Interview with Prof J. Feehally

Prof J. Feehally Dept. of Nephrology Leicester General Hospital Leicester, United Kingdom

Prof Zoccali: You are President elect of the Renal Association. Which programmes would you like to promote during the years of your presidential tenure?

Prof Feehally: I am very honoured that in 2004 I will become President of the Renal Association, which as you may know, is the oldest nephrology society in the world [it was founded in 1950]. During my three years as President I have a number of priorities:
• The UK government is presently reviewing the organisation of renal services and the Renal Association will have a crucial role in the next few years ensuring that the framework proposed by the government is as strong as possible for our patients, for nephrologists, and all those who work in the clinical renal team. In particular, we have to make sure that the government realises the number of nephrologists in the UK must continue to increase as we are still well behind the numbers in many European countries.
• The Renal Association has a proud tradition of excellent scientific meetings, which I want to be maintained alongside ever-improving educational programmes for established nephrologists as well as our young trainees.
• Nephrologists in the UK are especially well placed to assist nephrologists in emerging countries, for example in Eastern Europe and in the developing world. One of many reasons for this is the status of English as the international medical language. I want the Renal Association to work more closely with ERA-EDTA and the International Society of Nephrology so that we can increase the UK’s contribution to this vital worldwide work, offering training opportunities in the UK and contributing to education and support in other countries.

Prof Zoccali: Perhaps British nephrology was the first to stress the importance of audits as a basis for solid professional quality control. Could you tell us how audits are organised in British renal units?

Prof Feehally: The Renal Association has been publishing standards for the treatment of renal disease for more than 10 years; a new edition has recently been published [it can be found on our website: www.renal.org]. At first, each local renal unit undertook its own internal audit against those standards. But the Renal Association now has established the UK Renal Registry, which will soon be collecting data from all UK renal units. Data collection is entirely electronic, and at present concentrates on patients receiving renal replacement therapy. Annual reports are now published showing the performance of individual units compared to the Renal Association Standards [www.renalreg.com]. This is a powerful tool for continuous quality improvement, and to assist local units in negotiating for additional resources to strengthen their performance.

Prof Zoccali: A difficult question: British nephrology has strong links with American nephrology and many feel that these links far outweigh those with the European continent. What move would you like the ERA-EDTA to make to bring British nephrology closer to Europe and vice-versa?

Prof Feehally: In the past, British nephrologists were strongly associated with ERA-EDTA – they were among its founding members, and have been among respected office-holders over the years. But, I am aware that the number of British nephrologists who are ERA-EDTA members is dwindling. The natural links for British nephrologists with the United States are strong – so many of our young trainees have gone to the States for research or clinical experience, and then build collaborations and friendships while over there. Because there have been so few nephrologists in the UK there are also strong clinical pressures which mean that many of us have only had time to attend one international nephrology meeting a year, and our transatlantic links mean we have often chosen to go to ASN.
While I am President of the Renal Association I shall be strongly encouraging British nephrologists to become members of ERA-EDTA, to take advantage of the excellent educational opportunities now offered by ERA-EDTA, and to submit their best research to the ERA-EDTA Congress, which is developing stronger and better scientific programmes year by year.

Prof Zoccali: You maintain a constant and strong interest on IgA nephropathy. What led you to be interested in this topic? Which developments do you foresee in the next few years in this field?

Prof Feehally: I became interested in IgA nephropathy [IgAN] when I first met young adults with the disease, and was fascinated by the coincidence of episodes of visible haematuria with intercurrent infection. I wanted to understand why that happened. Of course 20 years later I still cannot explain it! But it has been extraordinarily interesting being involved as our understanding of the pathogenesis of IgAN has gradually unfolded.
In the next ten years or so I expect that we will develop a much better understanding of the mechanisms by which IgA is deposited in the mesangium and provokes glomerular inflammation. I expect we will discover that more than one mechanism is involved and that it will no longer be correct to think of IgAN as a single disease.
But I do not think this understanding of pathogenesis will impact on treatment in the next decade. Progress in treatment is much more likely to come from large pragmatic randomised controlled trials investigating combinations of interventions with low toxicity aimed at slowing disease progression. To make these trials efficient we will have to improve further our ability to identify very early on which patients with IgAN are going to progress. The results of such trials are very likely to apply to other chronic progressive glomerular disease, rather than be specific for IgAN.

Prof Zoccali. England is probably the most multi-racial country in Europe. How does ethnicity impact on your clinical and research work? Does the multi-ethnicity of your patients demand particular organizational adjustments?

Prof Feehally: There are indeed very substantial ethnic minority groups in the UK, mostly African Caribbean and South Asian in origin. We know that these populations have an incidence of ESRD three to four times that of the white Caucasian population. So the immediate impact is an increased demand for renal replacement therapy, particularly in those urban areas where the majority of the ethnic minority populations reside. There are also special challenges in renal transplantation since ABO and HLA patterns differ in these populations meaning considerably longer waits for cadaveric kidneys. Issues of language and culture also mean we often need to use additional specific resources to ensure that patients from these racial groups receive the same access to care and quality of care.
But I think the biggest challenge is yet to come. We must organise effective ways of early detection of renal disease in these high-risk populations to ensure that we make the best of the opportunities we now have to prevent or delay the onset of renal failure. This requires a national approach involving not only nephrologists, but also community-based medical care.

Prof Zoccali: Renal transplantation is one of your major interests. Which developments do you envisage in the next decade in this area?

Prof Feehally: Shortage of cadaveric kidneys for renal transplantation is going to remain a problem, and even the creative approaches taken in Spain to maximise donors in intensive care units, or the use of non-heart beating donors, as is already done in some centres in the UK, will not sufficiently meet our needs. I have no doubt that we will need to promote live donor transplants even further with continuing expansion of live unrelated donation and altruistic donation.
On the immunosuppressive front I anticipate a gradual reduction in the use of calcineurin inhibitors so that we can move to less nephrotoxic regimens. However, I think we must be very vigilant that the continuing emphasis on reducing acute rejection rates with our increasingly powerful immunosuppressive combinations does not result in substantial increases in infective and neoplastic complications of transplantation.

Prof Zoccali: You are professor of Nephrology in a large nephrology unit in Leicester. Working in such an environment must be very stimulating because of the variety of intellectual stimuli emanating from clinical practice, but also a challenge for the need of combining clinical and research work. Do you have problems in coping with these tasks?

Prof Feehally: There is never enough time in the day! I have been very fortunate to work with a small team of superb scientists so it has been possible to maintain our laboratory research alongside my clinical work. Inevitably, I am doing less clinical work than in the past because of other activities and responsibilities. But I think it is the combination of clinical and research work which is endlessly interesting, and also ensures that the research questions we pose are rooted in clinical issues. I think that I manage reasonably well in combining all these tasks and ensuring that I do each to the best of my ability – but perhaps you had better ask my colleagues how well I succeed!

Prof Zoccali: Which is the most frequent advice you give to young nephrology trainees?

Prof Feehally: It is a fantastic privilege to be a nephrologist. On the one hand, there are great clinical and intellectual challenges to engage us. On the other hand, responsibility for the longterm care of people with renal failure carries with it both demands and satisfaction. Privileges – yes. Responsibilities – yes. But it is also enormous fun – so continue to enjoy it!

Prof Zoccali: Which is your favourite hobby?

Prof Feehally: I play the clarinet – not very well, but well enough to enjoy playing in a musical group every week. I also think rugby is the greatest game in the world – and I watch my own club, Leicester Tigers, as well as England as often as I can.