Renowned transplant surgeon and University of Pretoria (UP) alumna Professor Elmi Muller has been appointed as Dean of the Faculty of Medicine and Health Sciences at Stellenbosch University (SU). Prof Muller specialises in general surgery and transplantation, and performed the world’s first kidney transplant between an HIV-positive donor and patient.

“Growth is everything, and although I am very happy with the work I am currently doing, I am also excited to make the leap to this new career path,” said Prof Muller, who is the first woman to be appointed as Dean of the faculty.

The pioneering clinician acknowledged that stepping into this new role will require a significant amount of learning to determine what is needed to accelerate the growth of the faculty and to help it sustain its success. “It will be important for me to care for the staff and be attentive to people’s needs,” she said. “But there are also bigger strategic issues to think of: how will I help to expand research and teaching; how will we catapult the faculty into the 21^st-century’s technology and endless possibilities; and how do we stay in touch with society’s needs and, more specifically, the needs of patients?”

Additionally, she says, her role will be to bring multiple stakeholders together. “I think of this as a boat trip: we need to know where we are going; we need to have the correct crew members with the correct skill base on board; we need to have good structures and processes (which is really the boat itself); and then we have to be strategic about our route, avoiding the reefs and stormy waters.”

Prof Muller is recognised for her clinical work and research, which challenged ideas about the suitability of HIV-positive donors for transplantation.

“When I started my career as a transplant surgeon, HIV-positive patients were not eligible for dialysis or transplantation,” she said. “HIV was also a contraindication to being a donor in South Africa, and if the donor’s results showed that he or she was HIV positive, we would decline them for transplantation. Between 2005 and 2007, I had to decline many potential HIV-positive donors.”

Prof Muller recalled other factors that worked against HIV-positive patients. Transplant surgeons, she explained, work closely with general nephrologists, who specialise in renal medicine and who make the medical decisions related to transplantation.

“General nephrologists in state hospitals in SA have to take into account policy that enables collective responsibility and allows them to make life and death decisions. Nephrologists have to accept that patients cannot be treated because they do not meet the medical or procedural requirements for dialysis. The reasons we have medical criteria are less medical and more economic.”

Patients are classified according to three categories, she explained. Category 1 represents a transplant candidate who has no organ disease, social concerns, nor cardiac or chronic problems – “an otherwise perfectly healthy and socially adjusted patient with end-stage renal failure”, Prof Muller said. “These patients are acceptable dialysis patients. They also have the necessary legal residency papers and contribute to the South African Revenue Service.” Category 2 patients are those with a well-controlled additional disease besides renal failure. This could be a patient with hypertension, asthma, well-managed psychiatric problems, etc. “However, this patient will only receive dialysis if there is a vacant place on our programme, and with 300 dialysis slots serving a population of about 2 million people, the odds are stacked against even Category 2 patients receiving dialysis,” she said.

In 2008, HIV was classified as a Category 3 disease. “In our context, this meant ‘untransplantable’. Patients seen as unfit for transplantation in the SA context would qualify for transplants in other places. These patients included type 1 diabetics and HIV-positive people. In SA, if you were in this group and presented with renal failure, you would be sent home. In short, one of the tasks of nephrologists in state hospitals in SA include decisions about which ill people the health system can treat and which – because of the budget and because public opinion demands it – must be sent away to die.

“Having come face to face with several HIV-positive patients in 2008, I made a decision to respond to the needs of these individuals instead of the exigencies of the healthcare situation. I took the decision to investigate using HIV-positive deceased donor kidneys to transplant HIV-positive recipients turned down for dialysis. It was a decision that would change their lives, and mine.”

Prof Muller holds an MBChB from UP, an MMed and PhD from the University of Cape Town and an MBA from Stellenbosch University. She says her medical training at UP was hands-on and practical. “As students, we worked in a hospital and were required to do many procedures,” she said. “This gave me a certain amount of confidence when I started to work as an intern.” Certainly, this was also the springboard for her eventually conducting a world-first transplant.  

As an alumna of UP, she believes that graduates have a responsibility to use their wisdom and experience to create opportunities to help younger generations of students. This can be done in many ways by providing mentorship, work experience or funding opportunities.