Drs. Johnson and Richie

In their own words:

Dr. Keith Johnson: Initially and always, it was appreciated that the best treatment for chronic renal failure was transplantation, so from the outset of the establishment of DCI, funds that were earned that might be in excess of what was needed to provide care for the patients were recycled back into helping patients who couldn’t pay for their dialysis and to support the transplant effort.

Dr. Bob Richie: You know…an old adage in surgery: “The enemy of good is perfect.” Anytime you try to make something good, perfect, you may run into trouble. It seems to me that’s what we are trying to do with some…programs is to have a perfect outcome. There are times when I think patients would be satisfied with a good outcome…. I think they might offer it to more patients and have a lot of people out there doing pretty well….

Biography:

H. Keith Johnson, MD, trained in nephrology at Vanderbilt University, thereafter staying on the faculty where he became an early American transplant nephrologist. He founded Dialysis Clinic, Inc., the largest not-for-profit dialysis provider in the U.S. in 1971, and has led DCI in broad endeavors of organ and tissue recovery, histocompatibility, and research. He has served numerous organizations, including UNOS, as president or trustee.

Robert Richie, MD, graduated from the Vanderbilt School of Medicine in 1959, and continued there to train in general, vascular, and thoracic surgery, joining the full-time faculty in 1970 after serving in the U.S. Air Force. After early efforts at Vanderbilt, Dr. Riche developed the kidney transplant program and led its transplant division for three decades. His numerous academic pursuits centered on transplant outcomes related to surgical interventions, histocompatibility, and immunosuppression.

Transcript:

Dr. Johnson: I’m Keith Johnson. I’m a transplant nephrologist, and I practiced at Vanderbilt Hospital from 1969 through 1999. For 30 years I worked with the transplant program there, working in conjunction as the transplant nephrologist.

Dr. Richie: I’m Bob Richie. I was on the full-time faculty at Vanderbilt from 1970 til 2000. I started out being Chief of Surgery at the VA and then subsequently took the job of Chief of the Transplant Section in 1976. I was there for those 30 years, and at end of 2000 I retired and am now Professor of Surgery Emeritus at Vanderbilt.

Dr. Peters: Bob, tell us about your earliest recollections of the American Society of Transplant Surgeons.

Dr. Richie: My recollection of the American Society of Transplant Surgeons goes back to the American College of Surgeons meeting at Miami Beach in 1974, at which time I think it was Dr. Fred Merkel of Chicago who called all of us together and we had a meeting at the Eden Roc Hotel. As I recall it was then we talked about the nuts and bolts of getting the association started. We elected Dr. Tom Starzl as our first president at that meeting. After that we moved to Chicago to the Drake Hotel and met there for many years, until we outgrew its size and had to go to the larger hotels in Chicago.

Dr. Peters: Dr. Johnson, please comment on some of the early triumphs and tragedies of kidney transplantation you were involved with.

Dr. Johnson: The earliest triumphs I think of in transplantation that both of us were involved with was the experience of transforming an individual’s life from a patient on dialysis to one with a successful transplant and observing the tremendous impact in this patient’s life and the family that occurred within days after the transplant had been accomplished. To my mind that has always and continues to be the most significant triumph of the discipline of kidney transplantation.

Perhaps the tragedy of transplantation is that such an opportunity has not been offered to a larger segment of patients on dialysis through the years, and that even after 30 plus years, we still find ourselves with a shortfall between the supply of organs for these patients and their needs.

Dr. Peters: Dr. Richie, you were a transplant surgeon, eventually, at two hospitals in Nashville. Please tell about the early days of transplantation at the VA and Vanderbilt Hospitals.

Dr. Richie: As I remember the early days, Dr. Charlie Zukoski had just done his fellowship at Dr. David Hume’s program at the Medical College of Virginia, and he was recruited by Dr. William Scott as faculty for the VA hospital. Of course, there was no funding for transplants at that time, and Charlie did the second kidney transplant at the VA hospital. I think that was when I was a 4th year resident, so that was 1963. Of course, this fellow had all kinds of complications. I remember telling Charlie, very succinctly, that this will never work. It won’t work. That was sort of the beginning. Charlie then went to North Carolina and joined the faculty there.

During the interval from 1965 to 1970, several of the full-time surgical faculty did the kidney transplants, and then I think it was in 1969, Dr. Scott recruited John Ackerman to do the transplants full time, but within a year or two, John had also moved.

I went into the Air Force and came back in 1970 as a full-time faculty and was doing vascular surgery and non-cardiac chest work. Dr. Scott called me in and said, “We need somebody to do the transplants until I can hire somebody.” I said ok. So I started doing them. I think in the first year I did probably 55. He kept looking and the second year I did another 56 or 57. The third year almost 60.

Finally in 1976, Dr. Scott said, “I’ve been trying to recruit a transplant surgeon for 5 years. I can’t recruit one.” But he said (I was Chief of Surgery at the VA at the time), “I can recruit a Chief of Surgery at the VA. I’d like for you to take the job as the Chief of Transplant.” That along with some prodding by Dr. Johnson—who had worked with me for 3 or 4 years, he put in a good word—that’s how I got to be appointed to be the Chief of the Renal Transplant Division.

Dr. Peters: So at that time, as the program in Nashville evolved, were you both working at both hospitals?

Dr. Johnson: Yes, at the time the program initiated and evolved, both of us had positions at the VA Hospital and at Vanderbilt. The VA hospital was, and I guess still is, called a Dean’s List Hospital, so as an academic physician with an appointment at Vanderbilt, we had part-time appointments at the VA.

Dr. Peters: Dr. Richie, this is one of the few VA’s in America that has continued to do organ transplantations. How has the VA been able to maintain a stable transplant service in Nashville and continue with that work?

Dr. Richie: I think we were always interested in doing that. Dr. Johnson and I thought it was important to have a place for veterans to be transplanted. When Dr. Wright Pinson came in the 90s, the VA started doing liver transplants, and he did most of the liver transplants in the entire VA system. That helped us to maintain our high profile in the VA, as far as transplantation was concerned. The VA also had a large bone marrow transplant effort, and they amalgamated all these aspects into a transplant center of which I agreed to be the director and continued in that capacity til I retired in 2000.

Dr. Peters: Let’s chat about dialysis and the development of DCI, how DCI intertwined with Vanderbilt and other institutions, and also how DCI got into organ procurement and organ donation.

Dr. Johnson: Dialysis Clinic Incorporated or DCI was set up initially in 1971. First dialysis was in May of that year. The reason for its establishment was because at the time there were no facilities to provide dialysis for patients in Middle Tennessee, except for the facility at the VA Hospital. So if you were not a veteran, the only other place to dialyze was a 3-bed acute unit at Vanderbilt Hospital. So clearly that was inadequate to meet the need. So a group of us decided that we would try to set up an out-of-hospital dialysis facility which could be run more efficiently at lower cost, much in the way the facility was being run out at the Northwest Kidney Center in Seattle, which was the model we followed.

Initially and always, it was appreciated that the best treatment for chronic renal failure was transplantation, so from the outset of the establishment of DCI, funds that were earned that might be in excess of what was needed to provide care for the patients were recycled back into helping patients who couldn’t pay for their dialysis and to support the transplant effort.

When DCI was first established, we had a problem. The problem was money. We wanted to set up a program. We thought at a time when people were mortgaging their homes to stay alive, to set up a dialysis organization that was for profit was philosophically and ethically inappropriate. So we all decided a not-for-profit approach to dialysis was appropriate, but to say that and then to try find funds was a different story. I was on a Christmas vacation with my Dad. The whole family was there. I took a walk on the beach with Pop. I explained to him the problem. He said, “Well, why don’t you do it?” I said we don’t have any finances to do this. He said he would stake us up to $100,000 to start the dialysis unit.

Fortunately, DCI started only requiring only $17,000 of that amount, due to the extraordinary, careful nature of our first administrator, John Grisham, an attorney in town. He helped us very greatly in the establishment of the organization. So that was his involvement and it was obviously critical that he was willing to do that.

Initially DCI also centered support on the organ procurement activity.

Dr. Peters: So, Dr. Richie, were you the principal organ recovery surgeon?

Dr. Richie: I was the principal recovery surgeon at that time. We employed a physician assistant, and he would identify the donor and call me, and I would drop everything; I could go on a pretty short notice wherever the donor was.

Dr. Peters: How did you all do your cross matching, your tissue typing? You developed that too.

Dr. Johnson: The tissue typing and all the histocompatibility and cross matching as well as the recipient workups initially were performed at the VA because the first transplants in Nashville were performed at the VA. They had a very good, and still do have a very good histocompatibility laboratory. And indeed, the patients, even though they were Vanderbilt patients, got a lot of their laboratory work performed at the VA, too. We were actually going along very nicely with this system until one of the patients was walking from the VA Hospital to Vanderbilt Hospital, when she broke her hip. Well, that was unfortunate for her, but it was a disaster for the program because the VA asked about what this private patient was doing walking across the VA parking lot. Once they found out the answers, we could no longer do our histocompatibility testing at the VA Hospital.

Vanderbilt at the time did not wish to put the resources into starting a histocompatibility laboratory, so we utilized the resources of DCI to establish a histocompatibility laboratory which now does the histocompatibility for all the transplant programs within the state of Tennessee.

Dr. Peters: Dr. Richie, you have some history with some of the science of transplant surgery. Some of the early papers out of Vanderbilt were quite good and remain so.

Dr. Richie: Our first clinical science paper I guess had to do with histocompatibility. I presented a paper on this “showing good results with better matching” at the Southern Surgical Association in Hot Springs, VA. I want to say it was 1977, 1978. The other thing we did clinically was thoracic duct drainage. Dr. Johnson got me into that. He seemed to think I could do more than I was capable of doing. That was to cannulate the thoracic duct in the left supraclavicular region. We drained the lymph, processed it, and froze it to kill the lymphocytes. Then we would check it with cultures. If cultures were negative, then we would infuse it back into the patient because they very rapidly get protein depleted. The amount of lymph that people can put out can vary anywhere from 6000 or 8000 cc’s a day to 20,000 cc’s a day, so you really have to stay on top of that. We ultimately confined thoracic duct drainage to those individuals who had a lot of pre-formed antibodies.

Dr. Peters: Dr. Johnson, there has been an evolution in kidney transplantation from what could be characterized as a nephrologist-driven program or a surgeon-driven program to a partnership.

Dr. Johnson: I think the collaboration of medicine and surgery developed in our program from day one when Dr. Scott convinced Dr. Richie to take over the responsibilities of the Renal Transplant Program. I recall the two of us sat down and discussed how we would divide the responsibilities for the transplant program. From that point on, we rounded together--did it for 30 years. Took care of the patients jointly and formed, I like to think, a very effective partnership in providing care for these patients, to the point that patients, quite regularly, mixed us up. They would call Dr. Richie Dr. Johnson and so forth, and me Dr. Richie. It was a very good 30-year partnership.

Dr. Peters: Ultimately both of you became involved in the academic nurturing of younger people. Fellowships developed, and Vanderbilt became a place where people came to learn about transplantation.

Dr. Johnson: The early nephrology training program at Vanderbilt did not have a specific entity called transplant nephrology, but all the nephrologists who rotated through the program spent time on the transplant service. I think this probably antedated the concept of formal training programs that were created for transplant nephrology. Then as time went on, of course, transplant nephrology became its own discipline, and the nephrology division at Vanderbilt found that some of the fellows wanted to stay on an extra year and take additional training in transplant. It was thought to be a good idea and has continued currently to be half funded by DCI as a transplant fellowship effort.

Dr. Peters: On the surgical side. Surgical training.

Dr. Richie: Dr. Israel Penn was on the ASTS education committee, and I was as well. We talked about the ASTS interest in formalizing transplant surgery fellowships. So I came back to Vanderbilt with this idea in mind. I went to Dr. William Scott and said I’d like to consider starting a surgical transplant fellowship. He said no, I’m not interested in that. I want our residents, our surgical residents, to get experience in transplantation, and if you have a fellow that position would dilute the resident experience. He said I will give you one or two surgery residents, at the more junior level, to work on the service, but I’m not interested in starting a fellowship. So we never had a formal transplant fellowship in surgery while I was chief.

Dr. Peters: Dr. Johnson, please comment about the Southeastern Organ Procurement Foundation and its evolution.

Dr. Johnson: The Southeastern Organ Procurement Foundation, SEOPF, started really before Medicare became involved in funding transplantation and chronic renal failure. It was established initially by David Hume and Bernard Amos, and the concept behind it was to try to share organs between different centers, to find the most suitable recipient based in certain respects on histocompatibility testing between donor and recipient, and to avoid wasting kidneys. Over time the appreciation of the rest of country for this type of sharing and the initiation by the government of the Organ Procurement and Transplant Network caused the evolution of the SEOPF model into what we now know as the United Network for Organ Sharing.

The evolution of SEOPF into UNOS was an interesting political evolution. Initially, of course, SEOPF was a local, by local I mean Southeastern part of the United States, effort. Gene Pierce had the vision and thought that this was a system that was too good to be limited to just one part of the country. So he started inviting other programs that were outside of this particular area. If they wanted to, they could join SEOPF, list their patients with SEOPF, and become part of the system.

The next step was a natural one and that was when the OPTN was legislated into existence, as part of the legislation pushed through by then-Representative Gore from Tennessee. It was felt by people who were with SEOPF at the time that perhaps an application should be made to try to obtain the contract to run the OPTN.

Gene Pierce thought this was, of course, an excellent idea, and there were a number of us who felt that this was also an approach that should be attempted. The organization was established. The bid for the contract to run the OPTN was successful. I think John McDonald was President of UNOS after it had obtained the contract for the OPTN. Mel Williams had been the initial president of UNOS before contracting could be accomplished. I was the 3rd President.

John McDonald was president for two years because it was felt important to have continuity because there were so many changes going on. I was Vice President for those two years, running the membership committee, having the opportunity to review credentials of all the new transplant programs.

Dr. Peters: What do you remember about those early UNOS years?

Dr. Johnson: I think the thing that sticks out in my mind is the fact that there was so much going on. That UNOS was trying to accept programs into the organization, to credential those programs in a way that was reasonable and safe for patients. But sometimes there was stretching the rules that we had already set up in the membership committee as far as credentialing, let’s say, transplant nephrologists. How much training did a transplant nephrologist need to support a program? There were many instances where established programs that had been doing the job for a long time were clearly surgically oriented programs. The job that was being done was excellent as far as we could tell, but they didn’t have, at that point in time, a credentialed nephrologist who was working with the program. As time went on, as other transplant programs were included, there was the challenge of perhaps having a transplant nephrologist who was expert, trained in immunosuppression, pinch hit along with a hepatologist to help out on the liver transplant side until that hepatologist became sufficiently sophisticated in immunosuppression. There was a lot of mixing and matching to achieve reasonable application of rules which were evolving themselves.

Then, of course, there was one instance where we were asked to review a program to start a heart transplant program in a new area and the data that were submitted to us disclosed that they had accomplished 4 heart transplants, successfully, but unfortunately these were all on pigs. So there was 0 clinical experience, but there was a great deal of political pressure to approve this particular program and I think we were called to Washington to discuss with the Senator involved why this program was not suitable. I think the only way we made the point was we asked if he would go there to have his heart operated on or his transplant if he needed it. So there were a lot of interesting and innovative things going on because those were certainly the early days of UNOS and the regulatory process which has evolved over time.

Dr. Peters: Dr. Richie, please comment about that regulatory process, as you remember it, and how it affected the transplant service.

Dr. Richie: I think what it did was to try to ensure some uniformity in recipient selection. It also specified what training surgeons had to have in order to do a transplant. If you didn’t have the appropriate people, then you were not in good standing with UNOS. One of the things that they have taken on in more recent times is what I talked about early on, that was credentialing of recovery surgeons. I remember, very vividly, we got a donor at Vanderbilt who was a heart donor and a liver donor. We got word that Pittsburgh was sending two surgeons down. Dr. John Sawyers was chairman at Vanderbilt at the time and he said, “They are not credentialed to operate in my operating room. You have got to go in there and be with them and oversee their procedure.” I said, “Dr. Sawyers, I think Drs. Henry Bahnson and Thomas Starzl know how to do this operation.” He said, “I don’t care. They don’t have privileges in my operating room.”

That put me to thinking. In reality, we go to other hospitals and we send people who are not credentialed at those hospitals. So we started talking about the possibility of credentialing donor recovery surgeons as well as transplant surgeons. I think it has finally come to fruition where these matters are resolved.

Dr. Peters: Other comments?

Dr. Johnson: We talked about the collaboration. Our concerns that we talked about earlier, the regulation through UNOS and through the government that may be having the unintended consequences of making transplant programs unwilling to offer transplantation to the patient who has risk factors associated with their transplant procedure.

Dr. Richie: You know Tom has an old adage in surgery: “The enemy of good is perfect.” Anytime you try to make something good, perfect, you may run into trouble. It seems to me that’s what we are trying to do with some of the modern programs is to have a perfect outcome. There are times when I think the patients would be satisfied with a good outcome. Like Dr. Johnson said, I think a lot of these programs want their statistics to be 99 or 100% pure or successful. I think they might offer it to more patients and have a lot of people out there doing pretty well if they would just think about it a little more.

This is when I had first started doing transplants. I had been doing them for about a month. We had a call one Sunday night that he had a kidney for us. We said fine; we had a recipient. I think Dr. Philip Walker was the nephrologist on call. The first thing I’d ask them if they said they had a potential kidney for patient X is how old are they? Phil said I think she’s about 55. I said ok. One kidney flew to Nashville and got here about 7:30 at night. We took the patient in the operating room. Interesting, just before we started, I went in to see this patient and said, “Blanche, how old are you?” “Well, I’ll be 66 on my next birthday.” The operation, needless to say, went off flawless, and Blanche lived to be 86 and saw her grandson graduate from Vanderbilt Medical School.

Dr. Johnson: As far as older patients are concerned, there was a period of time in the program here that we had a relatively high mortality rate. Remember that? When we looked at our data it was all in the older patients. The younger patients did great but the patients who were over 50 did not do very well. We sat down and we thought about that and said you know one of the things that happens when you get older is your immune system deteriorates. We said maybe these people don’t need 60 milligrams of prednisone, which we were giving everybody; maybe they just need half of that. So we adopted a protocol that we continued to treat the younger patients with 60 but we treated the older patients with 30 milligrams of prednisone with our ATS and with Imuran, and we found, lo and behold, over the next year, the results in those older patients mirrored in mortality. The mortality came right down and it was the same as the younger patients. Then I think we took the step in saying if this works for the older patients, let’s see how 30 milligrams is handled by the younger, and it was fine.

Dr Richie: We did a small pilot group of about 10 patients. I remember we presented that data at the Southeastern Dialysis Transplant Association in Atlanta. From then on we just halved everything. It worked, just cut the mortality down to 1 or 2% overnight.