The Transplantation Society: A Global Presence

What a pleasure it has been to gather together in Sydney for the XXII International Congress of The Transplantation Society (TTS). The Local Organizing Committee beautifully orchestrated a marvelous venue and superb social program. All those present strengthened bonds, initiated and cemented friendships, and reveled in new clinical and scientific information. Through the increasing global presence of the Society, we not only learned more about our own needs and problems but increasingly appreciated the achievements and difficulties of our colleagues from other regions and other cultures. Although prior TTS Congresses have been consistently successful, this may be the first where the true international influence of the Society was so obviously apparent. Most of us came across the vast Pacific Ocean to Australia in various states of comfort and discomfort on huge airplanes guided by sophisticated global positioning systems. Unerringly, they descended over Botany Bay to the airport. What a contrast to the original visitors to this region of the world who sailed for months over an endless sea, their ungainly galleons weakened by toredo worms and slowed by weed and barnacles. Although the navigators could determine latitude, longitude was so inaccurate that they were sometimes far distances from their expected location. Scurvy was rampant. Many died on the way. Since the 12th century, geographers had speculated that a southern land mass they called Terra Australis Incognita existed to balance continents in the Northern Hemisphere. Throughout much of the 17th and 18th centuries, Portuguese, French, Dutch, and British explorers followed favorable south-east trade winds and currents across the increasingly familiar diagonal trans-Pacific route to seek the treasures of the Indies (Fig. 1). On the way, they discovered New Zealand, Tasmania, New Guinea, and other lands, but kept missing Australia. Realizing a handful of ships that had been wrecked on the North West coast, The Lords of the Admiralty sent buccaneer-scientist-writer-navigator, William Dampier, to plant the British flag on the surface of the new land. He sailed on the Roebuck, put down a mutiny by an incompetent crew, and landed on the shores of the continent in 1688, but found it so uninviting that his unenthusiastic report extinguished existing official interest for nearly a century.FIGURE 1.: Representative trans-Pacific voyages of exploration before the discovery of Australia.Finally in 1770 and aided by a novel chronometer to assess longitude, Capt James Cook sighted the coast of Victoria in his ship, the Endeavor, and landed in Botany Bay (Fig. 2). On his way, he sailed by the entrance of what was to become Sydney Harbor but did not enter it, noting only that it “might provide safe anchorage.” From then on, however, increasing numbers of people arrived at one of the world’s great harbors to create one of the world’s great cities. This Congress has benefited substantially from their efforts.FIGURE 2.: The discovery of Australia by Captain James Cook, 1769–1770.There are striking similarities between the early adventurers who voyaged into the unknown and the visionaries who conceptualized the possibilities of organ transplantation, current investigators who pursue the ever-expanding mysteries, details, and control of the host responses, and clinicians who translate the findings into optimal patient care. Each has opened new vistas of knowledge. Each challenged and changed conventional thinking. Each has contributed mightily to the human experience. In 1966, a small group of interested clinicians and scientists founded TTS and elected Peter Medawar as President (Fig. 3). It is difficult to imagine that any of them could have predicted the influence and scope that their Society has attained nearly half a century later. Considered virtually impossible for centuries and against all accepted dogma at the time, the belief and hope of these pioneers that a diseased organ or tissue could be replaced with a healthy substitute, was based on sketchy scientific data and rare clinical clues.FIGURE 3.: Sir Peter Medawar, first President of The Transplantation Society.For instance, the overall world experience was collected in 1963, 3 years before the formation of TTS (1). Twenty-five participants from Europe and North America interested in the novel subject had gathered in Bethesda, MD to discuss the results. The numbers were bleak. Only 10% of the immunosuppressed recipients of the 216 kidney allografts survived over a year. The relatively few transplanted kidneys that sustained their hosts were exclusively from living sources; not a single kidney from a deceased donor functioned for more than a few weeks. In sharp contrast, 76% of recipients of organs from identical twins survived with functioning grafts. Despite these odds, the few convinced participants persevered. Azathioprine made its way from the laboratory to the bedside in the early 1960s. In combination with steroids, this agent remained the staple treatment until cyclosporin A became available 2 decades later. This fungal extract changed the face of transplantation, allowing not only consistently improved results in kidney allografts, but increasingly successful engraftment of liver, heart, lung, pancreas, and even small bowel. And, since the mid-1980s a plethora of additional effective agents have come into use, providing ever better results. Thanks to the clinical and scientific adventurers driving the field and their enduring spirit of inquiry, the advances that have occurred over subsequent decades have been so remarkable that transplantation has become routine and accepted treatment for many patents with end-stage organ failure. One critical reason for this success has been sustained research into the complexities of transplantation biology, much carried out by members of this Society. Medawar, one of the eight Nobel Prize winners belonging to TTS, set the tone for the new subject by extolling the limitless horizons of scientific inquiry, stressing the fallibility of prediction, and consistently endorsing the opinion of one of his heroes, the Renaissance essayist and philosopher, Sir Francis Bacon, that “experiments of use,” the insistent demands for practical application of laboratory findings, should never be allowed to transcend the “experiments of light” of pure science (2). Indeed, our field continues to benefit from the ability of our investigators to exploit the unexpected or serendipitous, to persist in the face of existing dogma, and to consider the unlikely as possible. For instance, who would have dreamed that the acceptance of skin grafts between nonidentical cattle twins would herald the applicability of immunological tolerance, that a drug used to kill cancer cells could allow the survival of genetically foreign tissue, and that composite grafts of a variety of tissues could function beautifully whereas skin grafts alone invariably fail. The Team More than 4400 delegates from many countries around the world who attended the XXII International Congress not only contributed to its remarkable success but also helped solidify TTS as the major global force in transplantation. With its mission of disseminating clinical and scientific knowledge, promoting education, and upholding standards of behavior, our Society has grown progressively in size and significance, thanks in large part to the efforts of a coterie of dedicated and interested individuals. The prescience and energy of the prior Presidents have been critical in sustaining its impetus. I feel extremely fortunate to have followed Kathryn Wood, a most imaginative and stimulating leader. My primary task has been to solidify and embellish the spectrum of ideas and activities that she and her predecessors put into motion. At the same time, the officers and councilors of the Society have worked beautifully together and provided much enthusiasm, support, and wisdom (Fig. 4).FIGURE 4.: Officers and Councilors of The Transplantation Society, 2006–2008.The International Headquarters in Montreal came into being 2 years ago. The transition to a free-standing TTS-owned and run organization was so smooth that it was hardly noticeable, thanks to the efforts of the committed and diligent staff: Filomena Picciano, Frank Lindo Verissime, Catherin Parker, and Mariko Nakanishi (Fig. 5). Through their efforts, TTS website is active and informative, the Tribune newsletter is interesting and current, and the daily complexities and demands of the Society and its Sections are addressed and answered in a timely and complete fashion. All of us owe them a great debt for their sustained excellence.FIGURE 5.: The staff of the International Headquarters of The Transplantation Society.A Director of Medical Affairs is also a new position. We have been particularly fortunate to have enjoyed the total dedication of a distinguished transplant surgeon and articulate proponent of our field, Francis Delmonico. His substantial and parallel efforts as Advisor for Human Transplantation of WHO, and as plenipotentiary of transplantation in general, have been crucial in the global activities, details, challenges, and influence of the Society. To further these initiatives he has traveled to an astonishing array of places and interacted with an astonishing number of individuals ranging between transplant professionals and heads of state (Fig. 6).FIGURE 6.: The Director of Medical Affairs, Dr. Francis Delmonico, and his global travels, 2006–2008.I must also recognize the support of our corporate sponsors. Their enduring enthusiasm for and generosity to the Society has allowed us to carry out many important aims (Fig. 7).FIGURE 7.: The Corporate Spon- sors.TTS Missions and Activities Among its other missions, TTS “provides global leadership.” Taking this mandate seriously during the past years, we have extended our visibility and representation into regions where we had hitherto paid inadequate attention. Aided by an important group of Country Liaisons from over the world, regional and national organizations are increasingly sharing interests and concerns with TTS. Collegial affiliations are providing a variety of mutual administrative, financial, and scientific benefits. TTS has had a strong presence during the past 2 years at conferences of Regional Societies and at meetings of the Sections of the Society. The novel series of new Key Opinion Leader meetings have been particularly successful (Fig. 8). A brainchild of Kathryn Wood, these small, closed gatherings has attractingly distinguished international speakers, principles from the local and regional areas, and most importantly, the presentations and contributions of their best young people. Lasting professional relationships, collaborations, and personal friendships have ensued. There have been 10 KOLS so far on several continents, with four scheduled for next year. They have become a hallmark of the Society.FIGURE 8.: Conferences of regional and national societies attended by TTS officers, Congresses of the Sections, and the new Key Opinion Leader meetings, 2006–2008.These growing activities are having a significant impact on membership. For instance, we have gained well over 400 new members since 2006, with more on the way. They are young, enthusiastic, and often from areas that had been previously underrepresented. They are our future. New Challenges The improved results of organ transplantation have been gratifying for individual patients and their doctors. Indeed, this is what we have all strived for throughout the entire experience. At the same time, however, these successes have generated new responsibilities and emerging and unforeseen problems. Cultural, regional, or national differences, conditions, and situations that many of us never appreciated or even conceived of have become important. Our expanding Society has tried hard to rise to the new challenges. During my time as President I have learned a great deal about what colleagues in developing countries face on a daily basis. They may have difficulties in obtaining basic supplies and acquiring expensive immunosuppressive drugs, may face inadequate laboratory backup, and must control a spectrum of infectious diseases. Lack of organized communication, poor roads, and even diverse regional dialects may create barriers between patients and caregivers. Yet these individuals produce results often comparable with the best available. Their achievements – indeed, the achievements of all of us in our various contexts – represent a triumph of human intellect, perseverance, and spirit. At the same time, however, we are all well aware that our advances have produced an ever-growing divergence between supply of organs and demand for them. Not only are desperate patients trying to survive in areas that often lack adequate resources to sustain them, but “transplant tourists” from rich countries travel to many regions throughout the world to buy organs that should rightly go to the local citizenry. Indeed, the WHO reckons that 10% of all organs in the world are transplanted as commercial transactions, practices that have allegedly grossed billions of dollars. Middle-men gain substantially from these activities. Some insurance companies (I regret to note that these are not infrequently from the West) encourage the practice to improve their “bottom line.” Some governments have cynically condoned organ sales as a ready source of national revenue. What happens to the donors is not considered by buyer or entrepreneur. “Host countries,” where thousands of organs have been bought and sold, are generally in the developing world where poverty is rife and local need is great (Fig. 9). The results are unacceptable: a recent follow-up study of donors from Pakistan is representative (3). Most of the paid donors were bonded laborers, little more than slaves and desperate to do anything to attain funds to buy their freedom. But 98% reported deterioration in their general health, whereas 88% reported no economic improvement after donation. The recurring theme of all such transactions is inevitable; the rich, the powerful and the connected exploit the poor, the underserved, and the helpless.FIGURE 9.: Some “host countries” for transplant tourists.This theme of exploitation has been of enduring ethical concern to our Society. Several of the original founders of TTS stated strongly within 5 years of its formation that “The sale of organs by donors living or dead is indefensible” (4). Other affirmations have emerged at intervals, including recent well-considered and powerful statements against such practices by the TTS Ethics Committee that are prominent on the website, and one published in April against organ trafficking that was signed by all living Past Presidents (5). TTS has been highly visible in speaking out against these practices, both alone and by joining important allies to work with health authorities in various “host countries” toward improved accountability and oversight of transplantation. We have been in an official NGO relationship with WHO for the past 2 years and are in increasing collaboration with International Society of Nephrology. Officials at the Vatican and authorities of the European Commission have become involved. As a result of these joint efforts, concerned surgeons in Pakistan, leaders of the Philippine Society of Nephrology, and committed advocates in China have pushed through laws forbidding or limiting organ trafficking. The recent Israel Transplantation Act makes transplant trafficking illegal. Additional countries and regions are seriously considering reforms. The results of such activities are unprecedented and a tribute to the hard work and perseverance of those involved. The activities of our Society in bringing some order and control into the commercialism affecting organ transplantation has been driven in large measure by the efforts of Francis Delmonico. A recent culmination of his labors and those of his colleagues was The Istanbul Summit on Transplant Tourism and Organ Trafficking. Under the umbrella of TTS and the International Society of Nephrology, over 150 transplant professionals, ethicists, lawyers, and health ministry representatives from 78 countries addressed this difficult subject. The group ratified a declaration coincident with the guiding principles of the WHO, prohibiting organ trafficking, and stressing that transplant commerce leads inexorably to social inequity and injustice (6). An extraordinary example of international cooperation, the results of this unique venture will have worldwide ramifications. Already, several important professional societies have endorsed its tenets. The declaration is currently being translated into Japanese. Other languages will follow. The Future What of the future of our growing Society? In addition to ongoing scientific and clinical education through congresses and the website, regional relationships and affiliations will broaden, membership will grow, and leadership will become more diverse and representative. Key Opinion Leader meetings and continued presence at national and regional congresses will increase the global profile of TTS. The Global Alliance in Transplantation, an affiliation of professional societies and corporate sponsors, will enhance standardization and dissemination of guidelines of care, will aid with data gathering and the formation of transplant registries, and ensure the continued pursuance of ethical principles. Many of these initiatives are already underway and others are in gestation. The Presidency Despite 2 years of apprenticeship, it is doubtful whether the incoming President of TTS can really know what to expect. Indeed, he or she arrives as a relative innocent in a diverse, complex, and increasingly visible international But the ongoing in collaboration with an active and available is a and experience. Through efforts, TTS is its as the organization of international transplantation. I would to all of – the membership – for the great have as President of TTS. I have many years in transplantation, both for patients and in the research In the international spirit of our Society, I have gained from many countries and enjoyed the of In the we were fortunate to host research from over the I that many of them have been successful in their subsequent and that many of them are I would also to my laboratory and for her and during these It has been an and experience. At the same time, I our next to the position. TTS is in

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