Zoccali: The ASN has gradually become the centre stage of world nephrology. Do you feel that the program of the congress and the many scientific initiatives of your society need some adaptations to accommodate the expectations of non-American nephrologists?
Blantz:
During the past several years, more than 50% of the attendees and greater than
half of the presented abstracts have derived from countries outside the USA.
The majority also come from outside the regular membership constituted by all
North American participants. We are attentive to this fact, and many of those
participating in the various symposia at the meeting are from outside North
America. However, this commentary does not answer your relevant question. We
have expanded our committee structures to distribute the decision making processes
on various functions of this professional organization, extending to functions
well beyond the annual meeting. We have considered creating a Corresponding
member of ASN Advisory committee to deal with issues that are unique to members
and attendees outside North America. We are also making concerted efforts to
replace members of various advisory and standing committees with Corresponding
members when appropriate to the issue. Many of these issues do not relate to
the annual meeting, but broader issues related to clinical and basic research
and the sub disciplines of nephrology.
We must continue to be aware that we are not a truly international society.
The ISN functions in that capacity and we respect and honour their functions.
We hope that they could hold sessions within the ASN meeting in the future that
would address issues that are unique to countries outside North America, particularly
nephrologic issues in the developing countries.
Zoccali: The main scientific congresses have reached almost prohibitive
dimensions. Do you feel that increasing use of the Internet and telecommunication
may eventually erode the base of congress attendees?
Blantz: The size of the annual meeting, and of other world congresses,
does present problems. The major problem is a lack of intimacy of like minded
or interest groups who may feel "lost" within the larger framework
of the meeting. In this area we have tried to create areas within the program
and within the convention centres in which participants in the same general
fields are more likely to encounter one another. The newer evening dinner symposia
are now part of the ASN program and we attempt to link up with parallel symposia
conducted on similar topics that same day. This could provide a "Gordon
Conference" spirit to certain scientific interest groups in attendance.
We now have a new and completely redesigned ASN interactive website. We hope
that this two-way means of communication between and among membership and ASN
staff and leadership will promote membership involvement in a meaningful manner.
It provides a vehicle for members to volunteer their service or join functioning
committees on topics of interest and within their talent areas. We have also
been studying how best to use this vehicle as a communication and educational
device, targeted to the specific demographic groups within the membership overall.
It is our impression that there is no perceivable limit to the need for postgraduate
education in some form. However, there are limitations in the capacity of nephrologists
and scientists from around the world and USA to attend the annual meeting on
a regular and consistent basis. The recent NephSAP has been well received and
has filled a void in education and as a resource for members. Electronic publication
has also been considered as an adjunct to any current and future publications
of ASN. Our new interactive website will be utilized to disseminate specialized
public policy and educational materials to subsets of our membership with interests
defined by prior demographic profiling.
In fact this has been a vigorous area of discussion among several committees
of ASN and the Council. Annual meeting attendance may have effectively plateaued
due to availability of time for travel, but I doubt that internet communication
will erode the attendance in the foreseeable future.
Zoccali: Building the Congress program of the ASN must be a very laborious
task. In the future do you think that the time and space allotted to Clinical
Science (as opposed to Basic Science) can be (or ought to be) increased?
Blantz: This
also has been a point of recent and ongoing discussion. It is the current feeling
that the meeting has a reasonable balance. Admittedly the attendance figures
would suggest that the majority of attendees are actively involved in clinical
practice in contrast to research or other academic functions. However, practicing
MDs come to ASN to learn about the new basic and clinical science breakthroughs.
The clinical sessions currently are very well attended, such that our clinical
participants appear to be well served. Although only about 50% of symposia are
actually clinical in nature in terms of practical issues, the total attendance
at these sessions tend to exceed those which are more basic science in orientation.
A rather high percentage of the abstract submissions and resulting posters deal
with highly relevant clinical topics. Many of the scientific posters also deal
with clinically applicable issues which appear to be of great interest to practicing
nephrologists from around the world and the
USA.
In summary, we are constantly interested in covering new areas of clinical relevance,
but we have made no decision to change the overall balance of the symposia and
clinical nephrology conferences.
Zoccali: Uremia is a rare disease but mild renal failure is fairly frequent
in the general population and seems to have important clinical implications
particularly for cardiovascular risk. Do you think that this may be an opportunity
for nephrologists to enlarge the territory
of their specialty?
Blantz:
We, meaning the Council of American Kidney Societies, are planning a major meeting
next September on this very topic, CKD. In advance of that meeting we will have
taskforces of nephrologists, health care professionals, insurance payors, government
agencies, disease management organizations, dialysis companies in this area,
pharmaceutical companies, internal medicine and primary care organization leaders
and HMOs and hospital systems who will sit down and try to design systems of
clinical care models and financial payment systems appropriate to the major
task of treating the millions of Americans who now have relatively early kidney
disease, with its attendant health risks. The manpower problems limit the direct
care role of the nephrologist because of the relatively small number of nephrologists
in practice in comparison to the huge patient population at risk, at least 20
million. Newer systems will have to be developed and the nephrologist should
or must have a role in remaking these systems, which may involve major roles
in preventive medicine for nephrology nurses and physician assistants and potential
group sessions. We must also have a role in teaching the elements of care of
the early CKD patient to internists and primary care physicians. Such systems
are not currently in place. Hopefully this upcoming meeting will be the first
in a series which seriously address all the many problems in altering a system
which currently is not up to the task.
This is an opportunity for nephrologists, and one they should not shirk. However
we are only 5-7,000 practicing nephrologists in the USA, and that is too small
a group to deal with 20 million with renal function of less than 50% of normal
or significant proteinuria, at least by the methods currently employed.
Zoccali: Which are the scientific papers that influenced you most?
Blantz:
This answer must be time or era dependent. Early in my fellowship I was impressed
with the studies of Kiil and Aukland on autoregulation of renal blood flow and
GFR and the studies of Thurau, Schnermann and their colleagues on tubuloglomerular
feedback systems in the kidney, since these observations were both interesting
and had potential clinical relevance to our understanding of kidney disease.
The later studies from NIH and Brenner and colleagues on the direct measurement
of glomerular hemodynamics were of course of interest to me since I had chosen
to enter this same field of investigation.
During the past decade became interested in the several pertinent observations
on the basis of hypertension and the specific role of the kidney. Guyton's papers
were pertinent to this issue, but later observations by Navar and Wilcox were
of significant importance to our understanding of this process and the neurohumoral
regulation of kidney function and its relationship to hypertension. It is not
a big step from these relatively basic studies to practical applications to
our understanding of hypertension.
Zoccali: In your research projects you utilize renal micropuncture, cell
culture, immunologic techniques, and molecular biologic analysis and other modern
laboratory techniques. In a way you are a "basic science oriented"
clinical nephrologist. Is it a challenge for you to maintain a balance between
clinical medicine and basic science in your training programs?
Blantz:
I grew up medically and scientifically in an era when the Physician Scientist
was the model, whereby you were expected to attend on the nephrology consultation
service and do laboratory research as well.
Our trainees have tended to become more specialized over time, feeling that
they must sacrifice on or the other discipline. I trained in Dallas at University
of Texas Southwestern in the early 70s where it was assumed you performed both
clinical and scientific functions as an MD in academia. I still believe that
one can do both, in fact, clinical medicine feeds ideas to the laboratory in
many circumstances. Pursuing an interest in regulatory phenomena is not very
different from solving clinical problems in the intensive care unit. Time is
the problem rather than balancing the two disciplines. The major problem is
not maintaining a balance between laboratory pursuits and clinical medicine,
but rather keeping the administrative duties under control. However, that just
requires saying NO to some extent, unless you develop a bona fide interest in
such tasks.
Zoccali: Both in the USA and in Europe nephrology is presently attracting
less trainees than before. What initiatives should be undertaken to reverse
this trend?
Blantz:
Actually, we find that the number of internal medicine applicants to nephrology
training programs has increased over the past 5-10 years and the overall appeal
of nephrology has increased. The limiting factor in the USA is the number of
funded positions for fellows, since federal and state governments have limited
the funding for clinical subspecialists. We have legislation in front of Congress
which could correct some of those problems for underserved subspecialties, such
as nephrology and oncology.
Attracting talented nephrologists into academic medicine, into clinical or basic
positions, continues to be a challenge. To some extent this is a problem of
medical schools, since many of our graduates are really not well trained as
undergraduates before medical school to pursue a career in research, either
basic or clinical. The requirements for Medical schools in the USA have narrowed
down the spectrum of applicants to premeds and biology majors, often not well
suited by education to pursue careers in basic research. Recent loan repayment
bills passed by Congress will help by paying off debts accumulated during college
and medical school, but the impact of these executive actions has yet to be
revealed.
The best encouragement for an internal medicine resident to enter nephrology
is provided by an excellent and balanced nephrology division at his/her training
institution, supplying physician role models whereby they can view first hand
what a trained nephrologist really does and can accomplish.
Zoccali: The population of dialysis patients is growing at a rate of
about 5%/year. In the near future do you think that it is possible that even
the affluent countries cannot guarantee treatment to everyone?
Blantz:
I have no crystal ball which is required to answer accurately this important
question. The longest term solution to this issue is to:
1) somehow expand the pool of available kidneys for transplantation, human sources
or otherwise,
2) develop scientific know how to "grow" kidneys from stem cell sources
directed by the proper and appropriate developmental molecules, and
3) find some treatments that effectively delay or prevent the progression of
disease. The latter has some great appeal, and may be most relevant to the issue
of diabetes and diabetic nephropathy, the category which seems to be contributing
most to the ever enlarging ESRD population, at least in this part of the world.
Early treatments might be developed which could either reduce the percentage
of patients with diabetes which develop kidney failure or significantly delay
or prolong the course to dialysis would have a huge impact upon the figures
you predict for the future.
Yes, one would predict that there will be severe financial contraints on our
ability to supply ESRD therapy to those who need it. That is inevitable if nothing
changes. Therefore investments in the above alternative solutions seem wise
to institute now, rather than later.
Zoccali: You have an interest on diabetes and renal function. Which is
the most urgent measure to be taken to halt the epidemic of renal disease in
diabetics?
Blantz: This answer is related to those supplied immediately above. Many scientists are spending major investigative effort in defining those genetic factors which favor the development of the renal and vascular complications of diabetes. This is worthwhile, but not the total answer. Efforts at better patient compliance are worthwhile as well, but not the complete solution to the problem I fear. I suspect that our best chance is to understand the early processes which create the very early abnormalities inherent to the diabetic kidney and find agents which when applied change the biologic environment sufficient to prevent the development of the renal complications, if not the vascular as well. Studies on prevention of kidney hypertrophy and glomerular hyperfiltration may prove fruitful, even in those patients who have either a genetic predisposition to progression or exhibit smoking and obesity, which contribute to these complications. Applications of such hypothetical treatments to all diabetics early in their disease, I would hope might be greatly helpful in preventing or delaying the kidney complications. However, we are still a long way from proving this hypothesis and submitting the concept to rigorous clinical trials. Obviously prevention of the development of diabetes would solve the problem, but that need not be stated.
Zoccali: How do you envision nephrology, dialysis and transplantation
in 2010?
Blantz:
Taking an optimistic view I would hope:
1. We would have defined those phenotypes and genotypes of essential hypertension
which contribute to the progression of kidney disease and would know how to
treat those subsets pharmacologically in an effective manner. Studies are making
good progress in these areas already. Since compliance in the treatment of hypertension
is still a big problem, on the part of doctors and patients, such therapies
would hopefully be simple and require single, but highly targeted therapies
if possible.
2. Hopefully we will have made progress in increasing the availability of organs
for kidney transplantation. This may involve changing existing laws and/or developing
viable non human sources of organs.
3. I would hope that nephrologists will have helped to work out systems of contacting
the millions of patients with early CKD and creating systems for interacting
with internists and primary care MDs who see this population to apply effective
treatments in the early stages of the disease. This would result in not only
slower rates of progression but less morbidity and mortality from the corresponding
cardiovascular complications which result from CKD. Hopefully research in the
intervening period will have defined the mechanisms whereby modest degrees of
kidney dysfunction contribute to cardiovascular risk.
4. Possibly we will have made significant progress in the science of "growing"
kidneys for those who need renal replacement therapy.
5. I am optimistic that investigations in acute renal failure and ICU medicine
will have provided us with insights into how to prevent the high incidence of
acute renal failure in the medical ICU and postsurgical patient and at least
answered questions as to how to best and effectively supply kidney replacement
therapy in the ICU and surgical setting.
6. We may have been forced to define a better role for the non MD health care
professional in the care of the patient with kidney disease. Manpower problems
will have forced us as a subspecialty to confront this issue head-on, and I
would speculate that participation of nurses and PAs could alleviate the burden
and limitation of time now experienced by the nephrologist, particularly in
the care of early CKD patients and potentially ESRD patients as well.
