Interview with Prof Christian Combe

Prof C. Combe Department of Nephrology Hopital Pellegrin and Universite Victor Segalen Bordeaux, France

Prof Massy: Why did you go into medicine?

Prof Combe: I chose to go into medicine because I thought that physicians are always useful to others, in all countries, at all times. This was important when I was 18 years old, questioning myself about what to do with my life. Other important points in my thoughts were that the study and practice of medicine are based on science, with a very wide range of possibilities of professional practices, ranging from being a family doctor to being a scientist, a journalist, a manager. In my professional life, I am now a physician, and also a researcher, a teacher, and last but not least, a manager. I think I have made a good choice, I like my job.

Prof Massy: How did you become interested in renal diseases? How important were your mentors in your choices?

Prof Combe: Nephrology is a fascinating part of internal medicine, which needs pathophysiological reasoning in a day-to-day practice. Although it is quite specific, particularly in the care of patients treated with dialysis or transplantation, nephrology is not limited to the kidney and its diseases, we have to care for patients in a global setting. These different points led me to choose nephrology in the middle of my internship, when I was in the Department led by the late Prof Claude Martin-Dupont, the founder of nephrology at the University Hospital of Bordeaux. Later, I went to work with my mentor, Prof Michel Aparicio, who reinforced my choice and guided me in my career. I had the opportunity to work at Tenon Hospital in Paris with Prof Raymond Ardaillou for a master degree in renal physiology and pathophysiology. As you know, Ziad, we learned a lot during this year of study which gave us a solid background in kidney physiology. Back to Bordeaux, another mentor was Jacques Bonnet, who is a Professor of cardiology, and was the director of my PhD thesis. For 16 years, I have always tried to work in the lab, we now have an emerging research team working on renal fibrosis and engineered stem cells. I also spent one year in Leicester, UK, in the lab of the late Prof John Walls. John had a fantastic personality, he was a man with considerable energy and organizing ability, I have very good memories of him and of this year in Leicester.

Prof Massy: Could you tell us the lessons we can learn from the Bordeaux/French experience regarding nutrition in nephrology?

Prof Combe: We have shown that many abnormalities linked to renal failure, including secondary hyperparathyroidism, insulin resistance, decreased Na-K-ATPase activity, and others, can be corrected by supplementing very low protein diets. These diets are safe and feasible in very carefully selected and monitored patients, but amino acids and keto acid supplements are no longer available in France, so we no longer use them. However, we are still deeply interested in nutrition. For instance, in a local collaborative work of all the dialysis centres of Bordeaux, we have shown that in patients treated with haemodialysis, an increase in protein intake tends to counteract the effects of inflammation on survival. The French group for the study of nutrition in haemodialysis was initiated by Xavier Leverve, Michel Aparicio, and others. We performed several studies, which were initially focussed on epidemiology and are now moving onto controlled therapeutic studies. Taking care of nutrition in patients with renal failure depends on all professionals, including nurses, dieticians, and even social workers. To obtain a better nutritional status requires continuous team efforts, and it is necessary to develop actions towards therapeutic education. This is a very good way to strengthen a nephrology team, with the final goal of being beneficial to patients.

Prof Massy: Reasoning on a global scale and as a DOPPS (Dialysis Outcomes and Practice Patterns Study) investigator, what is, in your opinion, the DOPPS input on the progress in nephrology research?

Prof Combe: The DOPPS is a very important study which highlights the need for epidemiologic studies. From its data, therapeutic actions have been led: for instance, in some centres, Kt/V was not routinely measured. When physicians realized that dialysis doses were too low in their patients, they increased it, sometimes by a very simple increase of blood flow, with beneficial consequences for patients. This type of practice is not evaluated in randomized studies, which are the gold standard to increase medical knowledge, but are performed in a very specific setting of centres involved in clinical research. Because of the diversity of the practices of haemodialysis in the different countries studied, the DOPPS provides unique information, such as the importance of increasing Kt/V over current recommendations, or the positive association of the use of statins with outcome in dialysis patients. DOPPS was designed by Fritz Port, Philip Held and Bob Wolfe to yield a broad range of data covering medicine, public health, economics, and biostatistics, which is part of its originality, apart from the huge number of patients included.

Prof Massy: As a current Editor-in-Chief of "Néphrologie et Thérapeutique", how do you evaluate the contribution of the French nephrology journals to nephrology education and research?

Prof Combe: As an editor, I think that we need a nephrology journal written in French. "Néphrologie & Thérapeutique" is the official Journal of the Société de Néphrologie, the Société Francophone de Dialyse, and the Société de Néphrologie Pédiatrique, all societies based in French-speaking countries from Europe, but we hope that we will be useful to French-speaking countries outside Europe, particularly in the Maghreb. One of our goals is to publish state-of-the-art reports, guidelines, and updated articles from the Medical Encyclopaedia, i.e. to be a means of continuous medical education. We also publish original reports, case reports, editorials, as any other medical journal. As an emerging journal, we do not have the ambition to have a significant impact factor, but rather to become of reference for our readers. For some invited contributions and research papers, English is welcome.

Prof Massy: How do you foresee nephrology in 2015? What kind of organisational, technical and scientific evolution do you see in 10 years time?

Prof Combe: Ten years is a short period of time, particularly to change organisations. However, we hope that clinical networks involving general practitioners, biologists, nephrologists and other professionals will allow a better detection of chronic renal diseases and a better efficiency in halting the progression of renal failure. If data in animals is confirmed, we will be able to treat patients with polycystic kidney diseases, and maybe other genetic renal diseases. Regarding dialysis, one hopes that home therapies will be encouraged, including daily haemodialysis and peritoneal dialysis. This will require a better demonstration to health authorities of the benefits of these therapies. I am convinced that ethical issues will be a major challenge regarding treatment of very old and/or very sick patients by dialysis. We'll have to address these issues with multidisciplinary teams. In the field of renal transplantation, it is quite likely that kidney donation will increase, at least in my country where it is not as developed as in the US or other European countries.

Prof Massy: How do you relax in your free time?

Prof Combe: I like outdoor sports, including skiing, mountain biking (in the mountains!), and hiking. I also enjoy going to the opera and reading, mainly novels and history books; the most important thing remains family life, although our 3 teenagers will not stay at home.