AJT 2001: the Genesis

From ancient times, health providers have dreamed of curing illness by replacing diseased tissues with healthy tissues from another person or animal. Witness the legend of twin brothers Cosmas and Damian, physicians in Syria in the fourth century who miraculously transplanted a leg. The success of transplantation in the 20th century represents a major achievement in science and medicine, and partial fulfillment of that ancient dream. In the process, the lessons we have learned have had many implications for other areas of science and medicine. Nevertheless, our field remains a work in progress, and the American Journal of Transplantation (AJT) is launched as an agent for that progress. In the evolution of a discipline, there comes a time at which the community is sufficiently large and complex to warrant a journal that it owns and controls. The community appoints the editorial board, gives them total autonomy, and requires them to be accountable. Profits from the activities of the journal contribute to the good works of the community. From this point of view the AST and ASTS have determined that the time is opportune to create a new journal for the international transplantation community, controlled by two of the major organizations in that community. This is a natural outgrowth of the annual joint AST–ASTS meeting, which is the main annual international meeting in transplantation. Given the rapid changes in communication technology, is a new print journal the right option for sharing ideas? Perhaps “on-line communities” should replace print journals (1Butler D Is your journal really necessary? Science may best prosper if print journals are replaced by online communities.Nature. 2000; 407 (DOI: 10.1038/35030209): 291Crossref Google Scholar). But the principal vehicles for transmission of information in most fields remain the online + paper journal. In this sense, I believe that the format we have selected for AJT will capture the benefits of the on-line community concept. Readers will be pleased with the extent to which AJT and its publisher will implement the state of the art in on-line technology. Moreover, the paper journal retains some advantages in portability, durability, accessibility, and as an organized archive that argue for its retention. The editors, on behalf of the societies, will produce AJT as an international journal for research in transplantation and the related disciplines. AJT should also be a catalyst for change, provoking debate, challenging dogmas, and developing new consensus. The publication priorities of AJT will be: 1Reports of original research in basic science, clinical studies, population analysis, or original analysis of an issue in health care delivery or public policy.2Critical reviews.3Contemporary updates in an area (“what”s new, what's hot').4Debates, controversies, and opinions.5Consensus documents in specific areas of transplantation, including clinical practice guidelines.6Commentary on the philosophical, ethical, or social aspects of transplantation.7Meeting reports that have been discussed previously with the editors.8Case reports with discussions. AJT is not a proceedings journal or a bulletin to promote society activities. Many activities of the societies will be reflected instead in the other publications and bulletins (e.g. the Chimera), and home pages of the journal (http://journals.munksgaard.dk/ajt) and the societies (http://www.a-s-t.org, http://www.asts.org/). At least initially, the editors have elected not to publish meeting supplements. Most authors are reticent to put new good work into a supplement where it tends to be poorly cited. Our solution is to publish peer-reviewed meeting reports, provided that the meeting organizers consult with the editors in advance. Many important goals of AJT will be achieved through development of the AJT home page. That page will eventually be home to transplantation classics, reference material that cannot be accommodated in the journal, an atlas of pathology images, the central repository of consensus process for transplant pathology (the Banff process), and other features. The development of the home page will help to increase the role of AJT as a reference for the transplantation community. The “American” adjective in the AJT reflects the fact that the journal is the offspring of the American societies, and implies no limitation in scope. This is an international journal, as shown by our distinguished editorial board and our international contributors (from France, Switzerland, Spain, Italy, Sweden, Canada, and the United States in the present issue). The readers are reminded that over 40% of the abstracts submitted to the annual meeting of the American societies are now from outside the USA, and AJT will reflect that dynamic community of world leaders in transplantation. The current editorial board has accepted their responsibilities for a defined period. As Editor-in-Chief, I was appointed for five years on the basis of an open competition. An open competition will follow at the end of my term. The rest of the editorial board has a similar expectation. This accomplishes two objectives: it opens the possibility of editorial experience to anyone in the field, and it limits the effects of the editors' biases on the direction of the field. The perks of being Editor-in-Chief are few, but one is the expression of opinions. There are some trends that I would like to see in our field and in AJT, my “top 10” list. 1Identification of the molecular mechanisms of graft injury in acute rejection in humans and the mechanisms of graft – host adaptation that permit transplant success on immunosuppression.2Robust clinical assays of recipient antidonor immunity (humoral and cellular) that would distinguish between rejection and immunologic stability in the individual patient.3The increased use of pathology in experimental transplantation. The new generation of immunosuppressive agents has been developed because of the emergence of standardized pathology end-points for acute rejection in the early 1990s, replacing end-points based on survival. Yet many experimental animal studies fail to describe the pathology of the organs. Perhaps we need a new “animal Banff” process.4Increased exploration of the cell biology of transplanted tissue, in addition to immunology. This does not diminish the importance of immunology: it adds cell biology to our scientific underpinnings. We transplant somatic cells and tissues with their own rules of survival and response to injury. The behavior of the transplanted tissue should have equal standing with the lymphocyte at the center of transplantation science. For example, Paul Terasaki has written “the greatest adverse impact factor in cadaver kidney transplants today is donor age”(2Terasaki PI Cecka JM Gjertson DW Impact analysis: a method for evaluating the impact of factors in clinical renal transplantation.in: Cecka JM Terasaki PI Clinical Transplants 1998. UCLA Tissue Typing Laboratory, Los Angeles, USA1998: 437-441Google Scholar). Then the cell biology of aging is now important. The same must be said for pharmacology of transplant drugs, which has not always been served well by the existing journals. As we progress in controlling the immune response we will increasingly face other barriers to success, and AJT welcomes excellent research in all transplant-related sciences.5Novel designs and end-points for clinical trials, with attention to the new guidelines in the WMA Declaration of Helsinki (http://www.wma.net/e/policy/17-c_e.html). For example, article 29 states: “The benefits, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic, and therapeutic methods.” Those proposing tolerance studies and trials of new immunosuppressive agents must adhere to this principle. If acute rejection is important enough to be the primary end-point of your trial, the control group should receive the best currently available methods for preventing acute rejection. In practical terms this means that we need new end-points.6More investigator-driven large-scale trials. Commercial interests are probably not going to coincide with the most important questions, and cannot be allowed to co-opt all the most talented investigators and limit the available trial populations.7Increased research in organ donation, organ preservation, and tissue injury.8Incisive new population analyses, to examine the determinants of success and evolve accurate descriptions of the course of transplants.9Clean language. This means rigorous definitions. When is chronic graft deterioration due to an ongoing immune process as embodied in the original concept of chronic rejection? How should we refer to those grafts with deteriorating function that fail to meet these criteria? If a patient has been on an immunosuppressive then discontinues this agent, when if ever is it appropriate to use the term tolerance? Can the patient be defined as tolerant if the graft shows infiltration and parenchymal invasion, or circulating anti donor antibody? If the patient has been off immunosuppressive drugs for 6 months with no rejection on Tuesday, but presents with rejection on Friday, was the patient tolerant on Tuesday? Dr Hugh Auchincloss takes on some of these questions in the minireview in this issue.10Disciplined English writing. Writing does not come easily to most of us. As one who struggles with this difficult art, I pay homage to the principles of George Orwell, outlined in his 1946 essay “Politics and the English language”:“1Never use a metaphor, simile, or other figure of speech which you are used to seeing in print.2Never use a long word where a short one will do.3If it is possible to cut a word out, always cut it out.4Never use the passive where you can use the active.5Never use a foreign phrase, a scientific word, or a jargon word if you can think of an everyday English equivalent.” The editors will be watching for simple, lucid English. Perhaps our model should be classics like the elegant understatement with which Watson and Crick (3Watson JD Crick FHC. Molecular structure of nucleic acids. A structure for deoxyribose nucleic acid.Nature. 1953; 171: 737-738Crossref PubMed Scopus (8424) Google Scholar) introduced the first description of the double helix: “This structure has novel features which are of considerable biological interest.” Note the absence of superlatives. And avoid the word “clearly”: I use it as a guide to the weakest part of the writer's argument. If the data are clear, you do not need to say “clearly”. If it is not, “clearly” cannot save you. The launch of a new journal reflects the efforts of many people. I would like to acknowledge the efforts of all of the editors and associate editors; the ASTS and AST leaders and administrators who spent many hours on this project; Peter Hartmann and his team at Munksgaard; Virginia Halloran for helping to prepare the referee databases; and above all the Editorial Office Manager, Pam Publicover, who did more than anyone to overcome obstacles for the launch of AJT. We are privileged to work in one of the most exciting areas of health care, where we enjoy both the opportunity to contribute to advances in basic science and the mandate to extend those developments to the treatment of human disease. Vexing, but interesting, social and ethical problems challenge us every day. The power of new genomic and proteomic approaches has opened new research opportunities. These pages will reflect that ferment. So, with incantations to Cosmas and Damien, Watson and Crick, and Orwell, we boldly launch AJT into this new millennium.

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