After struggling for decades with a shortage
of donated organs from cadavers, transplant
surgeons may soon have another source to tap
by Robert P. Lanza, David K. C. Cooper and William L. Chick
ORGANS that are now in high demand and in short supply for transplantation include (from left to right) the heart, kidney, liver, lungs and pancreas.
|Early morning, sometime in
the near future. A team of surgeons removes the heart, lungs, liver,
kidneys and pancreas from a donor, whereupon a medical technician packs
these organs in ice and rushes them to a nearby airport. A few hours later
the heart and liver land in one city, the two kidneys in another, and the
lungs and pancreas arrive in a third. Speedily conveyed to hospitals in
each city, these organs are transplanted into patients who are desperately
ill. The replacements function well, and six people receive a new lease
on life. Back at the donor center, surgeons repeat the procedure several
times, and additional transplants take place at a score of facilities distributed
around the country. In all, surgical teams scattered throughout the U.S.
conduct more than 100 transplant operations on this day alone.
How could so many organ donors have possibly been found? Easily--by obtaining organs not from human cadavers but from pigs. Although such a medical miracle is not yet possible, we and other researchers are taking definite steps toward it. Our efforts are driven by the knowledge that the supply of human organs will always be insufficient to satisfy demand. Within just the U.S., thousands of patients await transplants of the heart, liver, kidney, lung and pancreas, and millions struggle with diseases that may one day be curable with other
|kinds of donations. Notably, hemophilia, diabetes
and even Alzheimer's and Parkinson's diseases might weli be treated using
transplanted cells. So the pressure to devise ways to transplant animal
cells and organs into patients--"xenotransplantation"--steadily
The thought of combining parts from l different species is not at all new. Greek lore of more than 3,000 years ago featured centaurs--creatures that were half man, half horse--and the Chimera, a combination of lion, goat and serpent. As early as 1682 a Russian physician reportedly repaired the skull of a wounded nobleman using bone from a dog. But it was not until after the turn of the 20th century that doctors attempted with some regularity to graft tissues from animals into humans. For instance, in 190S a French surgeon inserted slices of rabbit kidney into a child suffering from kidney failure. "The immediate results," he wrote, "were excellent." Nevertheless, the child died about two weeks later.
During the next two decades, several other doctors tried to transplant organs
| from pigs, goats, lambs and monkeys
into various patients. These grafts all soon failed, for reasons that seemed
puzzling at the time. Before the pioneering investigations of Nobel laureate
Sir Peter Medawar at the University of London during the 1940s, physicians
had little inkling of the immunologic basis of rejection
So, with only failures to show, most doctors lost interest in transplantation. But some medical researchers persevered, and in 1954 Joseph E. Murray and his colleagues at Peter Bent Brigham Hospital in Boston performed the first truly successful kidney transplant. They avoided immunologic rejection by transplanting a kidney between identical twin brothers (whose organs were indistinguishable to their immune systems). Subsequently, Murray and others were able to transplant kidneys from more distantly related siblings and, finally, from unrelated donors, by administering drugs to suppress the recipient's innate immune response.
Medical practice has since grown to include transplantation of the heart, lung, liver and pancreas. But these accomplishments have brought tragedy with them: because of the shortage of nated organs, most people in need cannot be offered treatment. Of the tens of thousands of patients in the U.S. every year deemed good candidates for a transplant, less than half receive a do-
page 54 Scientific American July 1997
|nated organ. The shortfall will
become even more dire once doctors perfect methods to treat diabetes by
transplanting pancreatic islet cells, which produce insulin. Islet replacement
is simpler than transplanting the whole pancreas, but it may require harvesting
cells from several donors to treat each patient.
Fortunately, scientists did not entirely abandon the possibility of using animal tissues in patients after human organ transplants came into vogue. During the 1960s, medical researchers continued to investigate exactly why organs transplanted between widely different species fail so rapidly. A major cause, they learned, is that the recipient's blood harbors antibody molecules that bind to the donated tissues. (These antibodies are normally directed against infectious microbes but can also respond to components of transplanted organs.) The attachment of these antibodies then activates special "complement" proteins in the blood, which in turn trigger destruction of the graft.
Such hyperacute rejection of foreign tissue--which begins within minutes or, at most, hours after the surgery--destroys the capillaries in the transplanted organ, causing it to hemorrhage massively. Although this reaction presents an imposing barrier to xenotransplantation, recent experiments suggest that scientists may yet overcome it.
For example, in 1992 David J. G. White and his colleagues at the University of Cambridge managed to create "transgenic" pigs, bearing on the inner walls of their blood vessels proteins that can prevent human complement proteins from doing damage. They did this by introducing into pig embryos a human gene that directs the production of a human complement- inhibiting protein [see "Transgenic Livestock as Drug Factories, " by William H. Velander, Henryk Lubon and William N. Drohan; SCIENTIFIC AMERICAN, January]. White and his co- workers have not yet tested how tissues from these pigs fare in a human host, but organs from such genetically engineered pigs have functioned for as long as two months in monkeys, because the pig cells that are in direct contact with the host's immune system are able to quash the first wave of attack.
Other methods may also serve to thwart hyperacute rejection. In 1991 one of us (Cooper), along with several other investigators, identified the specific molecular fragments, or antigens, on
TRANSPLANTS OF TISSUES from animals to humans (xenotransplants) have been attempted experimentally using a variety of donor animals, from frogs to baboons and pigs. Most efforts quickly failed. But doctors may soon perfect ways to transplant organs, such as the heart, from specially bred pigs.
page 55 Scientific American July 1997
pig tissues that human antibodies target. The cells lining pig vasculature have on their surfaces antigens made up of a particular sugar group. So it may be possible to breed (or indeed to clone) a line of genetically engineered pigs that lack this troublesome sugar group.
One plan would eliminate the enzyme that adds the sugar in the first place. Alternatively, scientists could provide pigs with a gene specifying an enzyme that would replace the problematic sugar with some other carbohydrate structure. For example, they could give pigs the gene for an enzyme that replaced existing antigens with the human type O blood group antigen, which does not elicit an immune response. Or, in principle, the offensive groups could be removed by introducing into a pig the gene for an enzyme that degrades the undesirable sugar.
Yet another strategy to prevent hyperacute rejection would be to alter the recipient's immune system so that it cannot destroy the transplanted tissue. For example, using standard apparatus, doctors can remove from the patient's blood all the antibodies to pig tissue. It is also possible to deplete the complement proteins temporarily or otherwise interfere with their activation. Remarkably, animal studies suggest that if surgeons transplant a pig organ while the patient's immune system is so suppressed, the organ may--for reasons that remain largely mysterious--achieve accommodation, a state that enables it to survive even after the host's antibodies and complement return to normal levels. The transplanted organ then continues to work despite a distinct lack of tolerance from the host's immune system.
Unfortunately, researchers have not yet managed to induce accommodation reliably in animals undergoing xenotransplantation. But Guy Alexandre and his colleagues at the University of Louvain Medical School in Belgium have achieved it in certain patients who received human organs from donors with incompatible blood types--a situation that, like xenotransplantation, normally sparks hyperacute rejection.
HYPERACUTE REJECTION of a pig organ transplanted into a patient would very likely occur in minutes. It ensues after antibodies bind to the linear sugar chains lining pig blood vessels (left).
Investigators studying xenotransplanltation are optimistic that, with some combination of these methods, immediately harmful immune reactions can be overcome. Yet grafts of animal tissues in patients would still fall prey to more delayed forms of immune rejection, which can take days or weeks to develop. In particular, the so- called cellular immune response to grafts from animals is likely to be at least as strong as the robust attacks that white blood cells of the immune system often mount against organs transplanted from one person to another. Avoiding such delayed reactions might require massive doses of immunosuppressive drugs, such as cyclosporine, to be given indefinitely, and the risks of toxicity, infections and other complications would be excessive.
Newly devised immunosuppressive agents should help, but it would clearly be more desirable if the human body could be induced to accept animal tissues without requiring ongomg drug therapy. That happy condition might seem impossibly difficult to arrange. But hope springs from the observation that long- term organ acceptance, or immunologic tolerance, has occurred spontaneously in a few people who have receivedhuman organs. Doctors of these patients were able to reduce, and ultimately eliminate, the normal regimen of immunosuppressive drugs.
But tissues from pigs genetically engineered to carry the angular sugar groups found in people with type O blood should not elicit such reactions (nght).
One way to create tolerance involves modifying the immune system of the patient with bone marrow cells from the donor animal. (Bone marrow is the source of all components of the blood, including the white blood cells of the immune system.) Once introduced, the donated cells spread and mature, creating a "chimeric" immune system that is part donor, part recipient. The aim is to alter the patient's immune system so that it does not recognize as foreign either the donated cells or subsequently transplanted tissues from the same animal.
Following this strategy, David H. Sachs and his colleagues at Massachusetts General Hospital injected bone marrow cells from donor pigs (along with substances to stimulate proliferation of the cells) into baboons. These animals had undergone a course of radiation to deplete their immune systems temporarily and prevent rejection of the pig bone marrow cells. The researchers also filtered from the blood of the baboons those antibodies directed against pig tissues and administered a brief course of immunosuppressive drugs. Although the baboons' immune systems eventually killed most of the transplanted cells, some pig DNA survived in one of the baboons for almost a year. What is more, an important component of this chimeric baboon's immune system--the aggressive killer T cells--no longer reacted to the pig cells as foreign.
Such research may yield ways to prevent Immune reJectlon ot organs transplanted from animals, but truly effective measures are probably still some years away. Another scheme for evading rejection is, however, already undergoing clinical trials: immunoisolation. Following this approach, physicians physically sequester transplanted tissue within a membrane that allows small
page 56 Scientific American July 1997
page 57 Scientific American July 1997
PREVENTING DELAYED REJECTION of cross-species organ transplants might be possible by altering the recipient's immune system so that it includes components from the donor. To test this strategy in animals, a baboon slated to receive bone marrow cells (the source of all immune cells) from a pig was first given radiation and drugs (1) to prevent immune rejection of the transplanted cells. The baboon's blood was also filtered (2) to remove antibody molecules that would react with pig cells. Finally, the baboon received the bone marrow cells from the donor pig (3). Afterward, killer T cells isolated from the baboon's immune system did not attack cells from the donor pig. If other components of the recipient's immune system could be equally tamed, organs transplanted from a donor pig (4) should be able to survive indefinitely in the new host.
|molecules (such as nutrients, oxygen and certain
therapeutic agents) to cross it while blocking large molecules (such as
antibodies) and white blood cells from reaching the graft. This tactic
is feasible only for protecting isolated cells or small packages of tissues,
not for whole organs. So it does not address the needs of someone who requires,
for example, a new heart or kidney. It should nonetheless be valuable for
treating many disorders. And it offers some practical advantages: physicians
can manipulate cells or small masses of tissue comparatively
ENCAPSULATED ISLET CELLS from the pancreas of a pig may eventually serve to produce insulin in patients afflicted with diabetes. The biodegradable polymer membrane surrounding the islets allows insulin out but protects the islets from attack by immune components
| easily and can maintain them outside
the body for longer periods than are possible when working with intact
Recent attempts at using encapsulated cells from animals to treat liver failure, chronic pain and amyotrophic lateral sclerosis (Lou Gehrig's disease) have all shown promise in clinical trials. Medical researchers may soon try to implant immunoisolated cells from animals to provide the blood- clotting factors hemophiliacs need or to produce nerve growth factors that might help reverse certain neurodegenerative disorders.
Some investigators are especially eager to treat diabetes with isolated pig islet cells. Although one of us (Chick) pioneered the use of "perfused" devices (large sheathed implants connected to a supply of blood) for this purpose, it is easy to see some disadvantages to that particular technique. Most important, the patient requires major surgery, and the device is apt to become clotted. Engineering hollow plastic fibers or chambers unconnected to the bloodstream to isolate cells from the recipient's immune system also has drawbacks: although the surgery needed would be less traumatic than for a perfused device, it is unclear how well a patient could tolerate the plastic materials or having the implant replaced many times--a likely requirement of long- term therapy.
In an effort to overcome these diffi-
| culties, two of us (Lanza and Chick),
along with colleagues at BioHybrid Technologies, have developed ways to
encase cells in small, biodegradable capsules that can be injected under
the skin or placed in the abdominal cavity with a syringe. Less than a
gram of encapsulated islets from pigs should supply a diabetic patient
with normal amounts of insulin. Although a vast number of cells are involved,
the total volume required for these implants would be only a few dozen
In recent tests, encapsulated islet cells from cows remained alive in dogs for six weeks (the point at which the experiment ended). These results, and others from studies of mice, rats and rabbits, indicate that encapsulated pig islets would most likely survive in patients for anywhere from several months to more than a year. Eventually the tiny packages would degrade, so no surgery would be needed to remove the old capsules when the supply of islet cells needed to be replenished. Clinical trials of this technique should begin within a year.
The growing sense that xenotransplantation may be near at hand raises some critical concerns. In particular, many experts worry that animal donors might harbor diseases that, like the
page 58 Scientific American July 1997
|Ebola virus or "mad cow" disease,
can harm people. After infecting a transplant patient, such pathogens might
spread into the general population and spark an epidemic. Indeed, scientists
now believe HIV (the human immunodeficiency virus, which causes AIDS) originated
in monkeys and somehow jumped the species barrier to infect humans.
Thus, widespread transplantation of tissues from monkeys or baboons could conceivably put the general health at risk. Fortunately, the threat of such a catastrophe is markedly less with pigs as donors. People have lived in close association with pigs for thousands of years, and yet, except for the possibility of some flu strains, few serious diseases of swine origin appear ever to have arisen in humans.
Pigs could be especially good donors for other reasons as well. They are relatively easy to raise and have organs that are comparable in size and physiology to human organs. Breeds of pigs already exist that are free from certain known pathogens. And, unlike the case with primates, few voice ethical concerns about killing an animal that people routinely slaughter for food.
Still, many questions need to be solved before the transplantation of pig tissues into ailing patients becomes a reality. In addition to the challenge of immune rejection, scientists must also make sure that transplanted pig organs perform properly in their new hosts. Pig hearts and kidneys have functioned adequately in some primates for several weeks, and it seems likely that such organs would work in humans as well. But a pig liver would probably not be able to carry out the myriad functions of a human liver, although the pig organ may be able to sustain life for a short period of time, allowing, for example, the patient's own liver to recover from a temporary shutdown. It may take many years before physicians can routinely outwit evolution--as some have labeled the goal of xenotransplantation--and replace any failing organ with an animal substitute. But the transplantation of isolated cells and tissues appears poised on the threshold of modern medical practice. And we are optimistic that soon there will be some true successes to report.
Dealing with Viral Stowaways
The observation that pigs have passed only a few pathogens to humans despite centuries of close contact assures many people that transplanting organs from these animals would not give rise to any new and dangerous diseases. Still, there are reasons to be cautious.
Certain retroviruses--viruses that incorporate their genetic blueprint directly into the host's DNA--pose a possible threat. Pigs, as well as all other mammals, contain within their genetic stores so- called proviruses--sequences of genetic code that can potentially direct the production of infectious viral particles. (As much as 1 percent of the DNA people carry is made of such viral genes.) These sequences owe their presence in modern animals to past episodes of retroviral infection in their ancestors, when the viruses inserted their genetic code into sperm or egg cells. The offspring of the infected animals retained these viral genes, which were then passed from generation to generation. Over time, most of these vestigial viruses have evolved into forms harmless to their hosts. Yet some remain capable of activity that can cause disease in other species.
So scientists naturally worry about what the proviruses of pigs would do when conveyed into a patient along with tissues transplanted from these animals. Not only does this transfer offer the resulting virus direct access to human cells, it may also present it with a uniquely susceptible victim--one having, for the sake of preserving the transplanted organ, a compromised immune system. Under these circumstances, pig proviruses might be able to give rise to active retroviruses, perhaps causing illness. It is also conceivable that these pig retroviruses could mutate in human hosts or combine with human retroviruses to produce a completely new pathogen. The result might be quite dangerous: unlike the viruses that bring on a short- lived swine flu, certain retroviruses are potentially cancer- causing and produce lifelong infection.
Molecular biologists are working hard to identify troublesome proviruses lurking within pig DNA and eliminate them from breeding herds. The genetic manipulations involved may yet require significant effort, but the results of this work should help quell any remaining fears that xenotransplantation could cause new human diseases.
--R.P.L., D.K.C.C. and W.L.C.
page 59 Scientific American July 1997
ROBERT R LANZA, DAVID K. C. COOPER and WILLIAM L. CHICK share a long- standing interest in the transplantation of animal cells and organs. Lanza, who earned his M.D. in 1983 from the University of Pennsylvania, is director of transplantation biology at BioHybrid Technologies in Shrewsbury, Mass. As a student, he studied with heart transplant poineer Christiaan Barnard and Nobel laureate immunologists Gerald Edelman and Rodney Porter. Cooper holds M.D. and Ph.D. degrees from the University of London and is currently an immunologist at Harvard Medical School and Massachusetts General Hospital. He previously worked as a cardiothoracic transplant surgeon and director of research and education at the Oklahoma Transplantation Institute. Chick received his M.D. degree from New York University in 1963. He was formerly a professor of biochemistry and medicine at the University of Massachusetts Medical School, where he served as director of the Diabetes- Endocrinology Research Center. He now serves as the president of BioHybrid Technologies.
BARRIERS TO XENOTRANSPLANTATION. E H. Bach, S. C. Robson, H. Winkler, C. Ferran, K. M. Stuhlmeier, C. J. Wrighton and W. W. Hancock in Nature Medicine, Vol. 1, No. 9, pages 869- 873; September 1995.
XENOTRANSPLANTATION AND XENOGENETC INFECTIONS. L. I Chapman, T. M. Folks, D. R. Salomon, A. P. Patterson, T. l Eggerman and R D. Noguchi in New England Journal of Medicine, Vol. 333, No. 22, pages 1498- 1501; November 30, 1995.
YEARBOOK OF CELL AND TISSUE TRANSPLANTATION 1996/1997, Edited by Robert R Lanza and William L. Chick. Kluwer Academic Publishers, 1996.
XENOTRANSPLANTATION: THE TRANSPLANTATION OF ORGAN AND TISSUES BETWEEN SPECIES. Second edition. Edited by D.K.C. Cooper, E. Kemp, J. L. Platt and D.J.G. White. Springer-Verlag, 1997.