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Chapter 23

Table of Contents

Chapter 23

Renal Transplantation in Vietnam

Daniel L. Macken, M.D., Ronald P. Fischer, M.D., William E. Miller, M.D., and James H. Knepshield, M.D.

Kidney transplantation has been performed in the United States for many years. A successful homograft was performed in the Republic of Vietnam during hostilities and was a step toward instituting a renal center in that country, ultimately strengthening the medical community in Vietnam as a whole. The U.S. Army Medical Department was instrumental in the success of this effort through its MEDCAP (Medical Civic Action Program).

MEDCAP was a voluntary activity among medical teams in Vietnam. At the 3d Field Hospital in Saigon and the 629th Medical Detachment (Renal), MEDCAP activities brought about a close association with the University of Saigon School of Medicine, which provided perspective into the capabilities and problems of the Vietnamese medical community in meeting the health needs of the country. With assistance from the American Medical Association, the Ministry of Health in Vietnam, the University of Saigon School of Medicine, the United States Agency for International Development, and the American and French Army Medical Departments, a high level of cooperation and interest in plans for renal transplantation evolved, resulting in other benefits as well. Saigon Hospital, ultimately chosen for the first operation, was a Ministry of Health facility used primarily as a teaching hospital by the medical school (fig. 94).

The recipient of the transplant was a 20-year-old male Vietnamese student who had had more than a year of vague flank pain, and a month of weakness, oliguria, nausea, and vomiting. He had been admitted to the French hospital, l'Hôpital Grall, in Saigon, on 3 March 1969, where azotemia, anemia, and hypertension were documented. On transfer to the 629th Medical Detachment 3 weeks later, he was considered moribund. He arrived in a stuporous state, with a blood pressure of 160/110 mm Hg, pulse 110/min, and deep respirations at 26/min. The neck veins were distended. Anasarca and ascites were present. The heart was clinically enlarged and there were prominent third and fourth heart sounds. A diagnosis of congestive heart failure and chronic renal failure was made.

Hemodialysis was instituted and his general condition improved. Urine volume was less than 100 ml/day. An open kidney biopsy revealed severe chronic glomerulonephritis. The patient's mother volunteered to donate her kidney; she was evaluated and found to be an acceptable donor. Compatibility was determined by ABO cross-matching alone as tissue typing was not available.


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FIGURE 94.- Saigon Hospital, scene of the first U.S. military participation in a renal transplantation.

On 6 June 1969, the patient, pretreated with prednisone and azathioprine, was transported to Saigon Hospital where Dr. Nguyen Phuoc Dai, chief of surgery at the hospital and associate professor of surgery at the university, together with his team and one provided by the 3d Field Hospital, U.S. Army, performed the operation. The surgical team was composed of approximately equal numbers of Americans and Vietnamese (fig. 95). The donor kidney was perfused with a mixture of lactated Ringer's solution, papaverine, albumin, and heparin at approximately 5° C. War ischemia time was 2 min 25 sec. Cold ischemia time was 22 min 55 sec. After the intravenous administration of mannitol 25 g and furosemide 80 mg, a urine output of 3,920 ml was recorded in the first 24 hours.

On leaving the recovery room, the patient was readmitted to the 3d Field Hospital. On postoperative days 1, 3, 4, and 6, he was transported to l'Institut du Cancer du Vietnam where local irradiation to the kidney was delivered for a total tissue dose of 490 R. Two weeks after surgery, the creatinine clearance was 81.53 ml/min per 1.73 m2. An intravenous pyelogram was consistent with normal function. The patient was discharged on the 14th hospital day on oral prednisone 30 mg and azathioprine 100 mg daily. The patient's mother was discharged from Saigon Hospital after an uncomplicated course.

On 3 July, the recipient was readmitted with fever and oliguria and was believed to have an early rejection episode. He was treated with high doses of


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FIGURE 95.- The renal transplantation team. Front row (left to right): Lt. Col. Finn Gunderson, MC, Commander, 3d Field Hospital; U.S. Army nurse; Maj. Ronald Fischer, MC; Vietnamese nurses; Maj. Prentiss Smith, MC; Dr. Nguyen Phuoc Dai, Chief, Department of Surgery, Saigon Hospital; Maj. Daniel Macken, MC, medical coordinator for the operation (behind Vietnamese nurses); and Maj. James H. Knepshield, MC, Chief, 629th Medical Detachment (Renal), 3d Field Hospital. Members of the team from the staffs of the 3d Field Hospital and the Saigon Hospital are present in the background.

prednisone and with 390 R of local irradiation. The BUN (blood urea nitrogen) reached 77 mg/100 ml before returning to normal. The patient recovered without incident and was discharged on prednisone 75 mg and azathioprine 100 mg daily.

Six-month followup studies were performed in December 1969. The blood pressure was 112/80 mm Hg; serum and urine electrolytes were normal. Twentyfour hour urine protein was 330 mg. The creatinine clearance was 76.22 ml/min per 1.73 m2. The patient returned to school and was leading a normal life more than 2 years after the operation. He was lost to followup after cessation of the American effort in Vietnam.

Participation in a successful renal transplant by a U.S. Army medical team in Vietnam preceded the development of formal transplantation centers in U.S. military hospitals in the continental United States. The effort required interna tional cooperation, using Vietnamese, French, and American facilities and personnel. It was a step forward in Vietnamese medicine at a time when planning for its future was difficult and troubled. The 629th Medical Detachment (Renal) became the first Army unit to accomplish a successful renal transplantation.