anti‐HLA antibodies established an extremely important role for antibodies in transplantation, one that was quickly accepted and has rarely been challenged over the past 35 years since you and Dr Patel first reported the results of 30 cross‐match‐positive cases (8). There have been recent reports that with certain precautions, a pre‐transplant cross‐match test is not required. What is your position on not performing the test when it may delay the transplant by several hours? It has been repeatedly shown that clerical and communication errors are the most frequent types of error in cross‐matching. Because of this, I would be very much against skipping this important step. I disagree with suggestions that we could dispense with the lymphocyte cross‐match if by repeated testing the patient is shown to have no HLA antibodies. There was a case some years ago, where in the middle of the night, the on‐call resident mispronounced the patient's name on the telephone, resulting in the wrong patient receiving the transplant. If clerical errors are the source of mistakes, the cross‐match test is the only way to prevent this error. The argument that there is an urgency to proceed with the operation is invalid with kidneys as there is ample evidence that a few added hours of cold ischemia time would not materially alter graft survival rates (9Nishikawa K Terasaki PI Annual trends and triple therapy – 1991–2000.in: Cecka JM Terasaki PI Clinical Transplants 2001. UCLA Immunogenetics Center;, Los Angeles2002: 247-270Google Scholar). For hearts and livers, the situation may be more urgent. One solution might be a 30‐min lymphocytotoxic cross‐match. This would pick up only the strong positive cross‐match, which perhaps is the main problem to be avoided. Weak cross‐matches, such as those only detectable by flow cytometry, may be found after the transplant, but fortunately, they are usually surmountable with immediate increased immunosuppression. I would extend the argument to include red cell cross‐matching as well. The recently publicized death of a heart transplant patient at Duke University was a very unfortunate error, which could have been avoided. As I noted 12 years ago, after a death of a heart transplant patient due to an ABO matching error, there were eight previous such blunders (10Terasaki PI Red cell crossmatching for heart transplants (letter).N Engl J Med. 1991; 325: 1748Crossref PubMed Scopus (2) Google Scholar). We suggested then that organs first be sent to the blood bank, where red cell cross‐matching can be done, and then released to the operating room. We noted then that there is simply no excuse for not enforcing the policy of red cell cross‐matching. Red cell cross‐matching can be done within minutes. Why, when we are dealing with such a vitally important life‐threatening situation, is this simple test not done? It has been mandatory for every blood transfusion for over 75 years, and should certainly be mandatory for every organ transplant. We should no longer delay enforcing this rule. Question: You are a staunch supporter of HLA matching for kidney transplants, yet you have published at least two papers that seem to contradict that position. The first was very early and cost you your grant support (11) and the more recent was the demonstration that transplants from unrelated living donors had very good survival rates, despite the HLA incompatibilities (12). How do you reconcile these apparently contradictory positions? I developed the microtest specifically for matching transplants. It was a shock for me to see that so many patients with mismatches were doing well, as I had expected them to fail. For example, in our 1970 analysis, more than half of the HLA‐A2‐mismatched transplants were surviving. My statement then that mismatched grafts were doing well, is true today, but drew a lot of criticism at that time. I was able to see the facts earlier than others because of the microtest, which allowed us to test patients from many centers. We developed a mailing bag for shipping blood (Figure 2), allowing us to even test patients transplanted in Europe and Australia. The ideal material we found to prevent blood leakage (tampons), gave us headaches when we tried to retrieve the blood and so a large vise was needed to squeeze out the lymphocytes. Our first (and the very first) series of kidney transplant patients was HLA typed in 1964 with the helpful support of Dr Thomas Starzl, who shipped us blood from Denver for his pioneering series of transplant patients (6Terasaki PI Marchioro TL Starzl TE Serotyping of human lymphocyte antigens. Preliminary trials on long‐term kidney homograft survivors.Nat Acad Sci Monograph. 1965; : 83-96Google Scholar). Our Hague paper was based on 1216 kidney transplant patients from 52 world‐wide transplant centers (11Mickey MR Kreisler M Albert ED Tanaka N Terasaki PI Analysis of HLA incompatibility in human renal transplants.Tissue Antigens. 1971; 2: 57-67Google Scholar). Perhaps it was naive to just present the facts rather than state what everyone expected. On the basis of the experience with red cell incompatible transfusions and ‘theory’, we expected that mismatching should result in failure. But with immunosuppression, many mismatches can be overcome, as we have been forced to recognize. I learned from this that conventional dogma, or that which is accepted as true by most scientists at any given time, is not necessarily correct. Yes, the Hague meeting presentation led to a chain of traumatic events for me: My contract, which at that time was 80% of my support, was cancelled within 4 months of the Hague meeting. I was ostracized by my own tissue‐typing colleagues. However, in retrospect, our failure to prove the effectiveness of typing led to many compensating consequences. First, it pressed me to survive on my own by selling tissue‐typing trays to provide research funds. This activity continued at UCLA for 14 years, and given my limited ability to get grant funds, it would have been impossible for us to do our research without this source of income. It led to our PRA studies in 1970, when we thought that prior immunizations were confounding the matching effect (13Terasaki PI Mickey MR Kreisler M Presensitization and kidney transplant failures.Postgrad Med. 1970; 47: 89-100Crossref Scopus (166) Google Scholar). In addition, our 1972 report, with Gerhard Opelz, of the paradoxical transfusion effect (14Opelz G Sengar DPS Mickey MR Terasaki PI Effect of blood transfusions on subsequent kidney transplants.Transplant Proc. 1973; 4: 253-259Google Scholar) was a direct result of trying to explain our matching failures. Most importantly, it forced us to develop a registry in 1970 to determine why typing was not correlated. The UCLA Kidney Transplant Registry and later the UNOS Kidney Transplant Registry from 1987 to 1998 accounted for a significant portion of my subsequent work. The registry analyses of factors influencing transplants has been documented in numerous articles and in 17 annual Clinical Transplant volumes since 1985, edited with Michael Cecka. Dr Starzl commented on a more momentous consequence of our Hague findings that mismatched transplants often functioned well. He pointed out that it freed him to embark on a full‐scale assault on liver transplants, which were impossible to match for HLA because of the limited number of choices (15Starzl TE. The Puzzle People – Memoirs of a Transplant Surgeon. Pittsburgh, PA: University of Pittsburgh Press; 1992.Google Scholar). The second time we felt compelled to speak up was when we found, to our surprise, that an assumption accepted by everyone for over 20 years, was no longer tenable. We all thought that two HLA‐haplotype mismatches (as found in genetically unrelated donor transplants) would be much worse than one HLA haplotype of mismatch (as in parental donor transplants). When the donor kidney was in prime condition, as were those from living donors, this assumption simply was not true (12Terasaki PI Cecka JM Gjertson DW Takemoto S High survival rates of kidney transplants from spousal and living unrelated donors.N Engl J Med. 1995; 333: 333-336Crossref PubMed Scopus (1070) Google Scholar). Perhaps the only surprise to others is that I would publish this finding. The facts have always been more important to me than that which I wanted to see. I am pleased to see that a sharp increase in living unrelated donor transplants has occurred as one consequence of our report, contributing to a reduction of the kidney shortage problem. Question: The number of living kidney donors surpassed the number of cadaver donors 2 years ago and recent data suggest that very soon there will be more living than deceased organ donors in the US. Attitudes toward using living donors have clearly changed during the past decade. Is this an appropriate solution to the organ shortage? Now that clinical transplants are so successful, the most important issue before us is how to make this advance available for the many needy patients accumulating on waiting lists. Clearly, the shortage of donor organs is the main problem. As we predicted 5 years ago (16Terasaki PI Cho YW Cecka JM Editorial: Strategy for eliminating the kidney shortage.in: Cecka M Terasaki PI Clinical Transplants 1997. UCLA Tissue Typing Laboratory;, Los Angeles1998: 265-267Google Scholar), the 2003 waiting pool has expanded to 50 000. At that time, we pointed out that if living donors were increased temporarily, and the use of nonheart‐beating donors were established, the waiting pool would shrink to 20 000 by the year 2008. This would mean that the use of living donors could be discontinued. I am concerned about the increasing dependence on living donors, and have always regarded living donors as a temporary solution. To the three deaths of living volunteer liver donors in the US, we can now add a new death – that of a living donor in Japan. Living‐donor liver transplants are being performed in large numbers in Japan, and until this year, with no unforeseen donor problems. Obviously, the ‘no donor deaths’ record in Japan is now broken. By the proposed plan, with nonheart‐beating donors plus brain‐dead donors, all the required kidneys would come entirely from cadaver donors. Thus, the most important future task is development of approaches to utilize nonheart‐beating donors. Presently, only about 250 nonheart‐beating donor transplants are performed annually (3% of cadaver donors), despite evidence that results with such donors almost equal those of conventional brain‐dead donors (17Cho YW Terasaki PI Cecka JM Gjertson DW Transplantation of kidneys from donors whose heart has stopped beating.N Engl J Med. 1998; 338: 221-225Crossref PubMed Scopus (254) Google Scholar). Just as a whole new mindset and legislation was needed to enable procurement of organs from brain‐dead donors, we now need a similar broad change in thinking for utilization of nonheart‐beating donors. Ironically, when someone is considered as a transplant donor, the simple loss of the heartbeat, which should be a clear sign of death, now becomes complicated by questions concerning physician motives in caring for the donor. New legislation will be needed, just as we needed legislation for brain death. Question: Advances in immunosuppression have improved transplant success rates by reducing graft losses to acute rejection. Far less progress has been made in reducing late graft deterioration and long‐term graft failures. This is an area in which you have been very active in recent years. Where should the emphasis be in recognizing and reducing late graft losses? I believe that the most significant development in recent years is the C4d test of Feucht (18Feucht HE Schneeberger H Hillebrand G et al.Capillary deposition of C4d complement fragment and early renal graft loss.Kidney Int. 1993; 43: 1333-1338Abstract Full Text PDF PubMed Scopus (462) Google Scholar). Now, for the first time, we can prove that antibodies are bound on the kidneys, and once this occurs, the kidney gradually ceases to function. The next most important development in recent years was recognition that HLA antibodies that appear after transplantation may cause gradual graft failure. A few years ago, we reviewed 23 studies where chronic rejection was associated with the presence of HLA antibodies (19Mckenna RM Takemoto SK Terasaki PI Anti‐HLA antibodies after solid organ transplantation.Transplantation. 2000; 69: 319-326Crossref PubMed Scopus (323) Google Scholar). More recently, with Po‐Chang Lee, we published that all 29 patients who had chronic rejection had antibodies before failure, suggesting that the antibodies had been responsible (20Lee PC Terasaki PI Takemoto SK et al.All chronic rejection failures of kidney transplants were preceded by the development of HLA antibodies.Transplantation. 2002; 74: 1192-1194Crossref PubMed Scopus (298) Google Scholar). The appearance of donor‐specific antibodies in the circulation is a certain sign that antibodies are going onto the graft. Among 825 patients who rejected a graft, we found 96% had HLA antibodies (21El‐Awar N Terasaki P Lazda V Nikaein A Manning C Arnold AN Almost all patients who are waiting for a regraft of a kidney transplant have anti‐HLA antibodies.Transplant Proc. 2002; 34: 2531-2532Crossref PubMed Scopus (43) Google Scholar). I am currently gathering data on the presence or absence of HLA antibodies in patients with functioning transplants. We now know that about 20% of the patients with well functioning transplants have HLA antibodies. In a large‐scale prospective study involving 30 transplant centers, we showed that patients with antibodies are failing more frequently than those without antibodies. Our interpretation is that antibodies are causing rejection. If we accept this concept, then it follows we can monitor the effectiveness of immunosuppression by monitoring for the appearance of antibodies. Of course, the story is still incomplete. For example, there may be other antigens, such as MICA antigens and the second histocompatibility locus antigens, which produce failures. Another important consequence of identifying antibodies as a cause of immunologic failure is that we can separate the immunologic failures from the chronic allograft nephropathies of Halloran (22Halloran PF Call for revolution: a new approach to describing allograft deterioration.Am J Transpl. 2002; 2: 195-200Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar). In retrospect, I realize it was the humoral theory of transplant rejection that I have been pursuing all these years. The cellular theory, advocated by Medawar, has been the overwhelming theory throughout this time period, and perhaps even today, if one were to take a survey, it would still be the one most transplant professionals believe in. The transplant community has put a great deal of effort into developing drugs to control the cellular response over the past 30 years. Why I accepted the humoral theory as an act of faith in 1958 is still unclear to me. My first paper on antibodies to transplants was in 1959 (23Terasaki PI Antibody response to homografts. I. Preliminary studies of the time of appearance of lymphoagglutinins upon homografting.Am Surg. 1959; 11: 896-899Google Scholar). Since I thought antibodies killed grafts, I first looked for antibodies in immunized people (pregnant women), and this type of world‐wide effort led to the discovery of the HLA system. Hyperacute rejection and cross‐matching fit well into the concept that preformed antibodies against the donor lead to immediate failure (6Terasaki PI Marchioro TL Starzl TE Serotyping of human lymphocyte antigens. Preliminary trials on long‐term kidney homograft survivors.Nat Acad Sci Monograph. 1965; : 83-96Google Scholar, 8Patel R Terasaki PI Significance of the positive crossmatch test in kidney transplantation.N Engl J Med. 1969; 280: 735-739Crossref PubMed Scopus (1228) Google Scholar). Interestingly, the only practical way in which the state of immunity to transplant can be seen today is again a test based on antibody, the PRA test (13Terasaki PI Mickey MR Kreisler M Presensitization and kidney transplant failures.Postgrad Med. 1970; 47: 89-100Crossref Scopus (166) Google Scholar) and as we reviewed, there is accumulating evidence that chronic rejection is associated with antibodies (17Cho YW Terasaki PI Cecka JM Gjertson DW Transplantation of kidneys from donors whose heart has stopped beating.N Engl J Med. 1998; 338: 221-225Crossref PubMed Scopus (254) Google Scholar). This factor, together with our current prospective trials noted above, might well vindicate the humoral theory, recently reviewed in this journal (24Terasaki PI The humoral theory of transplantation.Am J Transpl. 2003; 3: 665-673Abstract Full Text Full Text PDF PubMed Scopus (521) Google Scholar). In accepting the 1994 Medawar Prize, which he shared with his friends Jean Dausset and Jon van Rood in Barcelona, Paul Terasaki quoted Sir Peter Medawar on the difference between artistic and scientific priorities: ‘I don’t think any scientist can be defended against a major artist; scientists are always dispensable, for in the long‐run, others will do what they have been unable to do themselves.' 1From the introduction to The Threat And The Glory – A Posthumous Collection of Medawars Essays and Speeches, edited by David Pyke. Paul Terasaki has made a number of important contributions to the field of transplantation … and he has already seen many of them improved upon by others. He has even improved upon some of them himself. Certainly he has accomplished the scientist's best hope … laying the groundwork so that others can do what he cannot. But there is something of the artist at work as well, in the passion and perseverance in following an idea through to completion. Perhaps his wife, Hisako, and their son, Peter, both accomplished artists, have influenced Paul Terasaki's work. I think it is something that could hang on the wall.