Dr. Klintmalm: I am Goran Klintmalm, I'm chief and chairman of the Annette C. and Harold C. Simmons Transplant Institute at Baylor University Medical Center in Dallas, Texas.
Dr. Verbesey: Hi, I'm Jennifer Verbesey, and I am the director of the living donor kidney transplant and pediatric program at the MedStar Georgetown Transplant Institute. And today, I have the pleasure of speaking with Dr. Klintmalm.
Good morning, Dr. Klintmalm.
Dr. Klintmalm: Good morning.
Dr. Verbesey: It’s great to speak with you, and I think that we’ll start at the beginning. I know that you didn't grow up here, that you grew up in Sweden. There's some rumors out there that you're actually a prince in Sweden; I don't know how that came about [laughs]. But maybe we could just start with where you transition from Sweden over to the United States and how that change happened.
Dr. Klintmalm: I was at the Karolinska Institute. I did my medical school there, and I also started my residency there. During my residency, I got very quickly involved in vascular surgery and did some significant studies on blood flow during hypovolemia. And the question came, what happens with the blood flow in a denervated kidney? So that was transplant.
Dr. Verbesey: Right.
Dr. Klintmalm: So, I got to transplant in January 1978. And transplant then, there were not very many programs, and the results worldwide were not very good. But I learned the basics for transplant and after a year and a half, in June 1979, I was closing a wound in the OR when I heard this overhead: “Dr. Klintmalm, there's a phone call from the United States at the front desk.” So I just threw the instruments at the nurse and said, “Close the wound,” and I ran out.
And on the other side of the phone was Dr. Carl Groth, who was the chief of transplant at the Karolinska, and he was at the ASTS meeting in Chicago at the Drake. Carl had trained with Tom Starzl and they were very close; he actually came back after his training to Denver for a couple of years as attending, and then he was called to the Karolinska to become chief of transplant.
But, at the Drake, Tom had said that “I'm looking for a fellow, now, July first,” three weeks later, and “Do you have anyone you would like to send over?” So Carl calls me up and said, “Well, Goran, have you heard about Tom Starzl?” and I said, “I heard the name.” “Well he needs a fellow here July first.” And I was thinking “three weeks from now?” I said, “Do I need to answer now?” Then Carl realizes that was a little bit too much to ask. “Well, I’ll call back tomorrow.”
So I got home in the evening. We were just moving into a new apartment in downtown Stockholm, Tina and I. Tina and I, we were not married. We lived in sin and enjoyed it. And I said, “Tina, come down, sit down,” and then in the sitting room I looked at her and I said, “You have no idea what happened today.”
Tina just looks at me. “We are going to United States.” So, I ended up in Denver August first—not July first, but August first—and Tina came a month later. So that's how I ended up in Denver and with Tom Starzl and learned about livers. It was a wild ride, and when you work with Tom, you even begin to breathe at his respiration rate.
And we became very, very close. So I came in August and essentially at Thanksgiving, the week after Thanksgiving, we had a visit in Denver by David Winter, who was the medical director of Sandoz Corporation. Sandoz is now called Novartis, but one of their co-workers discovered cyclosporine. The first cyclosporine trials were published by Roy Calne, the first one in April of ‘79, the second paper came out in The Lancet in November of ‘79.
So we had just read that, and Tom had been chosen as one of the three institutions in the country, in the United States, to receive cyclosporine. So we had a lunch meeting with David Winter in Denver, and we sat down at the table and had some very simple lunch and talked about cyclosporine. And here was Tom Starzl and there was me, very junior, and then there was David Winter. And at the end of the discussion, David Winter pulled out a tin can and then opened it up, and there was a plastic bag in it that was full of white powder. And he said, “Here’s cyclosporine; take it and use it” and put the lid back on. And that was the end of the meeting. Had that happened today, we would be in jail, probably for life.
But that's how I started out. Three weeks later, we did the first kidney transplant with cyclosporine. We had done probably five kidneys at that time and every one of them rejected after five to seven days. We could treat the rejection with steroids, and Tom Starzl was really the father of the use of steroids in treatment of rejection. And we were coming down from the fifth floor at the VA where we had a VA transplant patient and going down the elevator, and it was just he and I. This is what I have dubbed the elevator conference, and I’ve talked about that at times.
And I honestly don't recall who said what, but this was a very quick dialogue. And the first comment was: “Well, every patient has rejection.” After Roy Calne’s instruction, only cyclosporine, no other drug at all. And well, maybe you should give steroids to prevent rejection like was done with the azathioprine protocol. Let's start at two hundred. Yeah, but we don't need to do the old taper, the 200, 190, 190, 180, 180 coming down to 30 by 30 days.
Now let's get down to 20 in a week. So okay, let's do 200, 160, 120, 80, 40, 30, and then 20 in day seven. Okay, let's do the next case. That was IRB and all of it at right there, FDA and the whole nine yards. And the success was incredible and it was electrifying; nothing was impossible, only more or less difficult. And as we ran across something, we changed as a result. Tom never did the liver transplant the same way twice in a row, never, and he never explained anything, what he did and why he did it. Honestly if you didn't figure that out, you ended up in the dog lab for the rest of your tenure.
Dr. Verbesey: I know at that point things got much better, but whenever I hear you talking about the time before that, how did you guys survive? How did you keep going when things were going so poorly at first? Because nowadays, I’m not sure if people would push through such poor results and keep going. How did you guys deal with that and persist and move on?
Dr. Klintmalm: Well that is all thanks to people like Tom Starzl and John Najarian and Clyde Barker, the very first generation. They had a vision; they had a belief. They could see over the horizon where other people couldn't, and the opposition from other specialties, anesthesiologist, nephrologist, etc., were profound. That they had the ability to continue in spite of that is amazing.
But also the society in those days allowed people with a vision to follow their vision. Today we are not allowed to do that. Today everything has to be protocolized and controlled, and if you don't get the result you hope to get, you're going to be closed down. They figured out how to do it; as I said, every case was done differently. You did your surgeries, you followed the patient. In the cyclosporine patients, we made rounds, Tom and I, virtually every four hours. We went to every single kidney patient recipient, looked at how much urine, measured it, we took temperatures, and we pampered the kidney.
There's a figure in SG&O that I created for one of the papers that shows how after four or five days, the temperature goes up, the urine output goes down. The kidney becomes tender. It's even shown in the figure. We saw that, we diagnosed rejection, the inflammation that caused the tenderness and the fever, etc. We gave the steroids and the urine output came back up, the temperature fell immediately. The tenderness disappeared. So we did this every four hours. Tom just said, “Okay, let's go,” and then we just walked away, just the two of us. And he trusted. I was so junior, so young, and he trusted me and he gave me the reins. In those days, it was not about how many years you were into it. If you showed that you could do it, you got more reins, and they gave you more reins until you show that this is your limit.
When I came to Denver, I had a year and a half in the only kidney transplant service in Stockholm. I was already doing kidney transplants independently without any attending. And Tom knew that. I believe this is true: I was the first fellow ever in the history of Denver who was actually authorized to completely independently do kidney transplant.
Dr. Verbesey: You were doing that as a resident?
Dr. Klintmalm: I was a resident, and that's a fellow with Tom Starzl. Well, my first liver, Tom and I were walking into the operating room side-by-side and Tom just speaks. Without looking at me, he says, “Goran, do you want to do this liver?” And I said, “Yes, I do.” “Okay,” he said, and just turns around and walks out. Walks out, leaves the room. That was my first liver; that's the way it worked. I mean, he assessed that you were ready for it, and then it was up to you to show that you were.
Dr. Verbesey: I read once that he wasn't a very good assistant, right?
Dr. Klintmalm: No, he was not.
Dr. Verbesey: We talked a lot about doing the recipient, but you guys must have been figuring out how to do the donor side as well, right?
Dr. Klintmalm: Yes. In Denver, there was no organ bank; it didn't exist. There was an organ bank in Dallas, actually, that was created in 1972 by Alan Hull. But otherwise when there was a patient who became seriously ill or brain dead, how it worked was that surgeons called up Tom and said, “We have this; are you interested?”
So it was finding out and trying to accommodate and the technique, how to do this. The first author was Bud Shaw who wrote up how to do this multi-organ procurement. Yeah, it was a trial and error.
Dr. Verbesey: And then you moved together from Denver to Pittsburgh.
Dr. Klintmalm: Yeah, that was a big move. Tina and I loaded up our car and a U-Haul and started driving across the prairie in the opposite direction from the immigrants in the 1850s; we drove east. Pittsburgh was very cold and very snowy and very icy, and Pittsburgh was in very deep recession. All the Pittsburgh steel facilities had closed down, except one.
The unemployment was probably twenty to twenty-five percent. It was dirty, unkept. The rails on the bridges had sometimes fallen off because they had been rusting through and no one kept them. Tom came, we did the first cases, the whole world press was at the doorstep, and Tom pulled me in to sit next to him at the press conferences. It was unreal.
And it is what revitalized Pittsburgh. Two years later he threw out the opening ball at the ballpark, and he gave Pittsburgh back its soul, its pride. It was amazing, absolutely amazing.
When we moved to Pittsburgh in January 1981, when we started out, they were serious in Pittsburgh. We had four deaths for the first four livers, and the reason was that Tom was trying to make the donor operation to accommodate the way that the local kidney team wanted to get it done. And they didn't know. So after those deaths, Tom changed completely how donors were done, more or less the way we had done it in Denver. And that is how we do multiple organ donors today, almost identical.
Dr. Verbesey: And then didn't you go back to Sweden?
Dr. Klintmalm: Yeah, I went back in August of 1981. At that time, I kind of felt I would like to see if I could have a respiration rate independent of Tom Starzl. So I went back and then I helped get cyclosporine started in Scandinavian countries, and we did a trial for cyclosporine, and I did my PhD at the Karolinska, I got that done. I changed my focus from blood flow regulations in vivo to cyclosporine, which was kind of an easy transition.
And then we had Tom come as a visiting professor to the Swedish Surgical Society. It was in November 1983, and he sat down with Tina in our apartment, and I didn't know about this. And he said, “Tina, would you mind moving back to the United States?” I mean, Tom knew who's deciding all those things in a family; it's not the husband, it’s the wife. And she said yes. He had actually just before been giving a talk at Baylor in Dallas, and the chief of medicine, the famous Dr. John Fordtran, said, “We want to start a liver transplant program here.”
So in the last week of January 1984, I got home about 10 o'clock and I got this phone call at home; there were no cell phones. And I answered it and I just hear this voice: “Goran, have you heard about Baylor?” And when you work with Tom Starzl, even if you're in a coma, when you hear the voice you just wake up, and that's what you did. And I said, “Yeah, I heard the name.” I had no idea what Baylor University Medical Center was.
So, three weeks later Tina and I were site visiting in Dallas. We came, and the whole staff, the whole surgical and medical staff, stood essentially lined up. And here I was, 34 years old, and they want me to come. We had a handshake, didn't even have a contract, and on that handshake I decided to move—we were married then and had a son—move my family over to Dallas.
Dr. Verbesey: So, why was Baylor prepared to take on this challenge? Had liver transplant changed to the point where they were pretty confident in its success?
Dr. Klintmalm: The Baylor transplant program, I was lucky that there was no program there before I came. I had no one to tell me what to do and not to do, and actually instead the medical and surgical and administrative leadership really trusted me. I was, as I said, 34 when I came and was young; I didn't have any training in administration, an MBA or anything else. I reported only to the two chairs, medicine and surgery, and the CEO. And I developed a program the way it seemed logical to me.
It was integrated from the beginning. Multidisciplinary rounds to me is a nonsense term; I've done that my entire life. And for example, post-surgical medical involvement was not GI because GI didn't know much about ICU care. We did our own ICU care; we didn't have an intensivist. Instead, I chose transplant nephrologists because that's ICU, and the biggest problem we had post-liver, at least in those days, was the kidney function.
So everything was done in a very logical way. I hand-picked anyone in any specialty that I needed to have as consultation, like cardiology, like pulmonology. I hand-picked them from that entire department. So it almost organically grew into an institute-type model, and when we needed to do something or change something, we just pulled in the people that would be directly involved, and we always came to an agreement about how to get things done from the beginning.
And everything was protocolized from the day one, the immunosuppression, etc. Everything was protocolized. I very quickly got my own administration. After 10 years I had my transplant VP and I didn't report to the VP at all. She reported to me, and I reported to the CEO and the chair of surgery and medicine, but never about anything that was directly about individual issues or etc. They trusted me. They just wanted to know what's going on.
Dr. Verbesey: And did you model yourself after Pittsburgh?
Dr. Klintmalm: No.
Dr. Verbesey: You learned their ways and wanted to do differently.
Dr. Klintmalm: It was very different. Actually it was much more modeled after Carl Groth and how the transplant service in Stockholm was organized. We had our coordinators in Stockholm, we had multidisciplinary rounds from the moment I came there. From the beginning, we always worked it that way.
Dr. Klintmalm: So, ASTS has been a center of my professional life my entire life. It was at the ASTS meeting that Tom asked Carl Groth if Carl had someone to send to him. So I was sent off. Anyway, as I said, we started doing the cyclosporine at Christmas of 1984, and then in May of 1985, we had the ASTS meeting at the Drake and that was my first visit with the ASTS.
And it was phenomenal. John Najarian and Tom, of course, they were always nagging and sort of pulling each other's leg and trying to always have one up on the other one all the time. Tom talked about cyclosporine and everything else.
And I met with everybody, and we had the dinner that evening at Fred Merkel's house on the lakeshore. That was my introduction to ASTS in the 1980s. When I came back to the United States and came to Dallas, we produced lots of material, lots of new data about how to do the surgery, how to use cyclosporine, all these things. We were very active. So I was engaged. Virtually every year we gave presentations, initially at the Drake and then we moved in Chicago.
And I got involved in committee work in the late 1990s. I always have been very much involved in UNOS from the very beginning since 1987, but I got involved, got into committees, and then I was elected treasurer of ASTS. One of my legacies actually as ASTS treasurer: I could foresee that the Golden Age that we had in those days, where the pharmaceuticals were so focused on the development of immunosuppression and everything else, would one day disappear.
So I made a proposal putting a goal for ASTS to get a Foundation of 20 million dollars. And why 20 million dollars? Because just a rule of thumb, that would essentially give us a million dollars a year to use to support the meetings we had and everything else, the infrastructure of ASTS. And that was passed by the Council, and that's where we are today; we essentially reached that goal. So that's something I'm actually quite proud of.
And then I was made president-elect. At that time there were a lot of difficulties for ASTS. Previously, if you were not a surgeon, you could not become a member of ASTS. And in the 1980s, we had this explosion of super specialists with the sincere interest in transplantation who were not surgeons: GI, hepatology, nephrology, immunology, you name it.
So finally they got angry and formed their own society, AST.
Then I became president of ASTS in 2007, and I gave each and every committee tasks, and they were to produce the results by the fall meeting in September.
I didn't wait for September to come out with it, I made it from day one. I actually even tasked the Bylaws Committee to change the bylaws between the Friday of the meeting and a society membership meeting on Tuesday. And what I did was I increased the number of board members from six to nine, and I think that was a big step.
Dr. Verbesey: What was your goal? What were you looking for ASTS to do?
Dr. Klintmalm: I wanted to rebuild ASTS pride. Be proud you're a transplant surgeon! And I wanted us to take initiatives. I kind of took the initiative to make ASTS become not just an academic backbone for transplant surgeons, but also a professional. So I created the Business Practice Committee because I knew it was fundamentally important.
I am an amateur historian, and I was very aware that we are growing up. Some of the forerunners of transplant, the true pioneers, they were retiring from their clinical practices. So I wanted to create a history bank within ASTS, and this Chronicle is actually a result of that. And I had Tom Peters appointed our official historian. With my history background, I think this is immensely important. Unfortunately, most of the youngsters coming out today don't really know much about the history.
So this was major. I have to say the single most enjoyable thing I did as a president was something a little bit different. This was at the Council meeting, I think it was at the Winter Symposium Council meeting. I had, behind everybody's back, been working with Kim and others at the ASTS office creating the chimera pin. So when everybody came into the Council meeting, at each seat there was a box, and I said, “Please open this up.” And that was the chimera pin. Actually that was the single thing that I enjoyed the most of my presidency, to create this pin. And it was sort of to create this pride.
Dr. Verbesey: Right.
Dr. Klintmalm: Get the pride. And people to this day are sporting the chimera pin.
Dr. Verbesey So, it's been about 10 years. Are you happy with the way things changed after that?
Dr. Klintmalm: I think what I was able to bring to ASTS, what I could add, be that the Foundation funds for maintenance of our finances, be that increase in the council by 50 percent—that was huge. Overnight, we elected the nine-member board immediately following that, maybe five days later. We had new bylaws in five days.
And then these functional committees, like we said, I think maybe the most important being the Business Practice Committee. What we did then with the business practice, the Leadership Development Program at Kellogg, etc., all came out of that. I think these have been fundamentally important developments for our Society.
And I think it benefits virtually everyone, not just the fellows, but also the attendings. We were always seen as the experts on the Hill in DC as far as transplant surgery, but we got ourselves involved as direct representatives in discussions with CMS or HRSA or whatever. That was because we took a much more aggressive attitude as far as representation on the Hill.
It became something that I wanted to see as routine even if there was nothing on the docket. The point is you have to have presence all the time for the people on the Hill to know our representatives, so they can actually communicate at times when needed. And those are fundamentals in how to run this.
When everything is said and done, I like so many others feel there's nothing more important than family. I would never have been able to be where I'm at today without Tina, my wife. No way. I could be gone for days and Tina took care of my three sons and everything that happened. Sometimes I left from vacation. And I was called to come down emergently to Dallas. It's fundamentally important.
We are very tight to this day; my sons are 30, 32, and 35. We spend every Christmas and New Year's together. We make a trip somewhere in the world together, be that South Africa for a hunting safari or be that to go up to Triple Creek Ranch in Montana for horseback riding and cattle driving. We love that. I'm a passionate hunter, big game, and birds.
We are skiers, we are travelers, we’re historians. My sons and I, we go out and hunt. I started doing that with the boys when they were 10, 12 years of age, and there was a different thinking in those days. We didn't have any guns at home at that time. I was a hunter in Sweden, but I didn't have anything at home. But I thought that the boys are out seeing their friends and there are houses with guns around; I knew that.
So, I wanted them to know exactly how to handle guns. They shouldn't be curious, they should know how to do and what not to do and be very safe. And then from that, I started to take them out for hunting.
And so hunting has been a great way for someone like me to have private time with my children. And we have done that a lot. And at the same time we can go and they enjoy St. Petersburg and look at the art. We do a lot of traveling together. We are very close, and that's probably the thing I'm more grateful for than anything else in my life: the closeness of my family and all the things we have done together.