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Dr
John T. Daugirdas University of Illinois at Chicago School of Medicine Associate Chief of Staff for Research and Development V.A. Chicago - Westside Medical Center Chicago, USA |
Zoccali:
HDCN is perhaps the most used resource for CME in Nephrology worldwide. Could
you tell us how the idea of HDCN originated and how it has evolved to the present
format?
Daugirdas: I began HDCN in August of 1995. The idea originated
from a need to highlight key abstracts and advances presented at scientific
meetings: These sometimes do not appear in print for 6-12 months after initial
presentation, and, at least in 1995, several months were required for already
published articles to be indexed and appear on MEDLINE. For those interested
in how HDCN looked in July of 1997, click here: http://www.hdcn.com/hdcnold.htm.
In January of 1998, HDCN looked like this: http://web.archive.org/web/19980202183133/www.hdcn.com/.
So the evolution was gradual and continues.
Zoccali: The Internet has revolutionized scientific communication
and perhaps it will bring even greater changes in the near future. By now the
structure of medical journals has changed very little except that we have the
papers on our desk as soon as they are published (in PDF format). Do you think
that we will eventually have more friendly, Power Point based, “original
articles” as envisioned by DelaPorte?
Daugirdas: A very interesting thought. Of course we need to keep the present format for methodologic detail and references, but in addition to a free abstract, such as is now available on Medline, a free 10 slide Power Point presentation, perhaps also indexed on Medline, and prepared by the authors would also be very useful. One danger, of course, is oversimplification, as forced by the bulleted, Power Point format. Some journals such as the Annals of Internal Medicine are preparing lay summaries of their papers, which is another useful option.
Zoccali: Your Dialysis Handbook is very successful. It is a
well pondered source of evidence based clinical information. Have you planned
an Internet based version that can be periodically updated?
Daugirdas: In a sense, HDCN was partly designed for that reason and does fulfill this function. The topics page structure of the Dialysis part of HDCN closely follows the chapter layout of the dialysis handbook. My idea was, if I could prospectively follow the literature in this fashion, when the time came to update the Handbook in print format, it would make life for the chapter authors that much easier.
Zoccali: Hypertension is the leading word in your WEB journal.
Is this so because you think that hypertension is or should be the main area
of expertise for renal physicians?
Daugirdas: In the past several years, attention is increasingly focused on prevention of ESRD and on the CKD (chronic kidney disease) period, and it is clear that much of the cardiovascular disease responsible for death during ESRD develops during the CKD period. Much of this appears to be preventable, and an action plan has been put together in the form of the U.S. NKF K-DOQI guidelines for the CKD area. I believe nephrologists always needed to be experts in cardiovascular disease – one of the reasons I chose nephrology – it is such a broad specialty.
Zoccali: Dialysis dosing and adequacy is perhaps one of your
major clinical research interests. Many feel that we should develop more articulated
measures and indexes of treatment adequacy. What do you think about this problem?
Daugirdas: It is clear from the HEMO trial that we are reaching the limits of what we can accomplish by 3x/week therapy over a 3-4.5 hour period of treatment. More dialysis treatment time is required. Because there is so little “signal” during 3-4.5 x dialysis, there is also less interest in fine tuning measures of adequacy for this treatment strategy. The equivalent renal clearance as developed by Casino and Lopez and as modified by Gotch points out that “equivalent” renal clearances for the two arms of the HEMO study were only about 7.5 vs. 9.0 ml/min – only a 15% separation and far lower than normal native kidney function. Looking at HEMO dosages in this way, it is not surprising that a markedly positive dose effect on outcome was not found.
Zoccali: Do you think that daily dialysis may become a common
form of treatment of ESRD?
Daugirdas: Some of this depends upon funding, and this in turn depends upon conclusive demonstration of benefit in a randomized controlled trial. My ideal for therapy would be what I call “QOD NOC” or every other night nocturnal HD. A patient would come at 10 PM to the unit, hook up to the machine, and dialyze until morning while sleeping. The patient would get off at 6 AM in the morning, and go home. He or she would return every other night on a 2-week schedule, to eliminate the 2-day interdialytic interval. The Tassin data was very impressive in terms of BP control, dry weight gain, and even phosphorus control. The QOD NOC regimen is close to Charra’s Tassin strategy, but the dialysis is done while the patient is sleeping, minimizing boredom and maximizing rehabilitation, and it gets rid of the 2-day interdialytic interval. Also, one does not have to convert the home into a dialysis unit, and almost all of the waking hours now belong to the patient. There are thousands of dialysis units across the world where the machines are sitting unutilized during the night. So if found to be beneficial, a large number of patients could be switched over to such a dialysis regimen without any need for change in infrastructure. I hope this strategy will be one of the ones chosen for evaluation by the U.S. NIH in their new initiative. (http://grants1.nih.gov/grants/guide/rfa-files/RFA-DK-03-005.html).
Zoccali: Which are your present research interests?
Daugirdas: There are many papers to be written concerning the HEMO study – at least several years of work remain. The University of Illinois also is part of the CRIC consortium, which is an NIH-sponsored long-term observational trial of patients with chronic renal insufficiency. This trial will keep us busy for at least the next 7-10 years. Finally, I continue to be interested in more frequent dialysis and hope to participate in one of the initiatives to evaluate more frequent therapy in a formal, structured way.
Zoccali: Which advice would you give to a young colleague entering
a career in Nephrology?
Daugirdas: I always liked nephrology because it covers so many areas, including cardiovascular disease, endocrinology, artificial organs, calcium-bone homeostasis, immunology, rheumatology, transplantation, acid-base, and ICU medicine. So my advice would be that nephrology was a correct choice for a specialty, as it can be tailored to suit many divergent interests. Also, demographics suggest that the need for nephrologists will continue to increase dramatically in the coming 10 years.
Zoccali: Apart from HDCN, which is your favorite hobby?
Daugirdas:
Cross-country skiing, although with “global warming” there has not
been much snow in Chicago for the past several years.
