"So I would encourage the younger people to attend the [ASTS] meetings, read the literature, and think. When you get busy, you don’t think anymore or you don’t think very much in an imaginative way...
The word “thank you.” If the patient goes home and is successful and has a good kidney, then they were always very appreciative and that to me was by far the most important thing. If someone would say thank you and I knew they were better, that meant a great deal and the financial aspects of surgery are not very important. I’d rather have the thank you and a good result any day than worry about the financial aspects, and we didn’t do the billing you know, somebody else does all of that and the collections. But I was always appreciative of the families that would say thank you."
Arnold "Gil" Diethelm, MD served as the 18th President of the ASTS. He graduated from Cornell Medical College in 1958 and following a general surgery residency completed a fellowship at the Harvard Medical School. In 1967, Dr. Diethelm moved to Birmingham, Alabama where he initiated clinical transplantation activities and performed the first successful kidney transplant in the State of Alabama. Dr. Diethelm led many transplant efforts in the Southeast, embracing early efforts at organ sharing, and he continues to work actively in the organ procurement organization serving the citizens of Alabama. A transplant recipient himself, Dr. Diethelm received a new liver at the age of 70 and adds the perspective of being a transplant patient to his great leadership accomplishments in organ transplantation.
Arnold Diethelm: I’m Dr. Gil Diethelm from the University of Alabama, a kidney transplant surgeon since 1967.
Steve Bynon: Arnold Diethelm, can you tell us what interested you first in transplants surgery?
Arnold Diethelm: In 1962, I saw the first of several kidney transplant procedures done at the New York Hospital. I wanted to go somewhere where I could learn about immunology, transplantation and I had three ideas. One was Denver with Tom Starzl, one was Richmond with David Hume and the Boston was closest and they were willing to take me on. And at that time Roy Calne was in Boston and had just left. And Ross Sheil from Australia, Guy Alexander from Belgium had just left and so there were a number of people that I could follow.
Steve Bynon: Could you tell us a little bit about your life at the time as a transplant fellow?
Arnold Diethelm: Well transplant fellows in 1965 to 1967 were really research people. There was no clinical training program. I saw a few transplants and I must say that the clinical side was much of an afterthought to the fellowship.
Steve Bynon: Can you tell us one of your most memorable experiences as a transplant fellow at that time?
Arnold Diethelm: Well the most memorable experience was just before I was a fellow. The Governor of New York was pressured to have a prisoner at Sing Sing Prison in Ossining give an unrelated kidney to a child at the New York Hospital. And I went up to Sing Sing and there were three of us and that was a very impressive trip, depressing is what the word was. It’s a very serious place, nobody walks fast, nobody laughs, nobody shouts. The operating room was the bare essentials. The donor was a very nice young man; don’t know what he had done. We took the kidney out and the faculty surgeon did.
We took it back to New York on the New York Thruway going about 85 miles an hour. And I remember coming up to the toll gate and it looked like a needle and it got a little larger and a little larger and I don’t think the driver slowed down much under 80 and the kidney didn’t work and I was really discouraged with that.
Steve Bynon: How did that affect your thought process about becoming a transplant surgeon?
Arnold Diethelm: First I thought I better learn something about it and second I wanted to become a good one, or try to become a good one. And I knew that I was going to have to go somewhere and spend some time in order to do that.
Steve Bynon: What about later in your life, what are some of your most memorable events in transplantation as an attending physician?
Arnold Diethelm: Well the first several transplants in Alabama were an interesting experience. Nobody had ever done a transplant in Alabama; they had no interest in it. And a new surgeon, a chairman of the department, Dr. John Kirklin, had just come. And Dr. Kirklin wanted to make transplantation an important part of his beginning department and he and the President of the university provided the support and this became an institutional program. So it was really through the efforts of Dr. Kirklin and the President of the university, Dr. Joseph Volker that allowed the program to succeed.
Steve Bynon: Can you tell us how transplantation has affected your life?
Arnold Diethelm: Well it provided food for thirty-four years and then I developed the end-stages of hepatitis C, I guess in 1999. And I knew I had hepatitis C, I contacted the disease at the New York Hospital in a general surgery operation in 1964. And I had hoped that something else would get me before that did, but it didn’t. And I noted three things, first was a great deal of fatigue, I mean serious fatigue where you get up in the morning, feel well and at noon you are exhausted. I stopped operating because I couldn’t really get through a two hour operation. I never told anybody. Then I began to lose weight; that was the second feature, about twenty-five pounds. And it was to the point I would lose a pound or two a week. I never really thought too much about the illness until that point. So when all else fails, you go see a doctor.
And I went to see an internist and with some x-ray studies and some blood studies, it was obvious I had end-stage liver disease with hepatocellular carcinoma about two centimeters. And I must say I remember looking at those films, I was looking very carefully to see if I had a six or an eight or a ten centimeter lesion, but we just found that one two centimeter. So I had two choices, one was to do nothing and the second was to have a liver transplant. I didn’t talk to a lot of people in the country; I talked to Tom Starzl on the phone and told him just what I said to you. And we both agreed that probably a liver transplant would be best. I didn’t think I had enough liver reserve for a resection, I was sure I didn’t and I’m sure that would have been the right decision.
So with all of that, I really had to come to grips of a problem of taking a liver of a young woman who was 30 with two children might have or might need more than I did. I was 70 years old, had a good life and I couldn’t complain. But at that time the liver, as I remember, the tumors fell into a separate list. So if you had a liver tumor, you are not competing for a liver with a 30-year-old mother without a tumor. So at any rate, I had to make up that decision. I did it with the help of the people at Alabama and the transplant surgeon. And I didn’t jump too quickly; I must say I took two weeks or so to think it all over. And then I thought that sooner or later a 70-year-old man would have something the matter with him that would rule him out for a donor.
So I thought, “Well surely there is something else going on and I will probably be excluded.” And it didn’t work out that way, fortunately everything else turned out fine, except for the liver problem. So then the longest wait in the world is to wait for the telephone call for a liver or any organ. First you didn’t know it was going to come and second you weren’t really sure when. I didn’t want to go more than twenty yards from the house for fear I wouldn’t get the telephone call. And people would call me and I was pretty short on the telephone. I didn’t want to have a lot of conversation.
Then the liver did come, it came from a young woman, which was fortunate. A car accident, a perfect donor, and all organs were used, liver, heart, lungs, pancreas and both kidneys. So I went through all of that very well and I am a very lucky person. I realize that it is more luck to get the organ; it takes skill to make it work. And it takes a lot of work by a lot of people, the surgeons, the nurses, all of the other physicians that played a role.
Steve Bynon: Can you tell us about your early recollections about the ASTS, the American Society of Transplant Surgeons?
Arnold Diethelm: Yeah, I guess it was about 1972 or ’73 that I heard the Society was going to be formed and I thought it was a very good idea. Tom Starzl was the first President. His talk was brief, directly to the point, didn’t predict great things for the Society, but said it would be up to the people in the future and I think that has been true.
Steve Bynon: What advances in transplantation do you think are probably the most important for the patients today?
Arnold Diethelm: Well I think there have been two major advances in transplantation since 1967. The first is the development of immunosuppression. And there are two or three turning points in all of that. First was azathioprine and then combining it with prednisone, the second was cyclosporine and the third was Prograft. And I think without the development of immunosuppressive therapy, we’d still be similar to what we were in 19... Say 1970 or 1968.
The second major contribution was Fred Belzer’s contribution to organ preservation, a tremendous advantage. So I think that the two great advantages in transplantation have been the development of immunosuppression and I must say much of that has come from the pharmaceutical companies and then organ preservation, which evolved out of Fred Belzer’s interest.
Steve Bynon: What role do you think the American Society of Transplant Surgeons provided in allowing these advances to occur?
Arnold Diethelm: I think the American Transplant Society is first formed a program for discussion. In the early days, the discussion was more interesting than papers. And one was always interested what David Hume would say or Tom Starzl or John Najarian. As time went on, the papers became better, more thoughtful. And I think that they American Transplant Society was one of the first specialty societies if you want to use that word that came out of general surgery.
Steve Bynon: Could you have ever imagined in 1958 or 1960 that transplantation would be where it is today?
Arnold Diethelm: No. There have been four or five major fields of surgical advance since 1950. Cardiac surgery is one that evolved from the use of the pump oxygenator and cardiopulmonary bypass. Dr. DeBakey’s vascular graft is another one. Dr. Francis Moore’s contributions to the metabolic care of the surgical patient were tremendous. Dr. Stan Dudrick and Dr. Rhoades contributions to hyperalimentation, all of those played a tremendous role in the development of surgery between 1950 and 1970. And I think in many ways, transplantation benefitted tremendously from the opportunistic development of the immunosuppressive drugs.
Steve Bynon: If you could give a young member of the ASTS one piece of advice, what would you tell them today?
Arnold Diethelm: Well any advice I give them would not be very good and I think that the field of transplantation is caught in a quagmire. Its success has been so tremendously valuable that there is no doubt that if one can receive a kidney transplant or a liver transplant, they are much the better for it. The problem is in not enough organs. And the shortage of organs has become the major obstacle as I see it. And when you just think of people that die from liver disease that could be helped or if the people on dialysis, hundreds and hundreds or people have nothing to look forward to every day but another day on the machine. So I think the solution to this is a xenograft.
And I remember a very prominent transplant surgeon, I won’t mention his name, said the xenograft is just around the corner and it will probably will always be just around the corner. I don’t... I think he was a bit pessimistic at that moment. And I do think if you think of the xenograft of today, it’s not any more of a futuristic concept than cadaver transplantation was when I was at the Brigham, which it was almost unsuccessful. We had one or two patients that survived. So I think if I were a young person, I’d take a very hard look at the field of xenograft.
Steve Bynon: What role do you think the society should provide in the future of transplantation in this county? Which direction should they take, do you think?
Arnold Diethelm: I think the most important thing is to have a very good program every year or twice a year and address complicated questions and try to stimulate the younger people to think about it. There is a tendency to avoid hard questions. And I used to in one of my more pessimistic moods; I would look at programs, not just the American Society of Transplant Surgeons, but other, and see how many papers were on the program that had very little importance. And then the really difficult papers, there were very few. And it’s not surprising, it’s hard. It’s very hard to deal with the difficult questions and I think the xenograft is sort of in that position.
So I would encourage the younger people to attend the meetings, read the literature and think. When you get busy, you don’t think anymore or you don’t think very much in an imaginative way. There is a tendency for the busy surgeon to be involved with the day-to-day workings of the program, and that goes for cardiac surgery or any other aspect of the field. And I think that was an advantage back in the ‘60’s. We weren’t so busy; we had more time to think. I don’t know that we thought up any great solutions, but we did have time to think and talk and the meetings were very collegial. You could talk to people, listen to other people and the people that spoke then are the ones that we’d listen to today, Tom Starzl, John Najarian, David Hume and a number of others. Fred Belzer for sure.
Steve Bynon: Can you tell us about some of the most influential peers that you had in transplantation during your career?
Arnold Diethelm: I think since I was a young person in those days, I really didn’t know the people personally but I knew of them and I listened to them at the meeting. I think Dr. David Hume was a tremendously important person. He was very intelligent, very thoughtful, had a huge energy drive matched by maybe only one other person in transplantation. So I think Dr. Hume would have been maybe the leading surgeon of the fifties and sixties.
Fred Belzer was a very good friend and someone that I had great respect for and he made the major contributions in organ preservation. Fred said before he died that he had hoped to spend his last couple of years in cardiac preservation. He was quite sure that they could do better than what they were doing. The cardiac surgeons weren’t much interested in it. It’s interesting that all of the work that went into cardiopulmonary bypass and perfusion never related to preservation after the operative procedure.
I think one person that is often forgotten is Tom Marchioro. Tom worked with Tom Starzl for a number of years at Denver. He was an enormously hardworking, energetic individual and then when he ran the program at Seattle, the University of Washington. So those are several people that I would mention.
Steve Bynon: Okay. Doctor, could you tell us a little bit about the very early days of kidney transplantation at the University of Alabama, Birmingham?
Arnold Diethelm: Well the early days began in May of 1968 when we did the first living related donor transplant and we followed that with two cadavers and two more living relateds. And then we took time off to create the anti-thymocyte globulin which we had to do in our laboratory. The... We started the transplant program in the VA hospital because there weren’t beds in the university hospital or operating room time.
Life was different then and we really had very little support, except from Dr. Kirklin and Dr. Volker. Now the people in Alabama were suspicious of organ transplantation. They didn’t really think too much of it. The faculty thought it was just some idea out there and I had no competition. So we primarily stayed with living related donors until we put together a procurement program. The procurement program was started in 1974 or 1975 and that’s when we joined up with the Southeastern Organ Sharing Program in order to utilize the organs that we couldn’t utilize. We often had a lung O list and a short A list and we had to transport those A kidneys. So the Southeastern Organ Program was really a very valuable tool or instrument.
It led us to developing the organ procurement program which became quite an enterprise over another ten years and added a great deal to the total volume of kidneys that we transplanted every year. We had I guess maybe close to 50% relateds and 40% cadaver transplants. The development of organ procurement is a complicated and very hard, demanding program. I used to go on the runs for the kidneys. And you would get called and you would make the run and you would go down to the Gulf Coast and then it would be fogged in and you couldn’t land and then you would wait a little while and the fog would lift and you wish they still didn’t land because you couldn’t see anything. And then you would procure the kidneys and go back home and then start the transplants. And for a long time, I was by myself and so it would take eight, ten or twelve hours to get both kidneys transplanted and the patient squared away in the intensive care units.
So in those days, the organ procurement program was very simplistic. Now we have lots of coordinators and lots of surgeons and the work can be done and spread around in a very realistic way.
Steve Bynon: Can you tell us very much about the early days of UNOS and how that would relate to... It’s such a universal thing now.
Arnold Diethelm: Well I think the United Organ Sharing Program really was essential. And I used to take the attitude and some of my colleagues that I won’t mention took the same attitude that I shared every kidney that I couldn’t use and some people wanted sharing on a broader basis. But it’s awfully difficult to go through the whole procurement process and have a perfectly good recipient waiting for that donor organ and then to send it to the Northeast. And if that word got out in the state of Alabama, I might have been looking for another opportunity. So generally speaking, I tried to keep the organs at home. If we couldn’t use them, then we always shipped them out.
Steve Bynon: Can you tell us what you think the kidney transplant program means to Alabama, just out of curiosity? Or to the people in the southeast or…?
Arnold Diethelm: Well our kidney transplant program grew over a period of twenty to twenty-five years to one of the busiest in the country. And there were a period of ten years, consecutive years, that we were the busiest. The reason was really quite simple, first of all one has to know how to recruit nephrologists and the nephrologist sends you patients. And no patient walks in the front door of the hospital and says, “I want a kidney transplant.” It doesn’t happen that way.
So I went around and visited every nephrologist in the state of Alabama, a large part of Mississippi and a large part of Georgia. And I would visit them myself and let them know who I am and then I would write a personal letter to them. And I didn’t ask them to send us the patients; I just wanted them to know we were available. And then periodically I would send them a summary of how were doing and what the results were of living relateds, the cadavers and what our immunosuppressive protocols were and it worked out very well. And I think that had a lot to do with the volume. The kidney transplant program is the only program at Alabama. We were especially involved in the African American patient that underwent transplantation. And for reasons that aren’t clear today, the Caucasian does better with a kidney transplant than the African American. That has never been understood and I think there are a few ideas, but they are not to be discussed now really.
I noticed that Ron Busuttil recently showed that with a liver transplants, the results were the same so now that we have to reconsider not just the race, but perhaps the primary disease in the kidney recipient. And it may be that the African American has some different diseases that are more likely to recur. So perhaps rejection, chronic rejection in the African American is more a matter of recurrent disease than it is chronic rejection, that’s just a thought.
Steve Bynon: One last question, if I could phrase this correctly. Some people always told me in the past, you know you mentioned early, talking about rewards of having kept food on the table for thirty-four years, what is probably the most important reward you get from a patient?
Arnold Diethelm: The word “thank you.” If the patient goes home and is successful and has a good kidney, then they were always very appreciative and that to me was by far the most important thing. If someone would say thank you and I knew they were better, that meant a great deal and the financial aspects of surgery are not very important. I’d rather have the thank you and a good result any day than worry about the financial aspects, and we didn’t do the billing you know, somebody else does all of that and the collections. But I was always appreciative of the families that would say thank you.
I am now seven years post transplantation from the liver transplant and I am very grateful not only to the donor and the donor’s parents because after all, the donor couldn’t give permission since they were unable to speak and brain dead. So I felt very grateful to the parents and I must say I not infrequently thank the parents. I wrote them two letters and then I didn’t want to write anymore. I think it’s painful enough to hear it once or twice, but to hear every year a thank you letter, I thought that was too much. And if anybody has ever had a family son or daughter that died, after a while you try to forget those days. So am and will always be very grateful to the family and I outside of writing those two letters to them anonymously, I certainly thank them frequently.
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