UAB Synopsis, Vol. 27, No. 46, December 15, 2008
A native of Baltimore, Maryland, Arnold G. Diethelm, MD, graduated from Washington State University and received his MD degree from Cornell Medical College, with surgical training at The New York Hospital.
Before coming to UAB, he completed a 2-year fellowship at Harvard with Nobel Prize Laureate Joseph E. Murray, MD, who performed the first human kidney transplant (1954).
Dr. Diethelm is the author or coauthor of more than 210 publications in peer-reviewed journals, a member of 26 surgical societies, chair of UAB’s Department of Surgery for 18 years (1982-1999), and the recipient of numerous awards, honorary degrees, visiting professorships, and appointments.
One of the highlights of his career was his appointment as visiting scientist in the Division of Surgical Science and Division of Cryobiology at the Clinical Research Center in Middlesex, England. Working in the field of immunology under Sir Peter Medawar, another Nobel laureate, led to his lifelong interest in the field of immunological and tolerance-inducing medicine.
Dr. Diethelm’s dedication to scientific advancement has helped UAB emerge as an exceptional leader in organ transplantation.
Dr. Diethelm arrived at UAB in 1967 and was given a portfolio to establish a renal transplant program. It was handed to him by John W. Kirklin, MD, chair of the Department of Surgery. Dr. Kirklin had been recruited in 1966 by Vice President for Health Affairs Joseph F. Volker, DDS, PhD. Transplantation was in its infancy and many were cynical about starting a program in Alabama, but Dr. Kirklin had kept in touch with Dr. Murray, his Harvard classmate. Dr. Murray thought the time was right for the new program and recomended Dr. Diethelm, who faced questions over his choice of subspecialty as well as his decision to relocate in Alabama.
UAB Synopsis recently interviewed the retired surgeon about the early days of transplantation at UAB:
Synopsis: Why was transplantation so successful at UAB?
Dr. Diethelm: Two people made it a success, John Kirklin and Joe Volker. Dr. Kirklin was very thoughtful and in almost every way absolutely brilliant. He invested departmental energies into a program that was brand new. Dr. Volker established a $250,000 line of credit at University Hospital to pay for patients to have transplants when their insurance would not cover it, and most policies would not. That money was my lifeline, and I kept an accounting of it locked in my office. I never depleted that sum and I turned a little back to the university after 1973, when Medicare began full coverage for transplantation.
Synopsis: How did you get the program started?
Dr. Diethelm: I didn’t know how to put together a program. I spent the first 6 months developing a research laboratory with no clinical obligations. That allowed us to get equipment, train technicians, and begin some studies. Three months later, on May 8, 1968, we performed our first transplant — a brother-to-brother operation. A month later we did our first transplant using a cadaveric kidney.
Synopsis: What were the original facilities like?
Dr. Diethelm: All the early transplants were performed at the Veterans Affairs Hospital because, at the time, University Hospital didn’t have enough clinical space — beds, operating rooms, or ICU beds. The VA’s director, Clyde Cox, was a wonderful administrator and did as much as anyone to make the program a success.
Synopsis: Did Alabamians readily accept the idea of transplantation?
Dr. Diethelm: People were not out protesting the program; rather, they seemed apathetic about it. But it did gain speed. What paid great dividends over the years was that eventually almost every community had a transplant recipient. We would send a little notice to the recipient’s home-town newspaper saying the patient had been released from the hospital after receiving a kidney transplant, and that was good advertising for us.
Synopsis: What enabled the program to grow so large?
Dr. Diethelm: All kidney failure patients were on dialysis, of course, and under the care of a nephrologist. I visited every nephrologist in the state. I would find some reason to be in their town and ask if I could drop by and introduce myself. That worked well, so we had a personal relationship. For every patient who came to Birmingham for a transplant evaluation, I would write a personal summary letter to his nephrologist. That was something else I learned from John Kirklin, although he did it much better!
Synopsis: You developed a high degree of standardization in your program. How important was that to your success?
Dr. Diethelm: Again, that came from watching John Kirklin. Some people think that it’s too rigid a system and you are too standardized, eliminating the ability to be flexible. I don’t agree. I think you can be very flexible and still be standardized. The important point is that when a new idea comes along that’s better than what you’re doing, you need to convert to the new idea. We did this many times over the years with our immunosuppressive protocols and methods for organ preservation. It was a valuable learning experience for all of us.
Synopsis: What surprised you the most along the way?
Dr. Diethelm: Perhaps the greatest surprise has been the development of tolerable and effective immunosuppression.
The early days could be very discouraging. People forget how discouraging it was in the 1960s and early 1970s. Failure was common, and it was usually not due to technical reasons but because of acute rejection of the organ — as high as 35% in the first year — or infection, usually the result of too much immunosuppression.
Effective and safe immunosuppression is the biggest difference between transplantation today and 40 years ago. The biggest surprise is that the pharmaceutical industry could do it so well, so quickly, and so effectively — after all, there were bigger markets. A derivative of 6-mercaptopurine, azathioprine, came from England, and Sir Roy Caine tried it in dogs at Peter Brent Brigham, with absolutely spectacular results. Up to then you needed an identical twin for an organ donor, but azathioprine combined with prednisone allowed us to use kidneys from nonrelated persons, which meant cadaver transplants were possible.
We conducted human studies on antilymphocyte serum beginning in 1968 injecting horses with human lymphocytes and 2 weeks later obtaining blood. We would drive my Volkswagen to a barn in Trussville for the injections and phlebotomies before processing the serum. The serum injected into patients was a method of preventing rejection of the kidney. Many years later the serum became commercially available. In 1979 cyclosporine was introduced, making heart, lung, and liver transplantation feasible.
Synopsis: Heart and liver transplants started about the same time here, didn’t they?
Dr. Diethelm: I had visited Tom Starzl’s [liver transplant] program in Pittsburgh and was terribly impressed with the patients who had received cyclosporine. I came back home and mentioned to John Kirklin that I thought this drug may be the answer to the heart transplant program, too. UAB started heart [1981] and liver [1983] transplantation about the same time, but again we had a facility problem — we just couldn’t do everything. I was not anxious to have a large liver program that would exhaust the hospital’s resources. I had been fortunate that the hospital had been so generous, thanks to the backing of Dr. Volker and Dr. Kirklin. I did not want to outrun our supply lines, as they say in the military.
Synopsis: What’s ahead in the field of transplantation?
Dr. Diethelm: Limb transplantation is an area that should be pursued because it has a role, especially in children. Another area that I think has validity is cell transplantation.
But, if I was 35 years old today, I’d take a hard look at pig-to-human transplantation. That’d be a huge breakthrough. Others may say it’s just pie in the sky, but I don’t think so. When I was in medical school everybody thought transplantation was a joke. Nobody thought about transplanting across identical twins; then, you had to have a twin as a donor or you were out of luck.
In the same way, years ago people thought the young Dr. John Kirklin was eccentric when he invented the pump oxygenator at the Mayo Clinic to make open heart surgery possible. Many children with congenital heart disease needed this machine, but nobody really knew the incidence of the problem because there was no treatment for them.
It was a little like transplantation: When I arrived in Alabama somebody said, “It’s too bad you came because we don’t have much kidney disease in Alabama,” and I thought, “Gee, maybe I made a mistake in coming here.”