Interview with Prof D. Fouque

Prof D. Fouque Department of Nephrology Hôpital E. Herriot Lyon, France

Prof Zoccali: You have a strong interest in modern clinical epidemiology and have published several meta-analyses dealing with major nephrology problems such as the effect of diet on the progression of renal disease or the effects of carnitine administration in dialysis patients. Do you believe that interest in clinical epidemiology among nephrologists is less widespread than among other specialists, for example cardiologists?

Prof Fouque: The discovery of meta-analyses is quite new for nephrologists, since the first publications in the renal field were made in the early nineties. In contrast, meta-analyses have been used for more than five decades in psychology and for three decades in cardiology. Clinical epidemiology too is starting to arouse great interest in nephrologists but good studies should now comply with international standards (prospective design, limited number of items to be followed, large size of cohorts…). Thus, nephrologists appear to be more and more involved in this recent field.

Prof Zoccali: Do you believe that “evidence based medicine” labelling is now much abused and misused and that such a definition should be discarded?

Prof Fouque: There is indeed a risk of misuse of the concept of EBM and a number of speakers or meetings or company advertisements refer to EBM without having technical background or knowledge. However, I do not think that this label should be discarded but that it should probably be used with more caution. The quality of research is not always good enough to obtain forceful data and strong evidence in all clinical day-to-day situations. In my experience, no more than 20% of clinical questions have EBM answers. Thus, we should carefully follow the results of new trials and constantly adapt our strategies. In addition to industry-sponsored research, institutional and/or public support should be increased to promote better quality clinical research.

Prof Zoccali: How was the renal group of the Cochrane collaboration set up?

Prof Fouque: The Cochrane Renal Group was set up in 1997 after two years of meetings in Annecy, France and during international congresses (ERA-EDTA, ASN, ISN). After this, Jean-Pierre Boissel, MD, a well-known expert in methodology from Lyon, France, convinced us of the fundamental role of physicians in evaluating and disseminating the results of large clinical trials. After a formal application to the Cochrane steering committee, the Renal Group was officially approved, as of January 1st 1997. The editorial base was set up in Lyon, France, with six international editors, an administrator and a trial search coordinator. In 2001, the editorial base moved to Sydney, Australia and is now headed by Jonathan Craig, MD. Since then, the Cochrane Renal Group has published a number of systematic reviews on dialysis, as well as on transplantation and renal diseases in adult and child patients, the abstracts of which are available from Medline.

Prof Zoccali: I perceive that the number of meta-analyses being performed is less than that required by the current blossoming of guidelines. Do you think that this depends on the fact that, in the nephrology community, the number of people trained in this methodology is still extremely limited?

Prof Fouque: There is indeed a risk of downgrading the current reflexion on health care by publishing guidelines without strong research data. The development of guidelines should follow the production of forceful clinical research data, not appear parallel to them or, indeed, precede them. Without such data, and given the fact that guidelines try to answer all clinical questions, the recommendations could weaken over time. It is probably easier to become a guideline writer than an efficient clinical researcher.

Prof Zoccali: Nutrition is one of your main interests. What led you to fall in love with the subject?

Prof Fouque: Historically, our department developed a metabolic unit in the seventies under the direction of Prof Traeger. Subsequent to this I found myself surrounded by nitrogen balances, dietary reports, urea metabolism, and low protein diets. I was also very impressed by one of the first reports of Dr Scribner in 1960, explaining that during maintenance dialysis, nobody knew what the best nutritional intake for these patients might be. Forty-five years later, I should say that he is still right, and research did not entirely resolve this question.

Prof Zoccali: What is the main goal that you would like the ISRNM to achieve under your tenure?

Prof Fouque: Over the past five years, the Society has made an impressive move by starting its own journal (Journal of Renal Nutrition) and organizing international meetings every two years, generating a constant improvement in the level of science. We are now developing an efficient website and better communication between members. My goal would be to elicit international nutrition and dietary research by promoting epidemiology trials in various areas of the globe, since the ISRNM has members in more than 40 countries.

Prof Zoccali: What is the scientific paper that impressed you most?

Prof Fouque: I really enjoyed reading the series of Brenner and Hostetter articles on glomerular hemodynamics in the early eighties. More recently, I was very excited by the findings of Battheram and colleagues on newly discovered peptides and appetite regulation, in the New England Journal in September 2003.

Prof Zoccali: Being French and an expert in nutrition, you must like good wine. What is your favorite red?

Prof Fouque: I have a great taste for the north Côtes du Rhône called “Côte Rôtie”, a sunny strong Shiraz, which is the ideal accompaniement for a large beef rib (referring to the low protein diet story!).

Prof Zoccali: What research program would you start if you unexpectedly received a 100 million EU grant?

Prof Fouque: It would probably be to develop a large integrated health care structure to provide, evaluate and improve renal care at all different stages of renal disease. This structure would also help to analyse therapeutic customs and the way in which physicians adapt their own practice to new treatments, guidelines and research findings.

Prof Zoccali: What is your hobby?

Prof Fouque: I like the Alps during the winter season for skiing and during summer for walking and mountain biking.