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Peter Attia MD#155 - Chris Sonnenday, M.D.: The history, challenges, and gift of organ transplantation
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CHAPTERS
- 0:02 – 7:30
Why Chris Sonnenday Chose Medicine, Surgery, and Hopkins
Peter Attia introduces Chris, his former chief resident, and asks how he got into medicine. Chris describes his upbringing, his late decision on surgery, and why he was drawn to Hopkins and its mentorship.
- •Chris grew up with parents who wanted his work to serve others
- •He came to surgery late, drawn to entering people's scariest moments
- •A Vanderbilt program director encouraged him to apply to Hopkins
- •Mentorship under Keith Lillemoe and being surrounded by high performers attracted him
- 7:30 – 12:58
Staying Human Through Residency
Peter says residency eroded his own empathy and humanity, but he never saw that in Chris. Chris explains that a sense of obligation, high expectations from mentors, and his patients kept him centered.
- •Chris felt lucky to hold his residency spot and obligated to make the most of it
- •He thanked his mentors for their high expectations
- •Patients re-centered him when medicine got hard
- •Chris says the privilege of being part of their care still pulls him back to the right frame of mind
- 12:58 – 16:22
Team Leadership and Chris's Athletic Background
Peter asks about Chris's leadership, and Chris says he was a soccer team captain who always gravitated toward team activities. He ties this to residency teams and to why transplant appealed to him.
- •Chris was a captain on his college soccer team though not its best player
- •He always gravitated to team, collaborative activities
- •Being on a team pulled the best out of him in residency
- •Transplant requires a highly functioning team from diagnosis through recovery
- 16:22 – 25:17
Morbidity & Mortality Conference and a Culture of Accountability
Chris explains the weekly M&M conference and what it reveals about a department's culture. Peter recounts a case in which Chris caught a missed compartment syndrome and then presented it as his own fault.
- •M&M reviews cases with suboptimal outcomes and reveals a department's accountability culture
- •Chair John Cameron led M&M with his own cases
- •Peter recalls Chris presenting a case he rescued without blaming anyone
- •Chris says there is value in seeing system opportunities, not assigning blame
- •M&M has shifted toward doing what's right for the patient
- 25:17 – 31:13
Choosing Transplant and the Short Bench-to-Bedside Distance
Chris explains why he chose transplant while also pursuing hepatobiliary surgery. He describes the influence of Bob Montgomery and how quickly innovation reached patients in this young field.
- •Chris did transplant rotations under Bob Montgomery, a major influence
- •Liver transplant complemented his hepatobiliary surgery interest
- •Transplantation is a young field, with kidney transplants beginning in the 1950s
- •Innovations such as living donor liver transplant were created in the 1990s and early 2000s
- •He considers himself part of the second or third generation of transplanters
- 31:13 – 54:38
Early Kidney Transplantation and the Immune Barrier
Using kidney as the example, Chris describes the technical origins, the 1954 twin transplant by Joseph Murray, and the high mortality of later transplants. He then explains ABO, HLA, cross-matching, and the shift from antibody-mediated to cellular rejection, plus organ preservation.
- •Kidneys are placed in the pelvis as an extra organ rather than replacing the old ones
- •The first transplant in 1954 was between identical twins, avoiding immune barriers
- •Mortality in the 1960s and 70s was 50 to 70%, while dialysis life expectancy was months to a few years
- •Hyperacute rejection stems from preformed antibodies, while acute rejection is cellular and T-cell driven
- •Preservation solutions are still essentially what was worked out in the 1960s and 70s
- 54:38 – 1:00:14
Cyclosporine Transforms Transplantation
Peter proposes that cyclosporine was the turning point, and Chris agrees completely. He explains how it works and how it lifted kidney graft survival and reinvigorated liver, heart, and lung programs.
- •Sir Roy Calne's preclinical work showed cyclosporine prevented rejection
- •It interferes with the cascade after T cell receptor binding
- •One-year kidney graft survival jumped from roughly 60-70% to about 90%
- •Liver, heart, and lung transplant programs spread across the country in the 1980s and early 1990s
- 1:00:14 – 1:06:45
Rising Kidney Disease and Growing Demand
Chris explains that most kidney transplants are for chronic disease from diabetes or hypertension. Peter describes his longevity-focused view of kidney function, and both expect demand to grow with metabolic disease and an aging population.
- •Roughly 100,000 people wait for kidneys, about four times that number are on dialysis, and ten times as many have chronic kidney disease
- •Peter monitors kidney function with cystatin C and urine microalbumin to catch decline early
- •Creatinine is an imperfect measure of kidney function
- •Transplant is a victim of its own success as older patients now qualify
- 1:06:45 – 1:26:53
Living Donors, Paired Exchanges, and the Debate Over Paying Donors
Chris explains why living donor kidneys outperform deceased donor kidneys, mainly because of ischemic time. He then covers paired kidney exchanges and the unresolved debate over compensating donors.
- •Ischemic time is almost linearly related to graft survival and primes the immune system
- •A living donor kidney can beat a perfectly HLA-matched deceased donor kidney
- •Paired exchanges and algorithms by Segev and Gentry expand compatibility
- •Selling organs is illegal because it could be coercive, with Afghanistan cited as an example
- •Reimbursing donors for travel and time off work and offering health benefits are being explored
- 1:26:53 – 1:31:35
Fair Organ Allocation Across Regions
Peter asks about geographic disparities in access to organs. Chris explains organ procurement organizations, the shift to concentric-circle allocation, and how fairness has improved while the shortage has become more visible.
- •Supply and demand differ widely by region, as in California versus parts of the Midwest
- •58 OPOs identify donors and facilitate procurement
- •Heart, lung, and liver allocation moved to concentric circles, and kidney is about to follow
- •Moderately sick patients now wait behind sicker ones, highlighting the need for more donors
- 1:31:35 – 1:44:21
Defining Brain Death and Separating Care from Procurement
Chris explains brain death, its clinical criteria, and why it was needed for transplantation. He also covers the ethical separation between treating teams and transplant teams, and donation after cardiac death.
- •Brain death is tested with a clinical exam, an apnea test, and ancillary studies
- •Brain-dead patients remain on cardiorespiratory support
- •Care teams and transplant teams are kept separate, and transplant involvement begins only after death is declared and donation is authorized
- •Donation after cardiac death requires death to be declared by a provider unrelated to the transplant team
- 1:44:21 – 1:51:19
The Gift of Organ Donation
Peter shares stories of donor families he knows, including the Websters. Chris describes what donor families tell him, the scale of the shortage, and why he encourages people to communicate their wishes.
- •Peter describes families who donated every organ of a lost son
- •Chris says donor families often call donation the only good thing about the worst day of their lives
- •More than 100,000 people are waiting, and each year far fewer transplants are done
- •Registering and telling family eases an impossible decision for loved ones
- 1:51:19 – 1:59:00
Liver Transplantation: History and Technical Complexity
Peter introduces liver transplant and the 1960s work of Thomas Starzl, then asks what makes it so hard. Chris explains the liver's anatomy, portal hypertension, and clotting problems, which led to the late-1960s moratorium.
- •The liver has a dual blood supply and sits on the vena cava
- •Cirrhosis causes portal hypertension, collateral vessels, and ascites
- •Patients make fewer clotting factors and are debilitated going into surgery
- •Early patients did not survive beyond 90 days, causing a moratorium
- •Peter notes the liver has no extracorporeal support
- 1:59:00 – 2:08:28
Acute Liver Failure and the Baboon Experiment
Chris tells Mel Williams's story of connecting a patient with acute liver failure to a baboon's circulation. Peter then recalls a young Tylenol overdose patient, and Chris explains how acute liver failure is approached.
- •Extracorporeal liver support has largely failed, though the liver can regenerate
- •The baboon cross-circulation worked, but both the baboon and the patient ended up in body casts
- •Acute liver failure accounts for about 5% of US liver transplants
- •Chris says his center gives overdose patients the benefit of the doubt, with mental health support afterward
- 2:08:28 – 2:20:40
Hepatitis C, NAFLD, and Alcohol-Related Liver Disease
Chris explains how antiviral drugs cured hepatitis C and sharply cut the transplant need, while fatty liver disease and alcohol-related liver disease are rising. He and Peter compare alcohol and opioid crises.
- •Direct antiviral agents cured hepatitis C and caused a sharp drop in transplants for it
- •NAFLD is predicted to become the leading indication for liver transplant by around 2030
- •Alcohol-related liver disease is rising steeply, including in people in their 20s and 30s
- •Fatty liver patients carry cardiovascular comorbidities, making liver recipients resemble kidney recipients
- •Peter and Chris see alcohol and opioid problems as two sides of the same coin
- 2:20:40 – 2:30:16
Teamwork in Transplantation and the 2007 Plane Crash
Peter notes the size of transplant teams and asks Chris about the team members Michigan lost. Chris recounts the 2007 crash during a lung retrieval and the changes in procurement that followed.
- •Six people died when the plane carrying a lung procurement team crashed into Lake Michigan
- •Michigan still marks the loss each June
- •It showed how precious each team member is
- •More than half the time in liver transplantation, a colleague at another center now procures and ships the organ
