Jose Medina Pestana, MD, PhD, FRCS: Head of Transplant Division
Transplantation:
What event sparked your interest to
get into the transplantation and led you to create the world’s largest kidney
transplant center?
JMP:
After finishing medical residency training at the Federal University of
São Paulo in 1983, I was offered a position leading a team aiming at increasing
the number of kidney transplants at the same institution. At that time, less
than 500 kidney transplants had been performed annually in the
entirecountrywiththevastmajorityretrievedfromlivingdonors. My previous
experience had been scant, and I had only
takencareofahandfulofkidneytransplantrecipients.Toenhance my experience, I
spent 3 months visiting the 2 leading kidney transplant centers in Brazil: the Hospital
Evangélico in Londrina and the Hospital das Clínicas in São Paulo. Immediately,
I became passionate about being part of that group of transplant pioneers.
Realizing that transplantation involves cooperation of a well-coordinated team
from of a wide range of medical specialties, I envisioned that the field would
benefit from innovative working processes that I had been familiar with. As a
teenager, I worked as a lathe operator in a factory that produced parts on an
assembly line through interconnected working stations. Items were subsequently
assembled into final (nearly perfect) products, an approach that had been based
on Frederick Taylor's scientific management theory aimed at improving
efficiency.
With those
concepts in mind, I organized a transplant group that had the goal to perform
20 kidney transplants within1 year atthe Hospital São Pauloof
theFederalUniversity. One needs to remember: organs at this time came from “ideal” donors
and recipients had only minimal comorbidities. The allocation system for
deceased donor kidney allografts had been based exclusively on ABO
compatibility, a negative crossmatch test and time on dialysis. We even dared
to transplant nonsensitized male recipients without performing a crossmatch
test. Indeed, Professor Emil Sabbaga at the Hospital das Clinicas in São Paulo,
a transplant pioneer in Brazil provided clear directives.
After the first 3 years, we decided to
increase our deceased donor transplant program. Initially, I was unable to
motivate our surgeons to engage in the arduous and time-consuming
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The author declares no funding or
conflicts of interest.
Correspondence: Jose Medina Pestana,
MD, PhD, FRCS, Hospital do Rim and
Federal
University of São Paulo Rua Borges Lagoa, 960 04038-002, São Paulo, Brazil.
(medina@hrim.com.br).
Copyright © 2015 Wolters Kluwer Health,
Inc. All rights reserved.
ISSN: 0041-1337/16/10001-7
DOI: 10.1097/TP.0000000000001041
Transplantation ■ January 2016 ■ Volume 100 ■ Number 1
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process of organ recovery, which
most often took place in suburban hospitals. The immediate solution was to
enhance my own surgical skills and learn en bloc nephrectomy and in situ renal
perfusion, which I did at Moffitt California University Hospital in San
Francisco in 1985 with Prof. Oscar Salvatierra's group. Following that, I went
on to perform that procedure myself for over 10 years for our academic
institution.
The inauguration of Hospital do Rim in
1998, with 151 beds, offered the opportunity to fully implement my initial idea
of creating a large scale healthcare model, detailed in previous publications
in Transplantation.1-3 The completion of the Hospital do Rim had
been based on the tireless efforts of many people, particularly members of the
nephrology division of the Federal University of São Paulo. The concept reduced
bureaucracy, facilitated patient access, integrated multidisciplinary efforts,
and reduced the burden of multiple referrals all with the goal of optimizing
the treatment of patients with end-stage renal disease. Moreover, the increased
volume also allowed for continuing improvement in outcomes and
interdisciplinary opportunities for basic and clinical research. I could
envision that many other areas in medicine might benefit from comparable health
care concepts.
Transplantation:
Who were individuals and mentors
who influenced your career?
JMP: Professor
Osvaldo Ramos, who was a pioneer in
nephrology,haddevelopedmedicalresidencyandpostgraduate programs in Brazil
during the 1960s. He was my mentor, a trusted friend, and an advisor starting
with my first year in medical school. I owe him my decision to become a
nephrologist and later to get into transplantation. An earlier opportunity to
specialize in clinical epidemiology had not appealed to me but Prof. Ramos was
a tireless, natural leader with a Latin temper, always involved in multiple
activities, trying to find novel solutions for a wide range of key issues.
Professor Peter Morris later guided my efforts in experimental rat kidney transplantation
during a fellowship in Oxford in 1989. Sir Peter emphasized a focused,
friendly, and warm leadership. Numerous leaders in transplantation benefitted
from his mentorship. More recently, in 2012, a meeting with Professor Joseph
Murray had been very moving, and I was fascinated by Dr. Murray's friendliness,
his positive approach, and his natural leadership qualities. At age 94, he
presented with an immense enthusiasm for teaching and for our field in general.
www.transplantjournal.com 7
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Throughout my career, I have had the
privilege to observe the creativity of many individuals that provided unique
approaches considered “outside
the box.” Among them, Artur Beltrame
Ribeiro, a full professor of nephrology who actively participated in national
political debates, opening my mind to politics, social, and economic matters.
Transplantation:
What were the best and worst
experiences in your career?
JMP:
The best experience occurred in 2014 when we celebrated 10 000 kidney
transplants over 16 years at Hospital do Rim.Over the years, we
successfullyincreasedtheproportion of deceased donor kidney transplants,
allowing us to reducethepercentageoflivingdonorsfromover70%whenwe started to
less than 25% currently. During this time, we participated in numerous
international multicenter trials and trained many transplant physicians across
the country. I am especially proud of have being elected fellow of the British
Royal College of Surgeons and to the Brazilian National Medical Academy. An
additional highlight had been my appointment to the sixth annual Joseph Murray
visiting ProfessorshipatBrigham and Women’s
Hospital, Harvard Medical School in Boston in 2012.
My worst experience was the sudden death
of a living donor subsequent to a massive pulmonary embolism; her kidney had
been successfully transplanted to her oldest son.
Transplantation:
Where do you expect the greatest
advancements in the field during the next years?
JMP:
Solid organ transplants will continue to be challengingin everyaspect.I
believe liver and lung transplantswill remain the gold standard therapy in
patients with end-stage failure and a short life expectancy. For other solid
organ transplants, however, I predict that effective alternatives may arise.
Considering pancreatic transplantation, for example, the evolution of improved
insulin replacement therapies and the use of closed-loop insulin delivery
systems4 might outgrow immunosuppression and procedural risks.
Regarding heart transplants, there is potential for radical innovations with
the development of the fully implantable
artificial hearts.5
Most patients
will continue to benefit from kidney transplants; however, I imagine that the
quality and efficiency of all dialysis modalities will improve at a rate faster
than transplant-related outcomes as technological advancements seem to be
implemented more straightforwardly compared with attempts to modify the complex
biology of the immune system. With this prediction in mind, the decision to
transplant with organs from either live or expanded criteria deceased donors
will become more difficult. I believe that living donor kidney transplantation
may become increasingly less acceptable, especially with young donors, when
theytakeaveragelifeexpectancyand increasinguncertainties of the long-term
kidney health into consideration. Limited transplant functions and chronic side
effects of immunosuppression will make this decision even more challenging.
I expect that clinical expertise will
foster an improved integrated application of currently available
immunosuppressants. At the same time, I am pessimistic about the
developmentofradicalinnovationsthatwouldleadtorobust and durable tolerance
protocols through the application of stem cells or in the areas of
xenotransplantation or organogenesis. I also do not expect major advancements
in molecular diagnostics for acute rejection replacing histology as the gold
standard.
Transplantation:
What have been greatest recent
discoveries in the transplantation in your opinion?
JMP: The growing
success of composite organ and tissue transplants and the development of new,
highly effective and safe oral treatments for hepatitis C have perhaps been the
greatest innovations during the last 10 years.
Transplantation:
What do you see as the greatest
challenges for transplantation in Brazil and South America?
JMP: Latin America, a region with 20 countries and 600 million inhabitants, has relative social stability and few major conflicts. Spanish is the dominant language on the entire continent with the exception of Brazil, which somehow hinders the country’s full integration. Achievements in transplantation have been higher than initially expected, considering the limited economic environment and access to health care. The first transplant in the region occurred in the mid 60s, only shortly after the initiation of transplant programs North America and prior to the first transplants in some European countries. Renal transplantation was eventually established as a routine procedure in most Latin American countries after 1980.6 Thefirstsegmentalliveliver
transplant was performed in 1988 by Silvano Raia,7 Professor of
surgery at São Paulo State University in Brazil. Interestingly, the progress of
these programs has never been curbed by any political regime in the region. It
was initially under military government regime that most transplant leaders
graduated and received public funding to complete their training abroad, mainly
in United States, France and England. Subsequently these newly created
transplant programs were consolidated during democratic regimes, now governing
in most of the 20 countries of the region. Currently more than 15 000 solid
organ transplants are performed annually, including more than 12 000 kidneys.
Transplant
legislation is well regulated, even in countries where health coverage is not
universal, with donation based on altruism, family solidarity, and strict
prohibition of any kind of commerce. There are no persistent systematic
irregularities in the transplant process in any of the countries in the region.
In addition, Brazil has a universal public health system that has been
continuously providing immunosuppressive drugs to more than 50 000 transplant
patients during the past 20 years. This public health system also covers over
110 000 patients on dialysis. Waiting lists for corneal transplants are very
short and paralleled by the growth solid organ transplants, a clear sign that
organ donation and its social benefits have been incorporated in this society's
culture. These results are largely due to the decisive influence and active
participation of the Brazilian Society for Organ Transplantation, engaged in
educational strategies to increase organ donation and coordinating the national
transplant registry.
© 2015 Wolters Kluwer Medina-Pestana 9
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Latin American countries frequently face
economic instabilities that are largely linked to management deficiencies and
variability in prices of commodities in the global
economy.Ensuringcontinuousresourcestosupportstableandrobust health care remains
thus a major challenge. Obvious goals in organ transplantation are a reduction
of currently high delayed graft function rates linked to inadequate hemodynamic
donor management in addition to geographic disparities in transplant rates.
Transplant volumes, for example, are more than 5 times higher in the Brazilian
South and Southeast compared to Central and Northern regions, figures that
parallel the economic strength of those regions, clearly demonstrating
geographic disparities to access.
Transplantation:
What opportunities do you see in
Brazil and South America for transplantation?
JMP:Latin America
has witnessed the largest growth inthe number of organ donors per million
inhabitants worldwide. During the past 12 years, donors have increased from 2
to 8 per million. A further increase in organ donation seems possible short
term and should therefore represent the preferable way to expand
transplantation. A sensitive approach and prudent supervision appears necessary
when considering an introduction of nonrelated donation, paired exchange
programs and donations after cardiac arrest. This cautious approach is
furthermore supported by potential failures, legal disputes, and public
controversies that may also impact the current growth in deceased (brain dead)
donor availability. Transparency but even more so prudence in utilizing all
availableresourcesappearnecessarytoavoidanyirregularity in organ allocation.
Transplantation:
Why should people aspire to a
career in the transplantation field?
JMP: Key will be an
enthusiastic mentorship by an expert who is driven by commitment and passion
for the field and for those who benefit from the art. Transplantation is so
fascinating, as the field is second to none in allowing us toliveour medical
vocation,theinvisibleforcethatmotivates us to develop innovation, achieving
expertise in an exciting multidisciplinary approach combining science and
clinical excellence to provide patients with a new lease on life. The
transplant specialist is “wedded” to the transplanted patient assuring the
best possible outcome while constantly exercising critical thinking. Although
we like to see all our decisions based on evidence or meta-analysis, each
patient is unique and many of our decisions are not purely evidence driven.
Transplantation:
What is your advice to young
clinicians and scientists going into transplantation
JMP:
Generosity and focus are vital. Nevertheless, the most important piece
of advice is to put yourself in the patient's shoes and consider whether you,
with your medical knowledge, would accept renal transplantation with all its
complexities over dialysis. It seems prudent to understand the dilemma of
accepting an organ from a living or a marginal donor.
For scientists, my modest suggestion is to be guided by
“the perseverance of a visionary.”
Transplantation:
What do you like to do most when
you are not working?
JMP: I like to watch
any kind of sports, preferably in the stadium rather than on television.
Besides soccer, the Brazilian national sport, I am one of the few Brazilians
who enjoy being in a ballpark watching baseball or following a football game.
In fact, in 2013 I had the opportunity to watch the Super Bowl between Denver
Broncos and Seattle Seahawks at Metlife Stadium. I regularly enjoy physical activities,
I take stairs and avoid elevators. When my physical condition started to limit
my ability to play soccer, I took up long-distance cycling and have completed a
few cycle routes including the Camino de Santiago.
REFERENCES
1. Medina-Pestana JO. Organization of a high-volume kidney transplant program—the “assembly line” approach. Transplantation. 2006;81: 1510–1520.
2.
Lorber MI. High-volume kidney
transplantation in a developing economy.Transplantation. 2006;81:1521–1522.
3.
Oniscu GC, Forsythe JL. The assembly line
approach in kidney transplantation—back to the future? Transplantation.
2006;81:1523–1524.
4.
Thabit H, Tauschmann M, Allen JM, et al.
Home use of an artificial beta cellin type 1 diabetes. N Engl J Med.
2015;373:2129–2140.
5.
Carpentier A, Latrémouille C, Cholley B,
et al. First clinical use of a bioprosthetic total artificial heart: report of
two cases. Lancet. 2015;386: 1556–1563.
6.
Medina-Pestana JO, Duro-Garcia V.
Strategies for establishing organ transplant programs in developing countries:
the Latin America and Caribbean experience. Artif Organs. 2006;30:498–500.
7.
Raia S, Nery JR, Mies S. Liver
transplantation from live donors. Lancet.
1989;2:497.
