"ASTS has been, of course, very important and very successful. It’s interesting that, in the beginning; and I guess this was 1974 perhaps when it began with Tom Starzl as the first president. And one of my colleagues in Philadelphia, Banet and Fred Merkel encouraged Tom to participate in the formation of this society. I must say that in the beginning, I think that I was not sure that there was a need for such a society. And there were a lot of others who were in transplantation and in immunology who thought that it would be a redundant society, that there was already a society, an international society, of transplantation, and that this really wasn’t necessary. That turned out to be totally wrong."
Clyde Barker, MD serves the University of Pennsylvania as Donald Guthrie Professor of Surgery with a distinguished career at that institution as its Surgery Department Chairman and Director of its Transplant Program. Following his medical school years at Cornell University, he trained at the Hospital of the University of Pennsylvania serving his internship, residency, and a fellowship at that institution. He initiated that clinical transplant service which has grown to one of the largest and most successful in the world. Dr. Barker, a charter member, served as the 19th President of the ASTS during the years 1992-93.
Goran Klintmalm: We’re going to talk now about your involvement in transplantation. The first, let me know how you got interested in transplantation. What made you do this?
Clyde Barker: Well, my interest in transplantation is an interesting story, probably of interest only to me, but I’ll tell it anyway. When I finished my surgical training at the University of Pennsylvania, I was hoping for faculty spot, but it didn’t appear that there was any opening at the time, and I knew that transplantation was one field in which the University of Pennsylvania was not participating at the time. Now, this was in 1964, and there weren’t a great number of transplant programs anywhere in the country. But, at Penn, which was a very conservative institution, there was the feeling that transplantation wasn’t going to work and it shouldn’t be done there. But, I recognize that as a field that might be one in which I could catch on and get a faculty position at Penn. And therefore, I decided that during a vacation month, I would tour the transplant sites in the United States and see whether I really did have an interest in transplantation. And so, I visited some have a dozen transplant programs, and I found that I was very interested in it, particularly when I visited the University of Colorado, where Tom Starzl was just beginning his program. And in fact surely before I was there, he had done the first liver transplant, although this was not the first successful one. And I actually got a chance to scrub with Tom Starzl on a case, and that convinced me that I should be interested in transplantation. So, I returned to Penn, but decided that I would take a year as a fellow in vascular surgery, since the senior surgeon at Penn had been designated as the person who would do renal transplantation if in fact it was better to be done at Penn.
Well, I spent a year as a vascular surgeon, which turned out to be good because I made my living doing vascular surgery for the next ten years or so. But during the year that I was a fellow, there were no real transplants done, and therefore it the end of that year, I decided that I would take a year of basic science research in transplantation. And fortunately for me, Dr. Rupert Billingham, one of the pioneers in transplantation surgery, had just come to the University of Pennsylvania as the Chairman of the Department of Medical Genetics. And so, I went to work with Billingham for a year, and we developed a rather good relationship, and in fact, I worked with Billingham in his laboratory, just the two of us, on some experiments in which he was very interested in, in immunologically-privileged sites.
And in fact, he was so interested in the project that we were doing, that at the end of that year, he felt that I …. that he, was anxious for me to stay on, on the faculty, and as a result of that, he was able to convince the Chairman of Surgery, Jonathan Rhodes, and the Chairman of Medicine, Frances Wood, that maybe they should let me start a transplant program, which I did. And at that time, there was not any transplantation going on in Philadelphia, and in fact, there was very little care of end-stage renal disease patients. In fact, at the time, there was only one dialysis machine in Philadelphia, and only one patient who was on chronic dialysis, and therefore, when a candidate for transplantation came along, the alternatives for that patient were either to have a transplant or to die, because there was no room for him on a dialysis program. Fortunately, he had a number of willing family members who agreed to the donor’s of a kidney, and fortunately for me, that first transplant than I did work out, and the kidney functioned promptly. There was not very much trouble with rejection, even though all we have at our disposal was Imuran and prednisone to treat rejection or avoid it. And that patient did very well, and in fact, that patient now, some 42 years later, still has the kidney and has lived a full life with wife and children and grandchildren and is still doing extremely well. So, that was a very good start for me in transplantation.
And in the laboratory, my experience with Billingham continued to be very productive, and I would certainly be happy to admit that that experience with Billingham not only that ….. for that year of fellowship, but for the next six years when I was a faculty member in his department, worked out extremely well for me. We wrote many papers together on immunologically privileged sites, which was his major interest. He did the thinking; I did the work with microsurgery and other aspects of the…technical aspects of transplantation. But I gained at least whatever knowledge in transplantation and immunology that I subsequently was able to use in the clinical field, and that was a wonderful experience for me, and that was really, I guess, a long story as it goes and how I got interested in transplantation.
There were others who helped me along the way. I spent --- During the year of my vascular fellowship; I actually went to the MGH and spent about six weeks in Paul Russell’s laboratory. Paul was not there very often, but Tony Monaco and Mary Wood and others were very helpful to me in schooling me in some of the basic techniques in transplantation research, such as skin grafting of rodents and making antilymphocyte serum and doing thymectomy and other procedures that turned out to be very useful over the years as I…as my career as a transplant biologist evolved.
Goran Klintmalm: Can you tell me how a day as a transplant surgeon was in those days? What transpired? How did…come together? How do you take calls, and what happened with the donors, and how…this all fit in?
Clyde Barker: Well, it was quite a different time and transplantation certainly than it is now. There was no national organization. There was no list, even locally, let alone nationally. There was no united network for transplantation, and we were pretty much on our own. In fact, I was on my own completely for between five and ten years I guess. I usually had a resident with me who was interested in transplantation. But there were no other faculty members that were participating in the transplant program. So, I was on call, I guess, 365 days of the year, 24 hours a day. Now, that was not such a terrible schedule because in the beginning, before the first few years, the transplants that we did at Penn were living-donor transplants, and so it was possible to schedule those at a convenience, at my convenience. And even when we began to do cadaveric transplantation, it was pretty much possible to schedule those cases when we wanted to, to accept such kidneys as we thought would be suitable, and without going through a procedure of inquiring from others around the country, either on a formal or informal basis, as to whether the kidney was needed or wanted somewhere else. So, it was quite a different time. There was a flexibility that we lost when UNOS came in, and of course, without loss of flexibility, there was a great deal of benefit to patients and others. Because instead of deciding which of a group of patients might be most convenient for us to transplant, we actually had a list, in order of… and which patients were to receive kidneys, and that made it much equitable and fair and there is no argument, but this…but that this progress has been beneficial. But it
did remove the flexibility, which allowed a single person at our institution (and this was true at many other institutions as well) to function as a sole transplant surgeon in a program at a university.
Goran Klintmalm: Clyde, how were you perceived in interacting with your colleagues at Penn at the time? How did they see you as the transplant surgeon? What was the impression they had?
Clyde Barker: You during those early years when I was the only transplant surgeon at Penn, I think I got a great deal of credibility which I might not otherwise have had, in that I was doing something that was new, that was exciting, and which was recognized to be important. And I wasn’t competing with others more senior than I, as a vascular surgeon or as a general surgeon. As it turned out, because of that year of vascular surgeon training, I was [11:19] thought to be a vascular surgeon, and what I really wanted to be was a GI surgeon. I only took that year of vascular surgery because I could see that that was a road to getting into transplantation. So I was a little bit disappointed when I didn’t get the referrals to do big GI cases, but instead was doing varicose veins and femoral-popliteal bypasses and things of that sort. But I think I got a good bit of credit and cache for having started this program in transplantation, which by luck, turned out to be very successful, even from the very beginning. So, there was a credibility that someone my ….. my age might not otherwise have attained.
Goran Klintmalm: And as a transplant surgeon, what …. tell me some moments that really stand out in memory, like, you know, the big ….. the big kind, the big, hysto--- hysterical moments. I mean, some of the blunders and all that kind of ….. the rituals that were part of life then, that gained opportunities and gave you breaks that sometimes you didn’t expect ….. and some of those things you got away with.
Clyde Barker: Well, some of the interesting and memorable moments are rewarding ones to think about, and unfortunately, many of them are not so rewarding. Some of them are humorous, but many of them are not. I think that first transplant that I did when I was really a novice and had only seen one transplant done, let alone had ….. not having been trained to do transplantation, that was probably the moment that stands out most in my ….. in my early memories. But there were others. The first liver transplant that I did turned out badly. I got through the operation. And at that time I think Tom Starzl at Colorado may have been the only one in the country doing liver transplantation, and the results, even there, were not great. My patient did not survive. He survived the operation, but not for very long afterwards, and because of that, I called a moratorium on liver transplantation. Even though I had been working on it very hard in the laboratory and doing liver transplants in dogs, I recognized that it wasn’t going to be something that I could do by myself and make a success of. So, it wasn’t…It was another…more than a decade, before I started a liver transplant program and did it then only be recruiting others who had had specific training in it by Tom Starzl. There were some humorous blunders that I made. The one that I remember most clearly, and which I haven’t repressed, because it didn’t cause the patient great harm, was a day when, on a kidney transplant, I sewed the wrong two structures together. At that time, I was doing…I was using the donor kidneys ureter and sewing it into the recipient’s ureter, so that I had just a short segment of ureter from the donor kidney. And it was about the same size as the renal artery, and I sewed the ureter and the renal artery together. When I took the clamps off, it was obvious immediately what [laughter] had been done, and I was able to correct that without any harm being done to the patient. But that was something that I remembered and which, at that time, a young faculty colleague, who’s, unfortunately, now dead, but who a lot of people would remember, Leonard Perloff, was there, helping me with the case. And the senor vascular surgeon, Brooke Roberts, was not scrubbed, but was sort of looking over our shoulder, and after I had completed the anastamosis, but before the clamps were taken off, Dr. Roberts said, “Gee, that’s a beautiful anastamosis,” and ever after, for as long as Leonard Perloff lived, when someone would say that there was a nice anastamosis having been done, we would start to laugh because we remembered that case so well.
There were other very poignant things that happened. A lot of the patients at the time, of course, didn’t survive. Immunosuppression was not good. Initially, the outcome of kidney transplantation, even with a living donor, was no better than 50%, and so, there were a lot
of patients who suffered, and then ultimately didn’t survive. One of the ones that I remember well, which was temporarily…a success, was a patient who had escaped from Hungary and during the Hungarian Revolution when…when the Hungarians were throwing rocks at Russian tanks. This patient had a cadaveric transplant, but did very well, and for about five years, experienced no rejection, and was in great shape. He was a young man, and he had started a business, gotten married and was doing very well. And then he came into the clinic one day, and it was obvious that he had multi…he had malignant lesions, pigmented lesions, all over his back, and it was obvious that this was not something that was operable. And we didn’t know what to do about it. He was started on chemotherapy, and then a few weeks later, after he was already getting sick from his chemotherapy, we got a call from Milwaukee, where the other kidney from the same donor had been transplanted, and had been rejected, and the kidney had been removed and was filled with a pigmented tumor. And so we knew…we knew then that we had transplanted this malignant tumor, and by then, there was nothing we could do for our patient, and he went on to die, and it was…it was a sad recognition that bad things can happen, including transplantation of malignant tumors. And I think that was one of the early recognitions of that, as a matter of fact. Sol Penn of course went on to study that very extensively and had a registry of it.
Goran Klintmalm: How did transplantation impact your life?
Clyde Barker: Well, transplantation has impacted my life in a very important way. It’s, in a way, been my whole life. Not that my family isn’t extremely important to me, and not that I haven’t had a rewarding career in surgery. Exclusive of transplantation, as the chairman of a depart, of a department that I think was very successful for many years, and I was Chairman of Surgery for eighteen years at Penn. Longer than anyone else had been I guess will be for a while, at that institution, which is the oldest in the country. So, there were other things in my life than transplantation, but I would say that transplantation was the major thing in my life, not only as a clinical field, but in research, which was very important to me. In which I spent probably half my time as a young surgeon at a time when that my practice was not large and when there were not great demands on me as a clinical transplant surgeon. And getting interested in the transplantation of pancreatic islets, which was an entirely new field at that time, in the early 1970s, was something that was extremely important to me. And getting to know immunologists around the world through that experience with Billingham, and then subsequently, and following my own research career, was also very important. So I would say that transplantation has been the major factor in my scientific and clinical life, and other than my family, it’s been the thing that’s been the most important thing to me.
Goran Klintmalm: You were around when ASTS was formed. What do you remember of that time, and how do you think? What do you think about ASTS and what we should do in the future?
Clyde Barker: Well, ASTS has been, of course, very important and very successful. It’s interesting that, in the beginning; and I guess this was 1974 perhaps when it began with Tom Starzl as the first president. And one of my colleagues in Philadelphia, Banet and Fred Merkel encouraged Tom to participate in the formation of this society. I must say that in the beginning, I think that I was not sure that there was a need for such a society. And there were a lot of others who were in transplantation and in immunology who thought that it would be a redundant society, that there was already a society, an international society, of transplantation, and that this really wasn’t necessary. That turned out to be totally wrong. It was absolutely necessary, and I think that they that subsequent history has told us that if there hadn’t been a society of transplantation surgeons, that the field would not have evolved in the way it did. There was a certain amount of rivalry and jealousy on the part of those who were important in the international transplantation society. But Tom Starzl and his successors as the early presence the society persisted and made a go of it. And the society, which was initially thought of as being only a scientific society, evolved into one which has been extremely important politically and in the development of transplantation in this country and in the world in many ways. It was important in the formation of UNOS, the United Network for Organ Sharing. That probably would not have occurred, certainly not in the way that it did, if it hadn’t been for ASTS. There were certainly those in the government who might have wished to control transplantation in a way that transplantation surgeons and medical people in transplantation would not have found nearly as suitable. So it was important that ASTS and UNOS and SEOPF, which preceded UNOS in a way, and which Mel Williams and Oscar Salvatierra were able to manipulate in such ways with government influence and by getting together with leaders in the government, such as Al Gore and others, so that transplantation has evolved in the way that it has and in a way that the professionals in the field really have controlled the delivery of care to patients with end-stage-renal disease in a way that might not have happened if it hadn’t been for the ASTS.