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Dr. Najarian

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…in 1954, the first successful kidney transplant was done at the Brigham hospital between identical twins. And I said, that’s the field, that’s something. If you can put in an organ in an individual and save his life, that is remarkable and that’s the direction I want to go. That was 1954 and so from that point on, I wanted to learn immunology...

Biography:


John Najarian, MD graduated from the University of California San Francisco with a medical degree in 1952 and went on to complete his surgical residency at that institution. Recognizing the opportunities in kidney transplantation, he completed fellowships at the University of Pittsburg and the Scripps Clinic and Research Foundation; he was an early pioneer in clinical transplantation in California. In 1967, he moved to the University of Minnesota to Chair the Department of Surgery and to further develop its transplant program. A founding member of the ASTS, and the 4th President of the Society, Dr. Najarian has been recognized throughout the world for his significant accomplishments and contributions to transplantation. He remains active in numerous associations and holds the title of Professor of Surgery and Regents' Professor Emeritus at Fairview-University Medical Center in Minneapolis.

Transcript:

John Najarian: I’m Johrn Najarian. I am a retired Professor of Surgery at the University of Minnesota and currently still working there as a transplant surgeon.

John Roberts: That’s a great lead in. So tell us, you know you were at the University of California, San Francisco a long time ago and how did you get involved in transplantation?

John Najarian: Well it’s kind of a long story, but to try to keep it in a small capsule… I first wanted to be a cardiac surgeon and in 1954. That was my dream to be a cardiac surgeon because Brody Stevens who was one of the football players from the University of California, Berkeley where I had played was a cardiac surgeon and I had admired him so much.

But in 1954, two things happened. One, open heart surgery became a reality for the first time, primarily through the work of a bunch of cardiac surgeons including C. Walton Lillehei and others and Dick Varco at the University of Minnesota. So I thought that the only thing that would really progress in the area of cardiac surgery was devices, valves and things of this nature and this didn’t really interest me.

However at that the same time in 1954, the first successful kidney transplant was done at the Brigham hospital between identical twins. And I said, “That’s the field, that’s something. If you can put in an organ in an individual and save his life, that is remarkable and that’s the direction I want to go.” That was 1954 and so from that point on, I wanted to learn immunology because immunology was just a word to me at that time and so that I could get into that field because that’s where it was.

John Roberts: And in 1954, where were you in your career?

John Najarian: In 1954 I was in the services actually, in the Air Force. I was a Division Surgeon for the 34th Air Division in Albuquerque, New Mexico and working primarily at the Lovelace Clinic.

John Roberts: And had…? So you had finished your residence…?

John Najarian: Oh yes.

John Roberts: By that time?

John Najarian: No, I had not finished my residence. I had just finished medical school and one year of surgical internship.

John Roberts: I see. And tell us about how you…? You said that you wanted to go into transplantation because you know obviously sewing in an organ is great and the immunology… What did you do to further your interest in immunology?

John Najarian: Well the first thing I wanted to do was to find out where I should really learn immunology. As I say, it was only a word to me. When I was taught in medical school about immunology, basically was that it was something that allergic reactions and this sort of thing, but no real depth in immunology. So I decided to explore the possibilities of where I could go learn immunology, however I still had five more years of residency training in surgery, so I knew I was going back to the University and at the same time I kept asking individuals where I should go. And, little by little, it became apparent that probably the best place to go is to work with somebody like Sir Peter Medawar in England, who was kind of the godfather of transplantation and godfather of immunology at that time.

John Roberts: And did you go to England?

John Najarian: I contacted him through friends and Harold Harper in particular, I don’t know if you remember that name? He was in charge of biochemistry at the University of Minnesota. However, Peter said that it would be two years before I could work with him. So then I looked at Michael Woodruff up in Scotland and it would be at least a year before I could work with him.

And at the same time, I found that there was somebody called Frank Dixon who was doing tremendous work in immunology. I mean he was looking at antigens and antibodies and studying them in a way in which you really could understand. So I contacted Frank Dixon who was at that time at Pittsburgh and so when I completed my residency in 1960, I went as a fellow in his laboratory working with Joe Feldman and Frank Dixon learning immunology.

John Roberts: And where was the laboratory?

John Najarian: The University of Pittsburgh.

John Roberts: Okay. And after you spent time in the lab, what was your next step towards transplant?

John Najarian: Well what happened was the lab moved on from Pittsburgh. Moved on, the whole lab, all of us, including the fellow of which I was one, moved to La Jolla, California to the Scripps Clinic and Research Foundation in La Jolla. And there we continued on with the research that we were doing and I was really into it.

I was having more fun than anybody. I mean I was publishing articles in journals which I never even knew existed before, the journals of medicine and the like and experimental medicine. And as a result of that, I really became embroiled in immunology and Frank Dixon said, “You should stay here and continue on because you are doing so well and you are contributing and I had quite a bibliography going for myself at that time.” And I said, “Well I trained to be a surgeon and so therefore I really should leave and go into surgery.” And so I spent about two years, two-and-a-half years at Scripps and then went back to the University of California as an Assistant Professor working there and hoping to set up a transplant program.

John Roberts: And how did you set one up?

John Najarian: Well the first thing I had to find out, you know if it was possible and the only person that was doing transplants at that time west of Colorado… Tom Starzl was doing a few, but at the California was Will Goodwin down at UCLA had done two or three kidney transplants. And so I thought the possibility was that I could set up a program, but I’m going to have to have a little bit of help with respect to the actual technique because all of my studies for the past three-and-a-half to four years in immunology were all done in mice and rats and guinea pigs and the like.

And so as a result of that, I spent some time in the laboratory working doing transplants in dogs and eventually actually went back to Colorado, Denver, Colorado to watch Tom Starzl do a transplant in a human being so I could see exactly how and what the problems were. Then I went back to the university and set up the program there.

John Roberts: And what did you learn that were sort of the main problems other than obviously the immunology at that time?

John Najarian: I learned that it was a very… It was a difficult operation, but if done correctly it really worked very well. And it was kind of amusing a little bit because the first one that I did, we had a full viewing room and everybody at the University of California, San Francisco wanted to see this transplant. So the first thing I needed was somebody who could take out a kidney that I could really depend on. So I picked Jack Riley who was the Chief of Vascular Surgery, because Jack was one of the best technical surgeons I knew at the time. And I knew that Jack could take out a kidney better than anybody. So I asked him to do that and he said he was pleased to do it.

But the problem was that I was in a room where we were being observed by a whole bunch of people down at the corner end of the operating suite and Jack Riley was taking out the kidney in the next room. And as a good vascular surgeon, the kidney was pristine. Unfortunately also was the ureter, he had cleaned it off just he would clean off a vessel. There wasn’t a vessel on it. And I looked at it and went, “Oh my God.” And I decided the best thing to do was I looked up there and all of these people were looking down, I put it in. And I thought “Well maybe if it’s in there and it’s in the retroperitoneal space, it will get its own blood supply and survive” and unfortunately it didn’t. And eventually I had to take that kidney out and put another kidney in that patient. So that was the first of our beginning of a program.

But the program went on and while I was at the university, I did about sixty… A little over sixty kidney transplants.

John Roberts: And how many were living donor and how many were cadaver?

John Najarian: Most all of them were living donors and not all of them, but at least half of them were living donors. And I have always done at least half living donors whether it’s been livers or its been kidneys or whatever or pancreases and what happened was that with the living donor kidneys, that was not a problem because you would have a donor in one room and you would have the recipient in the other room.

But the cadaveric kidney, we had to somehow transport the patient from San Francisco General Hospital, for instance, to the University of California, San Francisco on Parnassus and we’d bring the patient who was now declared dead and the poor family disrupted as they were, would have to come with the family. We’d put the patient in one room and then we had the recipient in another. So the biggest problem we had is we had to find a way to preserve the kidneys so we could perhaps have a kidney that could be transported from one place to another and that’s where Fred Belzer came in.

Fred was up in Oregon with Burt Duffy, who eventually was my Chairman. And when Bert came down, he brought Fred Belzer with him. And he brought Fred Belzer in my office and I was in charge of research. And Bert said, “You know, can you possibly get this fellow to do some research?” Well I asked Fred, “Do you have any immunology experience?” And he said, “No.” And so as a result of that, I thought “Well what do you like to do?” He said, “I like to do vascular surgery.” And I thought, “Oh my God, what am I going to do with this guy?” And I thought, “You know what, you are just the guy. Can you get a kidney to be preserved somehow so it can be transported from one place to another and to be used?” And Fred began working on that.

And the story was quite long, but basically Fred kept putting kidneys from dogs and he kept perfusing them with blood and the kidneys would blow up and they wouldn’t work. And then he finally got rid of the red blood cells and he put in plasma and the kidneys would still blow up and they wouldn’t work. And his office was right next to mine and he’d say “Oh, Shit!” And this would… And I knew they had failed again. This would go on and on.

And one day, his wife called him and said “We have tickets to the opera tonight. Fred, you’ve got to get home early. We’re going with these other people, we’re going to dinner and we’re going…” And he had just bled a whole bunch of dogs, so he took the blood from those dogs that had been separated into plasma and put them in the refrigerator and says, “I’ll use them tomorrow.”

So he did this and by serendipity the next morning he came and he looked in the bottle and it was all full of flocculation. So he thought, “Oh my God, all of that work. Well why don’t I just filter it?” So he filtered it out and thus was born cryoprecipitated plasma and that was the first preserving solution and that began the whole field of preservation as far as perfusion preservation was concerned.

John Roberts: Great story. So you were at San Francisco for how long?

John Najarian: When I came back, I came back in sixty… I think it was early ’63, January of ’63 and I left there in ’67 to go to Minnesota. So I was there for a total of four years and I was promoted from Assistant Professor at about a 4 grade, which is way down to a Full Professor at about a 3 grade in one fell swoop when I… People were wanting me to go to their institution to run their transplant program, to be a Chairman of the Department and Burt Duffy got a hold of the President of University and says, “We’ve got to promote this guy or he’s going to leave.” So I had a promotion all the way from the bottom of the ladder right to the top of the ladder and it lasted about one year and then I left.

John Roberts: And what got you to Minnesota? What was the. . ? What was attractive about Minnesota?

John Najarian: Well to tell you the truth, I started looking. Because at that time, it wasn’t any place for our kids. The hippies were coming into the area, in the Haight-Ashbury area, and we were living just above Haight-Ashbury area just behind the hospital. And my wife would take the kids down there and here would be these hippies that were smoking pot and walking around with crosses and it just was the wrong place to be. And it was that whole era as you recall.

So I began looking at different institutions. And I looked at Cornell who called me and wanted… First was NYU, which really intrigued me because they had such good immunology there. But I went there and there was no place for me to raise four boys. And I had to live in Manhattan, because if I lived outside of Manhattan I was an hour-and-a-half away twice a day and a young, developing academician, it wasn’t a good thing to do. So I eventually had to turn that down.

And about three weeks later, I get a call from Cornell, we want you to come back and be the Chair. In those days, you only looked at one person; you didn’t have a whole series of people you brought in. And he says, “You’re on the top of the list.” And I say, “That may be true”, but I said, “I can’t go.” And he says, “Are you kidding? You’re not turning us down on the phone.” I said, “I think I am.” And I says, “I went to NYU…” “This isn’t NYU, this is Cornell.” I mean, they were insulted that I even bring that up. And I said, “It doesn’t make any difference, you are in the same area.” And I said, “It wouldn’t work.”

Well this went on and I looked at Barnes Hospital in St. Louis and actually ended up looking at twelve different places that had asked me to come. The thirteenth place was the University of Minnesota. And it turned out that I got there in a January and it was like this January. It was cold, the wind chill was down around -20o and I was in my car and I thought, “What the heck is wind chill? I never heard of this. Is that the temperature on your windshield or something like this?” Anyway I was there and I said, “My gosh, this isn’t all that bad. I could take this.”

And then I saw something I had never seen in the other twelve institutions, every single man on the faculty had a research laboratory and had a research grant. I said, “My gosh, you can make clinical surgeons out of investigators, but you can’t make investigators out of clinical surgeons,” so that was the intrigue.

And my predecessor, Owen Weinstein was very smart. If you wanted to go to a meeting, you better have a grant because that’s the only way you’re going to travel to a meeting. You wanted a secretary, you better have a grant or you don’t get a secretary. If you wanted to do anything, you had to have a grant. So all of the people that were there had a small grant and some of them were larger than others. So research was very prevalent there and Minnesota was a research institution and it was his primary forte that Owen Weinstein had built. And as Hopkins had built a bunch of clinical surgeons very well, Minnesota had built investigational surgeons very well.

And so I thought, “I could do this because I can train these people and they can become clinicians and do clinical surgery. And we have everything. We have the best of all worlds.” And so that was the intrigue of Minnesota. And the only other thing was that my wife had left Minnesota to come to California to marry a Californian so she’d stay in California and the first thing I did was bring her back to Minnesota.

John Roberts: And so obviously you never left Minnesota.

John Najarian: Still there.

John Roberts: What happened over those…? You know at that time did they have a transplant program at all when you got there?

John Najarian: They did, yes. They had done about seventy transplants before I got there and this was done by Joe Aust and Dick Lillehei, Rich Lillehei and Dick Varco and… Oh, I am blocking out the other fellow’s name, Bill… Anyway I am blocking out his name at this time. They were doing the transplants and it was done by committee and it was terrible. I mean you know if Dick wanted to do one, he did it. If Joe wanted to do one, he did it. And there was no… No coalescence of people. And as a result of that, I felt that the best thing in the world would be to get in narrowed down to one person. And it turned out that there was one person that was probably the best of the bunch. But unfortunately Joe Aust, one year before I got there, he left and went to San Antonio to set up their program. Dick Varco stopped doing transplants. Rich Lillehei wasn’t interested in that type of transplant anymore; he was spending his time, more of his time doing cardiac surgery.
And so it was a situation in which I thought that we could start a program and I would start a program but I would need somebody to help me. And that’s when I made the smartest move I have ever made when I was in Minnesota and that’s when I hired Dick Simmons as my associate. And I met Dick Simmons at a meeting in Paris, France, a meeting of the Transplant Society. And we sat down and talked for a little bit. We liked each other and I said, “Dick, you want a real challenge? Come with me and we’ll build a program in Minnesota.” And he said, “I’m coming right away. I’ll be right there.” And he did and the rest is history, the two of us then had a wonderful association for about twenty years.

John Roberts: So back, you know, when you got to Minnesota, what was your day like? Were you still doing research? Were you doing clinical surgery obviously?

John Najarian: Yeah I was doing clinical surgery, but I maintained the fact that I was the Chairman of the Department so about half of what I did was general surgery. I still did you know breast surgery, thyroid, stomachs, you know you name it, colon surgery and the like as well as transplants. And I was hoping as I was training people such as yourself that you’d do general surgery as well as transplant surgery because I hated the fact that somebody would buy some of our guys and say, “Okay you are a transplant surgeon, you do transplant.” And then if something comes up that’s general surgery, you bring in a general surgeon or an urologist or whatever is necessary. But it didn’t work out and unfortunately now people hire people because they are a transplanter. They hire people because they can do pancreas transplants and nobody in their institution there is doing them, so that’s unfortunate.

But what I was doing was I was doing at least half or more of my time was spent doing general surgery and the other half was doing transplantation. And eventually it became very obvious I certainly wasn’t going to be able to do research and that was obvious and so I got out of the lab. For a while I would have people in the lab and they would come and report to me on a once a week basis and then I would give them ideas and they would come back and report to me again. But little by little that didn’t work out well and so I got further and further away from research. And about the only research would then get, got involved with was one of the projects that I brought with me from San Francisco and that was the development of ALG.

John Roberts: Uh hum.

John Najarian: Minnesota ALG.

John Roberts: And so you know obviously Minnesota was. . . You know right on the leading edge of transplant research. How did you foster that within the division or department?

John Najarian: Well because if the Chairman is doing research or is interested in research in transplantation, that filters down to everybody. If the Chairman is a general surgeon or a heart surgeon or God-knows-what and transplantation is just being done by the transplant core, that’s a lot different than if the Chairman is interested in transplantation. So what I came to an institution and its primary… Was primarily known because of cardiac surgery, I mean that where it really started. It’s the birthplace of cardiac surgery, obviously open-heart surgery.

And so what I wanted to do was to make transplant just as visible as cardiac surgery. And because I was a Chairman and because my interest was in transplantation that spread out and I kept bringing in people and training people such as yourself to do transplantation. And that’s where the real joy came from.

John Roberts: And so but you managed to get people’s interest in transplant, keep them interested an obviously trained you know lots of great people. I think that’s a real feather in your hat. Just you know I think everybody today leading a division or a chair still has those same issues, you know how do you get people to you know succeed?

John Najarian: You have to have the interest. If you are the Chairman of the department and you have that interest and you can foster that in the… Into the you know the people that are beneath you and the people you are training and the people you are mentoring, something I will be talking about in a couple of days, I guess. But the important thing is that you have to, you have to give these individuals a chance to go. And you have to give them a decent project.

Well as you know when I went to Minnesota, there was kind of a strange kind of a program. It was a program where you might be doing clinical work as a resident and the next year, your second year, you might be in a lab. Or you might be doing clinical work and never get in the lab, it could go either way. And it was just a whim of my predecessor and what he thought you might be capable of doing.

So the first thing I… I don’t know if you remember my office, but my desk was always clean. To this day right now, you can go there and my desk is clean. I am a guy that really believes in making everything very neat and as a result of that, I have to have a neat program. So I said, “The best thing to do is to make everybody do the same thing, spend three years doing clinical surgery. Find out that you’re a surgeon because that’s what you really are. And then go in the lab. And they all went in the lab for anywhere for from two to three years depending, some went for four to five years. And then bring them out of the lab and finishing them off with two years of doing a lot of clinical surgery. And so this was the program that I set up and the program that I thought would best work and it did work very well.

So when you came and you applied, I said “You are going to come to this program. You are going to spend three years doing clinical surgery and they you’re going to go in the lab. And you will find somebody’s lab you want to work in because you see some real intrigue in that lab. You will go down and work in that lab for two years, three years and then come back and finish up in whatever field that you’re in.” And that worked out very well because I said, “If you want to be a general surgeon and just go out and cut and tie and do appendices and gallbladders and like, well then you could go to Hennepin County and you get very good training in general surgery and go out and go to a small town somewhere and do general surgery and you will be very happy. But if you want to come here, if you want to be an academic surgeon, you’re going to have to spend not five years, but you’re going to have to spend seven, some eight and some nine and some went on to ten years in your training.”

John Roberts: Uh hum.

John Najarian: And then you become a real academic surgeon.

John Roberts: Okay. Tell us about ALG. You know that was obviously a, you know big step forward in transplantation and you know how did all of that arrive?

John Najarian: Well ALG was something that was intriguing because it was. There was no question that anti-lymphocyte serum was the way to go. The lymphocytes obviously killed off the cells in the graft and so if we can kill off the lymphocytes, that we had the best of all worlds. And so as a result of that, anti-lymphocyte was something I was very interested in and so as a… We began looking at possibilities of getting anti-lymphocyte serum and we wanted to get lymphocytes and we started out by taking thymocytes as others did from cardiac cases, This is when I was in San Francisco. And we were injecting them into horses to see if we could make an antibody to them in the horses. So I had a group of horses down at Golden Gate Park, which occasionally we’d go down and ride. And we had them right there close by and we could make a serum that would work.

But the problem we had was two-fold. One of them was we couldn’t be consistent, sometimes it was good material and sometimes it wasn’t good material. And so as a result when I went back to Minnesota, the one thing I wanted to do was to continue with this research with anti-lymphocyte serum. I thought this was the best thing for transplantation. We had Imuran, we had prednisone, but it wasn’t enough. Our results weren’t really that good. We were maybe at best at around 50% graft survival after a year and less than that with cadaverics and slightly more than that with living related. So as a result of that, I said “What can we do and get something that is really worthwhile that is consistent?”

And so that’s when I went up to see George Moore up in Buffalo where he was growing lymphocytes you know by the pound. They had all of these big things that looked like some sort of a dairy farm or something up there and they were making lymphocytes. And I said, “This is ideal. You just sit there and you grow lymphocytes.” And so we learned how to grow lymphocytes and we took it back to the lab and grew our own lymphocytes and then we would inject those in horses and ended up with the best serum that you could possibly make.

And we worked out a deal with a veterinary hosp… Or the veterinary school, to have the veterinary students bleed the patient, bleed the horses, and then they would spin down the blood and they would get the plasma and that was what we used. And they would give the blood back to the horses and these were horses that were being used for gynecological examinations by the vet students. So everybody benefitted, the horses weren’t hurt, we gave them back the red blood cells. The vet students thought it was the greatest because they made money, we paid them to inject the horses and to bleed the horses and everybody was happy. And then we were getting this stuff back and we started using it and it worked unbelievable.

Put together with prednisone and Imuran at that time, we immediately took our results 20% better than they had ever been before. And everybody said, “I don’t believe that. That’s a bunch of hog-wash.” And then they would come and they would see our patients and our patients were doing well and our results were great. And they wanted them and that’s where the rip came in, they said “I’ve got to have some of that.” I said “You can’t have it.” I said “We’re making it and we’re using it on our own patients.”

And so eventually they wanted it and to take it, but in order to get it, I had to get an IRB and I had to go to the FDA and we went through all of that and got it approved. And we were approved for twenty-some odd years and we were able to get cost-recovery. In other words, you would buy from whatever institution you were at and we were to ship it to you, IRB and then we would then examine your place and find out what you were doing and get the results back.

And the FDA came to our institution, at least three or four times a year. They would check our results, they would check everything and they would check how the other institutions were doing. They would look over the books and everything and they would make some suggestions. We would take those and we’d correct things and they’d go back and they were happy and we were happy.

And as a matter-of-fact, in the… They used it as a standard. When people came up with an ALG that they wanted to know whether it was any good or not, they tested it against Minnesota ALG, because it was a standard at that time.

But little did I know that the FDA and some of the pharmaceutical houses were in bed with each other. Because the pharmaceutical houses would give them all kinds of money all the time, they would take them out on trips and they would spend lavish amounts of money on the people at the FDA. And so when, Upjohn is one, went and complained that we were unfair competition. We were a university and we were… Because every time they went out and tried to sell their Upjohn product, nobody wanted it. “We use Minnesota ALG and we love it. Why would we use your stuff?” And so as a result of that, they complained to the FDA and the FDA tried to figure out how they could stop us.

And it turned out that we had one leaky vial in San Diego that was reported. And when it was reported to us, we say “Okay, we can solve that problem.” We found out why it was leaking and we corrected the problem, but they put us on hold while we did that and they never took us off hold after that.

John Roberts: Hum.

John Najarian: Once they had us on hold that was the end. And that’s how it started and the rest you know. I mean it eventually went to court and they threw it out of court because there was no case whatsoever. As the judge said at the time, “There is no reason why this should have ever come to this level.” And but this was too late, it would take us $20 million to get up and running again. And we were that close to having had FDA approval.

John Roberts: Uh hum.

John Najarian: And it was really a sad situation. But one good thing came out of it. The building we built for $15 million to make ALG on the St. Paul campus is there and we use it for isolating our Islets now for Islet transplantation.

John Roberts: Great.

John Najarian: So good things can happen.

John Roberts: So just on that Islet thing, you had… Pancreas transplant was obviously a thing that I think Lillehei got started at Minnesota, right? And how did that expand?

John Najarian: Well when I got there, they had done the first pancreas transplant, pancreas and kidney transplant and that was done in ’66. And I came in ’67 and I then scrubbed in with Dick, Rich Lillehei on the pancreas transplants after that for a few times. And I came out of that room and I said, “This is a ridiculous operation, it’s never going to work.” And I mean, and it didn’t. I mean there was… You know either the pancreas would reject or the kidney or the bowel would reject and it was a big operation on a poor diabetic, Type I diabetic patient. One of them, only one, lived a year with both the kidney and the pancreas functioning. But after a year he committed suicide, it was really a sad case, a kid from North Dakota.

But at that time, I got David Southerland and I said, “Dave, this isn’t the way to go. We got to get the Beta cells out and we’ve got to inject Islets into these individuals.” I mean that only represents a miniscule amount of the entire pancreas, but that’s where all of the action is. So we started our Islet transplant program at that time, and I think first reported at the American Society of Transplant Surgeons in 1974.

Out of ten cases that we had done, and we showed that we could lower the… We could lower the serum glucose with Islets, but we could never make anybody insulin-independent. So we kept working on that and we finally got to the point where we could and we have been doing Islets ever since and pancreases ever since. And Islets really look good now.

We’re in the process of working with… With pigs, sterile pigs that we have that are in a sterile unit in which we are taking their Islets out and putting them into a… Putting them into primates and the Islets are functioning. And I would guess within the next three or four years, we will be doing experimental, clinical experimental work with Islet xenotransplants. I think it’s going to be the first xenotransplant to work.

John Roberts: Okay. So what was your involvement with the American Society of Transplant Surgeons? You were right there in the beginning, right?

John Najarian: Well like Jim Cerilli said, you know early on we didn’t think it was necessary and I agree. I didn’t think it was necessary either, I thought it was ridiculous. We had enough things going and we didn’t need to have a bunch of guys going in there and jawing about… There was only a few of us around that were doing transplants, Jim and Tom Starzl and a few others. And we were doing transplants in… Well maybe it would be a good idea to get together.

So when it got started, they called me because I think it was a second meeting. They didn’t have enough papers to put for a meeting. So they called me up so we had a whole bunch because we had a bunch of guys in the lab that were doing research, so we sent down about ten papers I think that made the meeting go.

And 1977, I was made the fourth President of the Society. One of the things in my Presidential address was that I stressed the fact that we really needed to somehow make this transplantation experience something that was… Just as we did at the University of Minnesota, something that was specific, you had to spend a specific time doing x. And the two things that that I said that they had to have was they had to have was they had to have the Boards in either urology or in general surgery and that they had to be trained at least for one year in transplantation. But at that time, nothing was done about it.

And to Jim Cerilli’s credit when he became President in 1980, he agreed that something like this needed to be done. And as a matter-of-fact, he pointed a finger at me and said, “You’re going to be the Chairman of this committee, Fellowship Training Committee.” So I started in 1980 and the idea was that we would get a series of places, individual transplant programs and see if they really could be official sites for transplantation. We did actual site visits and I was the Chairman of that committee for a period of ten years, from 1980 to 1990. And during that time, we did a series of site visits and we approved a number of sites that could be official sites for training.

Prior to that was amazing, people would go to a transplant unit like in Pittsburgh or wherever and spend about a month or two and they would look over some shoulders and the next thing you know, they would dash off and start a transplant program somewhere. It was absolutely ridiculous. Now we made it specific that way and it even became more important because I was sitting on the American Board of Surgery. And the American Board of Surgery was salivating to get transplantation brought in just as they brought in vascular surgery and I thought to myself, “If anybody could screw it up, it would be a bunch of individuals who didn’t know anything about transplants…”

John Roberts: Uh hum.

John Najarian: “…Trying to dictate what goes on in transplantation and how people should be trained.” So to avoid that, I said “Let’s do it ourselves. We’ll make a specific program, you are a member of the Transplant Society if you are one, Boarded, two, have had a year’s training in the transplant in an officially approved transplant site. And as a result of that, it staved off the American Board of Surgery and so as a result, we’re still functioning and doing well. And then after that, everybody had a two-year term. I think, were you one of them?

Fellowship Training... I know Nancy was and quite a few others, but each one of them for two years. So it worked out very well and I think it’s what’s working now. I don’t know, I mean I have not been involved with it but I’m delighted that it did work out. Because it put transplant on firm ground, it was a real thing. People just weren’t sewing in kidneys or sewing in this or that because they happened to look over somebody’s shoulder for two or three months.

John Roberts: So tell us one the great episodes in your life of transplant.

John Najarian: One of the great episodes?

John Roberts: Some wonderful things.

John Najarian: Well the most wonderful thing in my life I think was Jamie Fisk. As a liver transplanted, you appreciate that I’m sure. But at the time when I was called by her father who was a hospital administrator, Charlie Fisk in Boston, and at that time there were only two places in the United States that were doing pediatric liver transplants. Did you know that? I didn’t. It was ourselves…

Because as soon as I went to Minnesota, I started doing a series of transplants, pediatric liver transplants. And I did something like… I ended up doing about thirty-one liver transplants on patients under the age of 1. And I got some of them to live two or three weeks and some of them to live a few months, but none that went on for any long period of time. Our drugs just weren’t good enough at that time.

And as a result of that, it turned out that Jamie Fisk was born to Charlie Fisk who was an administrator in Boston and here he had this child with biliary atresia, a big huge protuberant stomach and he called Pittsburgh and asked them as one of the pediatric transplant places and was given the word that they would be three or four weeks before they could really see her and evaluate her and see if they could do her.

Well she was eight months along and she didn’t look like she was going to last that long. So then he called me as the only other place that was doing pediatric livers and I said I’d be happy to do it if I can get a liver, figuring I’d probably never get a liver. But you know I gave him a nice encouraging thing on the phone.

And so the next thing I know, he shows up with his kid, the kid is now nine… I think it was almost ten months old. They show up at our place and he and his wife. And he comes there and he’s in a waiting room and he’s there with two Native Americans, Indians, from North Dakota. And he looks over there at the two of them and he looks at his wife, here we left the medical Mecca of the United States and we fly over land… What did we do? How did we get here? And the next thing we know, he says “I walked in and he says that was saving grace.” I say, “We’ll get it.” Well what he had done then... I say, “But we need a liver.”

He then went back and he spoke to the pediatric… Oh the Pediatric Society and they had a meeting in New York and it was a slow news day. And he made a plea, he said “My child has biliary atresia” and they showed a picture of the child, a terrible picture with a big huge belly out to here, yellow as a gourd. And he says, “My favorite song is You Are My Sunshine.” And he says, “The last words are ‘Do not take my sunshine away.’”

Well there was no news that day and somehow or other the television was there, the papers were there and it went all the way across the county, everybody knew about Jamie Fisk. And within three days, I was given… Two or three calls in and finally this one call came in and it was a child that was in an automobile accident, automobile/train accident in Salt Lake City. And the child was ten months and was giving his liver to Jamie.

And so we went out there and we couldn’t get it right away. As a matter-of-fact, I think Nancy went out there to retrieve the liver if I am not mistaken, Nancy Ascher. And the mother was in the accident and she was in another hospital far away and she wanted to see the child and say good-bye to the child before it left and so we had to wait an extra day or two. And then they finally ambulanced the mother up and the mother saw the child and said good-bye to the child. And then the child came and we got the liver and we transplanted it into Jamie.

Now it’s three o’clock in the morning and we’re putting this liver in and I’ve got everything done except I haven’t made the vascular anastomosis and I can’t get from the hepatic artery to the aorta. And I don’t have the child; I just have the liver so I have no extra vessels and no vessels in the refrigerator, so we take out a Dacron graft and I put in a Dacron graft to the aorta. But while I was doing this, about three o’clock in the morning they said, “By the way John Najarian, before you leave there is a bunch of reporters down in the lobby of the hospital that are waiting for you. I thought, “Oh my God, do I go down and tell them the kid didn’t make it?” And so I got out…

Fortunately the kid made it and the rest is there. The child did very well; she is now 28-years-old. She is a teacher in Boston and has just done beautifully and it was… It was just one of the wonderful things that happened, to watch her grow up and develop and to do the wonderful things that she has done.

And it’s kind of the things that happen and you have to put that against those three or four or five kids that you did that never got off the table. And you had to walk down that long hallway to see the parents in the middle of the night and tell them that the child didn’t make it. That happened to me too many times. But you get somebody like Jamie Fisk and it makes up for all of it.

John Roberts: Okay. So any other kind things you want to relate to us about, you know, transplant and kind of what made it exciting for you, or, you know, feel changed the world or transplant?

John Najarian: Well I think a lot of things did. ALG did, there is no question about that because it immediately made 20% better on everybody. I think that you know that the new things that are coming along are really quite exciting. One of them I pointed out was you know the xenotransplantation of Islets from pigs, it turns out that the pig Islet lacks certain enzymatic requirements that are required that do not make a problem with respect to transplantation. And so if this will work, that will be something in itself. Because as you know, there about a million-and-a-half to almost two million Type I diabetics now.

John Roberts: Uh hum.

John Najarian: And there is no way that we’ll ever be able to keep up with that with pancreas transplants or Islet transplants. So it’s going to have to be xenotransplants and that the one xeno that may work, so that’s good.

The other side of the coin is stem cells. Stem cells are quite exciting and they are beginning to show signs of… That we’re getting something that does work. I mean at the University we have now been able to take hearts and take them apart and put in stem cells for muscle stem cells into to see the heart actually pump with stem cells and so that’s exciting.

The whole field of transplantation is exciting and it’s just unfortunate that… That there is always going to be this lack of donor availability. And I know that earlier they were talking about the possibility of paying donors and this sort of thing, I think that sort of thing is going to have to happen to some degree. Unfortunately if that does happen, no longer will this be a gift obviously, but I think it makes a lot of sense that if this will help in some way of increasing the number of donor organs that are available, it’s worthwhile. And it it’s properly regulated, I think it can be done. And Art Matas at our institution has been pushing this for a long time and he has finally convinced that he is right.

John Roberts: So what we want… I think why don’t you talk about is sort of where you see compensation for donors.

John Najarian: Oh.

John Roberts: And you know where, sort of the history and where it’s going and… You might talk about both live and cadaveric, this may be a… Because they are different as you well know. But they’re a death gratuity or a survivor benefit on the cadaveric side and the Art Matas program on the livings.

John Najarian: Well I think one of the biggest problems that we have in transplant today is the fact of a lack of organs and we’re looking for everything. We’re looking at xenotransplants as a possible and it is a possible, but it’s still off in the horizon. And then is there any way we can increase the number of transplants that are coming in? And I think we’ve tried everything. I think we really have pushed the envelope as far as we can with respect to cadaveric donation. We’re getting places that are, you know demanding that people put in… Have a donation of an organ, a cadaveric organ, if somebody dies in their hospital.

But the problem is also of living donor and so what we are seeing now is an increasing number of living donors in all programs, because people are waiting four years, five years, six years waiting for a transplant. And if you wait five years and you are on dialysis or six years, about half of those people are not going to be around six years later.

So what about compensation? Well, I think that for a long time Art Matas at our institution has been pushing on the live donor side that somehow that compensation be given for an individual that is going to have to travel to an institution, get away from his workplace, etc. and to do all of that to be a donor. And under those circumstances, I think the number of donations would increase and that the program that Art has put forth for living donors is a very good one. And although I was against it from the beginning because it really wasn’t what we all like to believe is the, you know the gift of life, it’s no longer a gift if you are going to get compensated for it. But it is still a gift and I think it’s a good thing and Art has convinced me on that.

And the other side of the coin is how about individuals who have passed away, individuals who are deceased donors? And I think there is also a problem and I think it’s necessary that somehow or other, the funeral expenses or other expenses of that nature be taken care of and that would be very easy to do. And once the word got out about that, I think when we went to look at the family of somebody who is in a hospital and is on a respirator and we’re asking for organs, if they know that at least if they do give, that some compensation will be occur to help respect to the funeral arrangements or the hospitalization or the like, that this would be worthwhile.

So we need to explore all of these avenues because at the rate things are going, you know we are having people who are selling organs illegally, they are doing all kinds of things. They are going to various countries throughout the world. You can you know sell an organ for $10,000 in some countries and $1,000 in other countries. It’s amazing; there is a whole list of them. I think Newsweek recently… It’s absolutely amazing. But I can understand it.

Say you were in renal failure and all you were looking at was the possibility of dialysis. I think, you know you would take every last dime you had to buy an organ. But if you did that, is the individual that gave you the organ, is that individual in any way going to be at jeopardy? In other words, is he going to be properly taken care of? Is he going to be properly taken care of financially, medically and every other way? Because I don’t think you want to see him suffer just so that you might live because you are getting a transplant from him because you can afford to buy it.

John Roberts: Uh hum.

John Najarian: And that’s what’s going on.

John Roberts: Because I really would be interested, is there ethical issues in asking for a person to put their life on the line to donate an organ when they are alive? That’s an ethical issue. It’s also an ethical issue to… people have made it one at least of paying a donor family to get permission to use the organs of their relative after death. Which of those two has a greater ethical problem?

John Najarian: There are two ethical issues to look at and one of them would be whether or not it is fair to ask an individual to put their life on the line to give an organ. My experience has been that people come to us, we don’t ask them. They are asked… They are volunteers, they are family volunteers. They are volunteers because they are in the same biblical study group. They are volunteers because they happen to go to the same church or in the same golf group or whatever.

They have a reason for coming forward and they come forward voluntarily. And I never would put my finger on a person and say, “You should do this.” But they come to you. They come to us and they recognize that now it is five years, six years, seven years before a person, that particular person is going to get an organ. And I don’t ask them. And whether that’s ethical to ask them whether they… I don’t think any of the individuals who are recipients ask them. So I don’t know that I would look at those as two different, as two possibilities.

But to give money to somebody who for one reason or another has in the hospital, now is on the respirator and you want them to be a donor. To ask that family, knowing full well that the family will get compensated certainly would make us feel a lot better.

John Roberts: So where do you think the greatest harm would be to take a kidney from a live person or to pay a family for a cadaveric organ, what’s the greatest moral harm in that situation?

John Najarian: I don’t know. I… I just feel that, that the gift of life, the book that was written by Dick Simmons’s former wife said it all. And it said that it is a gift; a gift has to be given voluntarily.

John Roberts: Uh hum.

John Najarian: We never put ourselves in a position, you don’t, I don’t, to ask anybody to do anything.

John Roberts: Uh hum.

John Najarian: They come to us and the most important thing we do is to make sure that they are not being coerced. And for a long time, it was turning out that a… An unmarried male was being put forth by a family as a potential donor because everybody thought he was having too good a time and really wasn’t pulling his weight. And therefore he should be the donor because everybody else in the family was decent people. So it got to the point where we wouldn’t accept an unmarried male, a member of the family.

But even though we laugh about that, the truth of it is that we always have somebody else talk to the individual that has been brought forth to us. They go off and they see another person, it’s either transplant coordinator or we have several other psychologists that they can see, that they will see before we finally accept them as a donor. So by the time we as physicians and surgeons get down to the bottom line where we are actually going to do the operation, they have been screened very well, maybe my hands are clean.

John Roberts: There is one thing that we’re trying to do, John. We’re trying to put together very short vignettes for those folks who have passed on, folks like Belzer, Myron Kauffman, others. Would you pick a couple of our departed colleagues and just talking to John here, say a word or two and we are going to cut this out of your deal and put it in a…

John Najarian: Oh God, I love Tom Marchioro. Tom Marchioro to me was an unusual individual because you heard from Jim Cerilli about Pittsburgh or rather Colorado. But Tom Marchioro was the… Was the solid base there.

Tom Starzl was crazy, you know he would just go off and he’d do these things… The time that I watched him do a transplant for instance, it was in a patient that had an infected wound and he was putting in a kidney transplant and he kept putting one towel after another towel after another towel after another towel on top of it. And Marchioro was looking at me and kind of shaking his head as if this was the only person in the room that really thought that what we were seeing was wrong.

And I always liked Tom Marchioro. He was a straight-shooter all the way. And when he went up to Seattle, I thought that was great and he did… He set up a good program there. I visited him a couple of times and I had nothing but the highest respect.

He was originally a cardiac surgeon that Tom talked into becoming a transplant surgeon. And as a result, Tom was very good technical surgeon as well, but honest as the day was long. And when you knew and you heard something from Tom that you could accept it and it was the truth. And I don’t know what your experience with was.

John Roberts: The same.

John Najarian: Yeah.

John Roberts: Interesting guy.

John Najarian: First class guy.

John Roberts: Yeah.

John Najarian: These other people that you mentioned, Fred Belzer for instance. As I mentioned, Fred Belzer by serendipity came up with something as far as preservation was concerned. But Fred took a program at Wisconsin that was nowhere and much to the regret of those of us in Minnesota, built it to a be a wonderful program because it siphoned off a lot of, a lot of our patients off to Wisconsin that prior to that had never gone there. And he ran a very good show, he really did. And I was a Visiting Professor there on a couple of occasions and Fred ran that program I thought as well as you could run any program. And he did it, he did it extremely well.

Myron Kauffman, gosh that was such a shock when Myron died. I mean he and I were together… We’d get together and talk about old times. Spent a lot of time talking about old times and an old MCV guy like Myron, he was… Everything to him was you know… It’s just; he was just one of those people that you just really enjoyed. I enjoyed his company so much. I never worked with him as an individual, but I worked with him on committees and things of that sort with the American Society of Transplant Surgeons and Myron Kauffman gave very much to setting up the programs as far as donation is concerned.

And I think really got the program going as far as the UNOS is concerned. I mean UNOS really depends on its beginning from Virginia and Myron Kauffman was responsible for that. Um… I can’t think of anybody else off-hand.

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