Transplantation in the 21st century

Remarkable results have been achieved in the field of organ transplantation over the past 40 years, perhaps inconceivable in the pioneering days of the 1950's. Factors which have contributed to these results include better immuno-suppression, matching for HLA, better preservation, and resolution of most of the technical problems associated with organ transplantation. Nevertheless, major problems still remain to be resolved. Chronic rejection leads to a steady attrition of all solid organ grafts. In addition, the penalty of our more potent immunosuppression is becoming evident with the ever-increasing incidence of cardiovascular disease and malignancy in long-surviving patients. These problems would be solved by the achievement of tolerance to an organ graft. However, there will never be sufficient human organs or tissues to meet the demand, which has led to a revival of interest in xenotransplantation, but enormous immunological and infectious problems have still to be resolved. New immunosuppressive agents, both drugs and biological agents, are being evaluated continually in the laboratory and some are going on to clinical trials. The explosion in molecular biology is allowing new approaches, such as genetic engineering, to be taken in the achievement of tolerance as well as solving some of the problems of xenotransplantation. Cloning of tissues and perhaps even organs may become possible in the future. Undoubtedly transplantation will look very different in twenty years' time as we enter the "Dawn of the New Millennium".