In Their Own Words:
The impact of transplantation on my life has been immense. It’s the best decision I ever made. I have had more fun learning, doing, improving, sometimes really achieving and I particularly enjoyed my role in the organizations that relate to transplantation.
William "Bill" Pfaff, MD graduated from Harvard University and went on to receive his medical degree from the State University of New York at Buffalo. Dr. Pfaff had further training at the University of Chicago, Stanford Medical Center, and the National Institutes of Health. Board certified in both general and thoracic surgery, Dr. Pfaff, a charter member of the ASTS, did the first kidney transplant in the State of Florida. He had an abiding interest in transplant organizations through his career serving as President of the Southeastern Organ Procurement Foundation, the United Network for Organ Sharing, and leading the transplant program as well as the Organ Procurement Organization at the University of Florida Gainesville. Continuing to serve as Professor of Surgery emeritus, Dr. Pfaff maintains an interest in the long-term outcomes of kidney transplant recipients.
William Pfaff: I’m Bill Pfaff; I’m a professor emeritus of surgery at the University of Florida.
Randall Sung: Can you…? Let’s start off with how and also when you first got interested and involved in transplant surgery.
William Pfaff: My early involvement in transplant surgery was almost accidental. I had arrived at the University of Florida in 1965, planning to work on the physiology of injury, particularly the consequences of injury biochemically. After I arrived there, I fell in with some nephrologists. They were seeking a surgeon that was conducive to their own thinking and they decided to try me. And so I started doing renal vascular surgery, which I had but scant experience before. And next I helped them start a dialysis program; it was the first dialysis program in North Florida. So I did dialysis access for them.
At the time, nobody was paid to do dialysis or was paid very little in most cases. And so soon their dialysis unit was filled and there was no way to expand it because it was a money-losing proposition for the institution. So they said, “Why don’t you start a transplant program?” And I said, “Lord, I have never even seen a transplant.” They said, “Well it’s pretty straightforward isn’t it?” I said, “Yeah, we can work on that a bit, let’s talk about it some more.” And we talked about it and decided to go ahead.
And so about ten months after I arrived, I did the first kidney transplant, I actually started the first program in the State of Florida. It was a grand time.
Randall Sung: What was the typical day like in the early stages of starting the transplant program?
William Pfaff: A typical day in transplantation had nothing to do with transplantation, because I had to first… I had to promise the institution that I would do no more than ten a year. And as a result, I spent most of my time doing general surgery and actually continued to do general surgery throughout my career and had a variety of interests that had nothing to do with transplantation.
Any time I had in the lab back then, which ultimately disappeared was related to transplantation and so I continued those efforts for quite some time. But that became overcome as well.
Randall Sung: And were there a lot of difficulties, challenges you had to overcome in those days?
William Pfaff: The challenges that we mainly had to overcome were ignorance and our own as much as anybody’s. And so little was known that the language of today would be totally foreign, it would be Japanese to an Englishman. And that the depth of scientific basis was scant, so most immunologists thought that going ahead with a transplant program was adventurous but dumb. And they foretold failure and indeed initially we majored in failure, so that the graft survival with cadaveric transplants in the 1960’s was forty-some-odd percent and was slow in rising. But so I spent more time doing a variety of general surgery until we were funded by Medicare.
We also started out doing only cadaveric transplants. Again in the mid-sixties, graft survival for living related donors was about 60% and we wondered whether that was sufficient to justify a donor, a live donor, making that sacrifice. And so we deferred until 1968 and then said “Well at least there is a better chance and we think we can do better than has been here true heretofore” and that we learned practically from each other, that is between institutions from that is between institutions from friends, relatives and whoever. But we improved on the basis of a lot of simple things, cooling a kidney, how long and just a whole variety of adventures.
Randall Sung: Can you describe some of your more memorable moments in transplantation, you know either triumphant or embarrassing or amusing?
William Pfaff: The memorable moments in transplantation were probably individual at times and particularly with patients that you enjoyed warm friendships with. When we first started doing children, because we had children galore in our program at a fairly early point because we had a pediatric nephrologist. Most people didn’t, so we were transplanting children from South Carolina to South Florida.
And I had one colleague who once they had a pediatric nephrologist offended him by hitting him on the jaw and so as a result, that pediatric nephrologist sent all of his children to Shands Hospital at the University of Florida. That continued for a while. But I can’t remember very many embarrassing incidents. It’s the kind of thing I think most of us would choose to forget. But it just didn’t happen very often that we were over-wrought, overcome by nature as it resists in rejection and all that follows, no question.
When we first encountered CMV [cytomegalovirus], we said “God, this is a horrible consequence.” One of those very friendly patients that I talked to you about earlier was an airline pilot who was just a joy. And about ten weeks after transplantation, he got sick as stink and he got sicker and sicker and died. And those always bothered all of us; we had a pretty coherent bunch. And so most of the time our attitudes toward patients were shared, collective and were similar and we had some patients that nobody liked. We had a lady by the name of… Well her last name was Pleasant and she was known as “So-and-So Unpleasant”. But she liked me and I found her frustrating at times, but also could enjoy her. She was, she was brassy, she was loud, she was demanding of the nurses, she was abusive to nephrologists, but she liked me and I liked her. So we got along.
Let’s shift to the formation of SEOPF, which was essentially the first organ allocation organization, I guess you would say. I became interested in the Southeastern Organ Procurement Foundation, SEOPF, at the invitation of a bunch of guys. When they decided to expand, they were going to do so gradually and a guy by the name of Jim Pearce, not related to Gene Pierce, P-e-a-r-c-e, thought there is no possibility that a small city like Gainesville, Florida, still only the county is 200,000 and the city is 100,000 with probably a large number... I have never been able to figure out how many of the university students are actually legal residents of Gainesville and how they are counted. But we were told that no, we couldn’t join. We could become an associate member because they were going to concentrate on the bigger cities.
So Emery had already been in there and was an early member, Miami was added. My friend Ben Vander Werf was then the head of the program in Miami and it turned out that we did more transplants than Emery for a long, long time. So it’s only in the recent times that... But we were drawing patients from all of Northern Florida, Southern Georgia, some from Southern Florida for a variety of reasons, and so we actually had a pretty wide draw that contributed to our growth. For a time, there was no transplant program in Orlando and the senior nephrologist there was formerly one of our fellows, and so that was a draw for a time. But all of these things evolved over the years, and Jacksonville for example has a transplant program and has had for a number of years.
But Gainesville was successful, the quality of the program was always competitive and so we joined SEOPF about a year or two after were turned down and that was a consequence of our interest and ultimately theirs.
Randall Sung: How did you get organs prior to joining it or prior to the existence of SEOPF? Were there battles over donors, how did it all work?
William Pfaff: The start of organ procurement in our institution was pretty crude. I had a physician assistant at a very early point. He was in the first graduating class of our own institution, so he became a jack-of-all-trades. And amongst other things, he became involved in organ procurement and ultimately that was his main job. But he started out doing what PA’s have always done on our service, as an adjunct to the conduct of the service. And it’s always been particularly true in transplantation. Only in recent years have they been added to other services. But we started out with a PA; of course I was my first coordinator.
And the first time we shared a kidney, we had a Baxter Travenol preservation device that came out just a little bit before Fred Belzer’s machine became available. So I said “Well Ben is going to try the Belzer one that came out.” So I said “Well why don’t I go ahead and try the Baxter one and we’ll see how they compare. In the meantime, we’ve got something to get some experience with both in the lab and then ultimately in a quick transit from Gainesville to Miami.”
That was an adventure because a medical student and I did it. And we arrived at the VA Hospital where the transplant program was then being carried out, almost out of oxygen, almost out of ice, we got the guard to get us oxygen and ice and had called Ben beforehand and so he was soon on site. We went to bed for a couple of hours because I had done the first kidney in Gainesville, did the transplant and then we got in the car and drove. But that was a memorable night. We did get a hamburger along the way.
Randall Sung: So you had to go all over Florida and the Southeast?
William Pfaff: Well we were sharing before there was. . . Before we were members of anything, so we decided we would share within Florida and the only two programs at the time were Miami and Gainesville. And so Ben and I also conducted a couple of studies together and we became pretty fast friends.
Randall Sung: And was it in SEOPF, was there uniformity or was there a lot of disagreement with respect to who was going to get what organs; it’s essentially sort of the beginning of policy?
William Pfaff: The priority for sharing in SEOPF was left up to the institutions to begin with and that sharing was voluntary. There were institutions that agreed to share all the time, there were institutions that agreed to share some of the time and there were institutions that said, “I don’t want to share. I will neither give nor receive.” We said, “That’s fine, you are the control group.” And so we were aiming at several matters, number one the issue that existed for twenty-some-odd years is to whether or not matching is imperative and if so, how much? And how deep does the match go?
And the other issue that I’m going to talk a little bit about tomorrow is what’s better, reducing ischemic time and getting a higher probability of immediate function or transplanting a patient who is highly sensitized and needs a well-matched kidney in order to be successfully grafted or the advantage of a well-matched kidney on an individual who is not sensitized versus the cost, particularly in ischemic time that ensures? This was a particular problem for us in that we didn’t have a major airport with international planes coming and going, transcontinental or trans-whatever. Everything that comes to Gainesville has to pass through Atlanta and so that offered a temporal impediment then added to ischemia time. So preservation became an important element in the relative success across the whole field. But initially the airline said, “You’ve got to fly first-class. You have to have a first-class ticket for the machine and you have to have a first-class ticket for the coordinator.” The advantage is that the coordinator accumulated massive amounts of free flying points and we all... I never really asked whether they put the two drinks, they were always allowed anybody that was flying in first class whether they put them into the machine or not. And we never did a study on that.
Randall Sung: I assume that you saw the transition and were probably well involved with sort of... UNOS is kind of modeled after SEOPF is my understanding or at least the intent of it was. You know, what was that like taking a more smaller organization and sort of expanding those principles nationally, if that’s what happened?
William Pfaff: Actually the relationship between SEOPF and UNOS is pretty complex. SEOPF actually grew and the southeast actually extended north to Wisconsin and New Jersey and West to Arizona. So sometimes you will see maps that emphasize a state where they are distorted. Well the southeast was distorted, because ultimately we had eighty-two members. Now a number, a modest number of those members were tissue typing laboratories or OPOs [organ procurement organization] that served multiple institutions and were represented by usually their director. But the vast number were transplant programs and were either represented by a surgeon or in some instances, a number of instances, nephrologists.
The evolution was really forced in that the National Transplant Act really initiated by Congress, and particularly after the Gore hearings, demanded a national system. I don’t know… There was, I don’t remember who the players were who said, “Wait, it isn’t fair for some individuals to get shared kidneys and others not. That there would be a national system was demanded and shoot, we had to go along with it. Because if there were going to be criteria on which payment was based, there were going to be new realignment of organ procurement organizations. There were going to be new realignments of a variety of associations as it evolved.
I... I was not bitter about the coming of the United Network for Organ Sharing, UNOS. But I was very fond of my days in the Southeastern Organ Procurement Foundation because of the interrelationships that we had that were sort of central to our education. So I learned from people all over the southeast and the expanded southeast. And people who were directors and thus many of them heading their own transplant programs in their institutions had a lot to contribute and we had a lot to give each other. And so it was that personal education, interpersonal education that was important. The same applied to the other disciplines, I mean were taught histocompatibility by quite a variety of people. We were taught via our own coordinators, near and distant, about new refinements, new approaches and new successes, so I regaled.
But we kept SEOPF for a good number of years because when you sent off one guy from the southeast, because initially what is now three and eleven was one. I’m not sure I have got the numbers correct, the distinction between the various regions, but the southeast split at a later time, four and eleven maybe. Unimportant, but the southeast originally had less representation. It had the greatest population for the southeast region and that was to present the idea that SEOPF was not going to be a big grab giant that was going to take over the national system. But actually of the original members of the leadership, the presidents, a disproportionate number were from SEOPF because of their history and interest.
And so John McDonald I think was... Well actually Mel Williams was the first president sort of by acclimation and that related to long-term relationships between SEOPF with Gene Pearce and recognition of his talents and so the first fully elected president. I think we elected Mel by acclimation at an organizational meeting. The first widespread election took place and John became…
I was on the original board and the years on the board were extended so that what was initially going to be one and two years were two and three just because everybody was learning the new ropes, many of which of those ropes were imposed by the Department of Health and Human Services.
Randall Sung: Do you see many differences at UNOS at that time and today?
William Pfaff: I’m not as familiar with how UNOS. The questions is, you know is there a difference between UNOS now and then? I knew more about things that happened from 1986 through 2001, well 2000 I guess, when I was a past-president. And there were subtle changes, there was... The major task of the organization has always been organ allocation and it gets talked to death. Well not quite to death because it rises up again each and every meeting. But the idea of allocation is all-consuming.
The relationship with the government keeps switching and so things were sort of... Were not as much a mal-relationship perhaps in the very early years. In the middle phases, particularly during Donna Shalala’s term, we had a nasty time of it. And it happened to overlap with my presidency and she seriously was wanting to get rid of such an organization that was dominated by physicians and surgeons and other nasty people like that. I don’t know that she has ever said this, but that’s what we thought. And so there was consideration on her part in having the Rand Corporation do the job.
The advantage always in both organizations, Southeastern Organ Procurement Foundation and United Network for Organ Sharing, has been the wisdom of the members on the board and the feedback that was achieved either through regional meetings or other conversations with their colleagues elsewhere. So the idea of taking or trying to gather the expertise of any field that is going to develop further or has a problem with equity for the general population has been the development of new information from those people who have something to give. And most of them are willing to do it.
Randall Sung: Switch gears a little bit; you talk about your involvement with the ASTS and what the society meant to you.
William Pfaff: The AST was initially brought into I guess pre-birth at a meeting of the American College of Surgeons, I think in 1973. And it seemed like a good idea, the problem was the transplant... Transplant society met then I think over only every two years. It was a meeting that many people would not likely attend and particularly with a large number of younger people. If you asked a Chairman of the Department of Surgery if you could take a little trip to Europe, most of them have reservations, probably even more today. And so getting a variety of people to participate, and particularly junior people, was very difficult.
The early meetings of the ASTS were a delight. They were all at the Drake Hotel. We went back to the Drake year after year. Started outgrowing the ballroom at the Drake, but it was... We during breaks everybody got a chance to talk to friends from distance. I always thought it was an addition, a valuable addition. I gave a paper I think the first or second meeting and it was just good sport. But in particular, it was another opportunity aside from those that we have talked about, to gather with your peers and talk openly and without rancor in the main, occasional rancor.
Randall Sung: How has transplantation impacted your life?
William Pfaff: The impact of transplantation on my life has been immense. It’s the best decision I ever made. I have had more fun learning, doing, improving, sometimes really achieving and I particularly enjoyed my role in the organizations that relate to transplantation. I mean I have told you that SEOPF was a blast. Our state organization was a blast.
Simultaneously, we obtained funding for end-stage renal disease within the state before there was anything else. And so we talked some money out of Tallahassee, an impossible task these days. We made rabbit anti-thymocyte serum for use at the University of Miami and the University of Florida and it was funded by the state. As time went on, they said “Well I don’t know whether we want to do this anymore.” And we said “Well you know getting into the manufacturing of anti-thymocyte serum could be a problem at some point in the future.” So for ten years, we made our own.
A couple of friends of mine, immunologists, were the producers. Well the rabbits were the producers, but on the other hand rabbits produce well anyway. But for a time we thought it was a good idea and then began to question whether it was in truth. And we finally decided it may not be necessary. At a later point, our program switched to ATG. They probably had better controls than we did, production controls. They may have had better batch control and so there were a lot of facilities that we lacked. But overall the fun of transplantation has been both clinical and intellectual and personal.
Randall Sung: Those are all of the questions I have. Is there anything else that you’d like to talk about?
William Pfaff: I haven’t got anything right off the top of my head. I’m a little sleep-deprived and that will impair, but I am also getting hoarse. Tom, you got any thoughts?
Randall Sung: Because that’s the way the... Tell us several vignettes that you might recall from your presidency of both SEOPF and of UNOS. I can remember some frustrating times when you were President of UNOS, spending weekend after weekend at stupid meetings and so on. But whether the frustrating time or the good times, could recall because I think that you have a unique position in our honorees here having been President of both of those organizations and oddly enough, I never figured out why not President of the ASTS. So if you could talk a little bit about SEOPF and UNOS a little bit more.
William Pfaff: At times there were frustrations in both SEOPF and UNOS that were products of different matters. And in SEOPF the ones I remember best were how we solve problems and in general, it was by consensus. So a wouldn’t do it. And we always thought that if you had that close of a vote, the problem was not going to be solved and the participation and willingness would be absent. And generally those relative figures would switch with conversation, so those who were for it may not have been as strongly for it the next time we talked about it a few months later. And so a is not convincing for a change in policy and so most of the time we went all the way to come up with a better solution, a better explanation, a better approach, but so that we had consensus. If it was going to be worthwhile and the effort that everybody was going to put into it.
All of the membership were volunteers and all of the attendees were volunteers, because there were oftentimes more than one individual attending the meetings, so that you might have one director who was the voting person, but there were nurses, coordinators, and histocompatibility people on occasion. Each of these groups had their own workshops that would be conducted at the same time. But every once in a while, we got into a good wrestling match and with people who were very honest about it with each other, say “I don’t think you should do this because. . .” And then you would carry on from there.
I didn’t feel that I was frustrated ever when I was an officer in SEOPF. Sometimes actually I was frustrated with the length of the Executive Committee Meetings, which used to be unending back in the seventies and eighties, particularly the seventies. We must have had more serious talkers then.
In UNOS the frustration was usually external. Oh I take... No, that isn’t true, it was internal as well and I’m sure that you were aware of the big wars over livers, the liver wars of 1998 to 1999. And there was a gang of seven, seven large programs that said “Oh we don’t want to give up our priority, our primacy.” And there were a bunch of smaller programs, interestingly generated by graduates of the bigger programs because not everybody could stay in Pittsburgh or not everybody could stay in San Francisco, they had to go elsewhere.
For a time, there were large populations of surgeons and still are in those institutions. But most patients who have end-stage liver disease could not afford the bus and cannot get in short of three day’s time from someplace deep in the depths of the middle of the county to Pittsburgh. And once there they had no means to feed their families who wanted to come and see what happened when father, son, brother or cousin has his liver transplant and was going to be saved. You always had to go when somebody is going to be saved.
But the external frustrations during the Shalala years were real. It was a matter of who was going to call the shots and we ended up essentially at a stand-off with the shots largely being called by the Board of Directors. And it we were fearful that it would be much, much worse and that we would have somebody who was a six-month expert in the Department of Health and Human Services who would deliver edicts. And I don’t know whether we were really close to that or not, I just don’t know, because I don’t think we were ever square with each other, that is the government and the board.
There were many ideas particularly regarding openness on the board; they were very different, because the whole purpose of SEOPF was collegiality and learning from one another. And the whole effort in UNOS has been to meet a perceived need. And some of them were controversial as Hell, as a matter-of-fact many of the matters that you have put on the program for this meeting amplify that. I mean life-years, I have always had a problem giving priority to any individual group, the young, the old, the rich, the poor and I always felt that every patient that we accepted for transplantation was getting a roll of the dice because a lot of them were not going to be transplanted. They would sicken and die and lose their opportunity at some point because of the bad things that happen to people with end-stage disease, kidney or liver or whatever.
And so is the preservation of a child, middle-aged or elderly person more important? It depends what their contributions are and their contributions are so different. Is a grandfather’s ability to have influence on his grandchildren important? Yes. Actually, we made such a priority many years ago when we first started, we’re choosing patients who are going to be transplanted and that was a committee function that included the nephrologists, surgeons, pediatricians in our program.
And for a time we thought the best thing we could do was transplant a young mother, because she gave success not to just her life, but those of her kids. Grandmothers are okay, but mother are important, more important most of the time. So I can’t define what a criteria would be, a criterion would be that is most important in deciding who gets a kidney. And so I thought if we accepted somebody, they should have an equal shot, because I have transplanted some patients who turned out to be terrible people. I have probably failed to transplant a large number of people who were wonderful people because they didn’t get... Their roll of the dice didn’t turn correctly and so I think I sort of stopped guessing. I said, “If we accept them, they get to roll the dice.”
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