Interview with Prof Norbert Lameire

Prof N. Lameire Chief Renal Division University of Ghent Ghent, Belgium

Prof Zoccali: You are a dedicated clinician and highly reputed clinical governor. How do you react to the ongoing restructuring of roles of doctors and other health workers and to the pressure imposed by the escalating health costs due the increasing number of patients with renal insufficiency?

Prof Lameire: Although in most European medical curricula the training of our medical students is focused on the approach of the individual patient, we can no longer neglect that medical care should be placed in a social and even global perspective. The tremendously increasing costs of care of our patients with end-stage renal disease must on one hand not lead to a limitation of this care purely for financial reasons (I believe we in Western Europe are rich enough that we can spend money on even less important issues!) but on the other hand, we should, as the nephrological community, pay more attention to an expansion of kidney transplantation and peritoneal dialysis as treatment of our patients, modalities which I believe are less costly for society than in-centre haemodialysis. Other forms of heamodialysis (home and low-care centres) should be further encouraged. By far the most effective and economic way is, however, prevention of ESRD by earlier detection of incipient renal failure and more adequate and earlier treatment of all risk factors. Better coordination and cooperation between nephrologists, primary care physicians and other health care providers is therefore urgently needed. The ERA-EDTA could act here as an important vehicle for organising this model of nephrological care. We also have the duty to help our colleagues in the third world, who often work in difficult circumstances and where the prevalence of kidney diseases is at least as high as that in the Western world.

Prof Zoccali: You have been one of the first nephrologists to stress the importance of basing clinical practice on solid diagnostic, prognostic and therapeutic studies. Do you believe that more effort should be paid to disseminate clinical epidemiology among renal specialists?

Prof Lameire: Nephrologists, internists and certainly primary care physicians taking care in the management of renal patients should of course be more aware of the epidemiology of renal diseases. Since hypertensive atherosclerotic diseases and diabetes type II are the leading causes of ESRD, at least in the Western World, our graduate and postgraduate teaching should put most emphasis on these problems. I have not seen one single new case of Goodpasture syndrome over the last 5 years, and still this topic and many other exceptional diseases receive disproportionate attention in our medical curricula.

Prof Zoccali: Do you think that clinical research receives scarce attention from national health systems and more in general by funding institutions? Do you believe that there is a need for independent clinical trials and observational studies or that clinical trails are now so costly that they are beyond the reach of the individual investigator or of scientific societies?

Prof Lameire: Clinical research becomes more and more the area of pharmaceutical and non-pharmaceutical industry. This is due to the simple reason that more “independent” institutions cannot or will not provide the necessary financial support for often very costly clinical research protocols. We can deplore this but on the other hand, I am a firm believer that even industry-sponsored clinical research can be independently performed and when the financial support structure is transparent. I have no objections to such research. I believe that the nephrological community should be grateful that many important large-scale and industry-sponsored clinical investigations have led to better understanding and treatment of many important kidney diseases.

Prof Zoccali: You are co-editor of Nephrology, Dialysis,Transplantation and sit on the editorial board of major nephrology journals. What is the main challenge of medical journals in general and nephrology journals in particular today? Should they sub-specialize or should they strive to maintain a generalist format?

Prof Lameire: The major challenges today regarding medical journals in general and nephrology journals in particular are to preserve their independence and quality in the presence of increasing production costs. I believe that especially in the nephrology field, more than enough journals are present, and one may even question whether all these journals can be read by the practicing nephrologist. The past and present editors of NDT have aimed at a steady increase of the scientific quality of the original contributions without forgetting that our journal plays an important educational role for the practicing nephrologist in Europe and abroad. A good mix of research and clinical practice papers is necessary, and both the academic and non-academic clinicians should base their clinical work on solid scientific evidence.

Prof Zoccali: Your clinical research interests are wide-ranging and span from intensive care nephrology, peritoneal dialysis to uremic toxicity. Presently, what is the research topic at the top of the list in your mind?

Prof Lameire: My “old loves“ are without any doubt acute renal failure and, over the last 20 years, basic and clinical research in the field of peritoneal dialysis. More recently, and this must reflect my age, I became more and more fascinated by the world-wide dissemination of clinical and basic evidence into nephrology. I am so fortunate to be a member of the K/DOQI guideline group, and through my activities in the ERA-EDTA and NDT I hope to be able to continue to contribute to this dissemination in future years. Education of young students and trainees in the scientific and human aspects of our profession is probably the most rewarding job that a clinical academician can have.

Prof Zoccali: What advice would you give to a young colleague entering our specialty? What would you envisage to increase the attractiveness of nephrology for talented young doctors?

Prof Lameire: Of course I am biased, but nephrology is, among all the specialties of internal medicine, the one with the broadest application of general medicine; after all we are also the first–line physicians to many of our dialysis patients. It is also the specialty where somebody attracted by intensive care medicine can become very happy. Our specialty is also very much involved in the care of an increasing number of elderly patients with all the ethical and social problems associated with this evolution. Nephrology is also attractive to the basic researcher, and more and more we will need to have brilliant young people involved in molecular biology and genetics to be able to explain their findings to the practicing clinicians, so that their scientific results will lead to application at the bedside. I therefore am in favour for the development in Europe, as in the States, of nephrological departments where basic research and clinical activities are “under one roof” and where a multi-disciplinary approach of problems is possible. On the other hand, a good clinical nephrologist should have a more than adequate knowledge of pathophysiology and should, in my opinion have had a basic training of at least 3-4 years in general internal medicine before he/she continues his/her training in nephrology.

Prof Zoccali: How do you manage to combine your research, editorial and managerial duties with that of Director of a busy Nephrology Unit?

Prof Lameire: The management of these “duties” is only possible by having a fantastic staff, a very well-organized secretariat (the real managers of the division), the friendship of many colleagues all over the world and a family with a lot of patience, love and understanding. Both the ERA-EDTA and the ISN are the organisations where I find myself very much at home.

Prof Zoccali: You are the European coordinator of the Nephrology Disaster Relief Task Force. I feel that the activity of this task force is not known enough by our colleagues. Would you briefly tell us where and when this task force has intervened?

Prof Lameire: The ISN Commission of ARF has first, under the leadership of Kim Solez and then under my responsibility, created the Task Force for Renal Disaster Relief, following the major earthquake in Armenia in 1988. The European Branch of this Task Force has been very fortunate to have excellent partners who cooperate in this endeavour, including Doctors without Borders, the EDTNA, and the dialysis industry. The Task Force has successfully operated in Turkey in 1999 after the dramatic Marmara earthquake where in close cooperation with the Turkish Society of Nephrology (nephrologists and nurses) close to 400 patients with Crush syndrome were dialysed. Further interventions took place in India and recently in Algeria. The Task Force tries very hard to establish a similar structure in Latin and North America. Many European nephrologists and dialysis nurses are on the volunteer list of the Task Force.

Prof Zoccali: What is your favorite hobby?

Prof Lameire: When not busy in preparing lectures, papers or answering interviews, I am a passionate reader of historical books (my main interest is the history of the 2nd World War). I played the cello in my younger years and I hope to find the time after my retirement to begin playing this wonderful, but difficult instrument again. I listen to classical music and love to see a good film. After my retirement I am certainly planning to study Italian, probably the most lyrical language in the world.