Special article Twenty years of renal transplantation at Ohio State University: the results of five eras of immunosuppression Ronald M. Ferguson, M.D., Ph.D.*, Mitchell L. Henry, M.D., Elmahdi A. Elkhammas, M.D., Elizabeth A. Davies, M.D., Ginny L. Bumgardner, M.D., Ph.D., Ronald P. Pelletier, M.D., Amer Rajab, M.D., Ph.D. Department of Surgery, Ohio State University College of Medicine and Public Health, Ohio State University Medical Center, 363 Means Hall, 1654 Upham Dr., Columbus, OH 43210, USA Manuscript received April 30, 2003 Abstract Over the past 20 years, more than 4,000 patients have undergone an abdominal solid organ transplant at Ohio State University. The 20-year period can be divided into five eras, each defined by an immunosuppressive protocol used during that period. With each successful era came a new immunosuppressive protocol that produced an incremental improvement in outcomes of patients and graft survival resulting from the application of the newest and most sophisticated combination of immunosuppressive drugs. The incidence of acute rejection episodes and graft survival from each era are compared and demonstrate the substantial improvement in results that has been achieved over the past 20 years. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Renal transplantation outcome; Immunosuppression The evolution of the field of solid organ transplantation is a story written in the operating rooms, the corridors and the laboratories of surgery departments in the academic medical centers of the United States. Since the initial renal transplant performed at the Brigham Hospital in Boston in the 1950s and through to the present day, each incremental step of progressive evolution in transplantation has focused on out- comes of patient and graft survival, acute rejection, how outcomes might be improved and how best to prevent acute rejection without sustaining unacceptable comorbidity of the therapy. To trace the progressive, clinical developments in solid organ transplantation is to track the development in pharmacologic immunosuppression. Immunosuppression is a discipline that is unique to transplantation. Transplanta- tion is the only area of medicine in which the recognition and vigorous rejection of a life sustaining organ becomes the primary focus of therapy. Indeed, it is the prevention and treatment of acute rejection that has formed the basis of clinical transplantation over the years and provided the driving force for experimental transplantation in the labo- ratory. With important new advances in immunosuppres- sion have come leaps forward in our ability to control and prevent acute rejection and therefore to improve the out- comes of patient and graft survival. These chronologic ad- vances define separate eras of improvement in clinical trans- plantation. The past 20 years of transplantation at Ohio State University have afforded us a great opportunity to be a part of this progress. Over the past 20 years, we have seen four separate eras of transplantation at OSU and are currently in era five. Each era has its own time frame and is characterized by its own immunosuppressive protocol used to prevent acute rejection and maintain graft survival. Each protocol was carefully modified based on clinical trials that allowed experience to be gained with a new combination of agents followed by a comparative analysis of outcomes to document clinical im- provement. What follows is a description of the outcomes and results for each of the eras of pharmacologic immuno- suppression for the past 20 years. Pharmacologic immunosuppression began with the ex- perimental report by Schwartz and Dameshek [1] that 6-mercaptopurine (6-MP) had the ability to prevent exper- * Corresponding author. Tel.: +1-614-293-6322; fax: +1-614-293- 4541. E-mail address: ferguson-2@medctr.osu.edu The American Journal of Surgery 186 (2003) 306 –311 0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(03)00219-8