Interview with Prof B.J.G. Pereira

Prof B.J.G. Pereira Professor of Medicine, TUSM Tufts-New England Medical Center Boston, USA

Prof Zoccali: Prof Pereira you are a special type of clinician-investigator because you maintain a strong interest in clinical research while serving also as President and CEO of the NEHCF at Tufts-New England Medical Center. The challenge posed to you by such diverse duties must be tantalising.

Prof Pereira: My day is an exciting mixture of challenges. The healthcare environment in the US is complex, changing and challenging. As is the case all over the world, demands are growing, but resources are not keeping pace. Consequently, a large part of my day is spent on financial and organizational issues, strategies to meet the challenges of the environment and identifying opportunities to grow. However, the best part of my day continues to be the time I spend with my research teams. I have carefully carved out time to keep abreast and engaged in my first love – kidney research.

Prof Zoccali: You started your career in Bangalore, India then moved to the USA. You had a very successful and fast career track. Which was the main difficulty for you realizing your accomplishments?

Prof Pereira: I have been very fortunate in that I arrived in the US into a very nurturing environment at Tufts-New England Medical Center in Boston. Drs Nicolaos Madias, John Harrington and Andrew Levey had created a strong family atmosphere in the Division of Nephrology along with a strong scientific discipline. Consequently, many foreign medical graduates had trained in the Division and launched very successful careers. This tradition continues to date. Naturally, starting all over again in the US (I was Chief of Nephrology in India) was a burden as was the challenge of fitting into the American culture.

Prof Zoccali: You are also President of the National Kidney Foundation. This Foundation has several merits and the determination to promote the production and the diffusion of Nephrology Guidelines is perhaps one of the greatest. How important is in your vision involving patients and health authorities in Guidelines production?

Prof Pereira: The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) has been one of the greatest initiatives of our times. Through a structured process of evidence based guidelines, developed by the experts, and reviewed by all stake holders, we have been able to impact on patient outcomes like never before. Before publication of these guidelines, all stakeholders, including patient groups and the governmental agencies are provided an opportunity to review them and provide input. In fact, the credibility of these guidelines are so high that at least in the US, quality of care is measured by the ability to meet the targets set in the guidelines and in some cases even payment is linked to these measures.

Prof Zoccali: Which are the programs and projects of the Kidney Foundation under your tenure?

Prof Pereira: The NKF KDOQI has continued to grow. In the last two years, we have developed new guidelines on CKD, Lipids, Bone and Mineral Metabolism, and Blood Pressure. In addition, within the next year, we will have new guidelines on Atherosclerosis in Dialysis, Anemia and an update of the original guidelines on Hemodialysis, Peritoneal Dialysis and Vascular Access. Further, we are working with the global kidney community on “Kidney Disease - Improving Global Outcomes”. On the early diagnosis side, we have launched the Kidney Early Evaluation program (KEEP) which screens individuals at risk for kidney disease. Thus far, over 25,000 individuals have been screened in the US. We have developed a Kidney Learning System (KLS) which catalogues all the professional and patient educational material and implementation programs. The NKF continues its leadership in the field of transplantation and we co-hosted an International Conference on the Care of the Living Donor and several consensus conferences on different issues in transplantation. The NKF is the leading voice of kidney patients and professionals in Washington DC and plays a powerful role in legislation. Finally, we have worked hard to bring the different kidney organizations in the US closer to speak with one voice on issues of training, research and patient care.

Prof Zoccali: Which are the most important changes that you foresee during the next 20 years in the treatment of kidney diseases?

Prof Pereira: In the scientific arena, the Human Genome Project will revolutionize our understanding of the inherited diseases of the kidney and the individual susceptibility to kidney disease. Genetically tailored therapies will bring safer and more effective drugs into clinical practice. Cloning could be the answer to the shortage of organs for transplantation. The biggest challenge will be the manpower needs to care for older and sicker patients and the ability of governments to pay for the increasing demands and cost of innovation. The debate on “rationing” care is likely to emerge in the developing countries. For the developing world, the divide between the rich and poor, private vs. government payers for kidney care is likely to continue. The challenge to all of us is - how do we dedicate the limited resources to providing the maximum benefit to the greatest numbers?

Prof Zoccali: Reasoning on a global, world scale, which is the main challenge facing Nephrology today?

Prof Pereira: The world is rapidly becoming a single playing field and the barriers to commerce, culture, communication and science are rapidly disappearing. In this environment, scientific and policy decisions by one country have implications for the whole world. A typical example is the sale of human organs in some developing countries. Although most developed countries ban organ trade, their citizens are the major clients for purchased organs from the developing world. The same is true for cloning, reproductive rights and so on. Consequently, policies will have to be developed with a global perspective.

Prof Zoccali: Which is the paper that influenced most your research interests?

Prof Pereira: The cloning of the hepatitis C virus in 1989 (Choo, Science 1989, 244:359) launched my research in the field of hepatitis C in dialysis and transplantation, working with my mentor Andrew Levey. Concurrently, the Interleukin Hypothesis (Henderson, Koch, Dinarello, Shaldon, Blood Purification 1983, 1:3) led to my interest in cytokines in dialysis, while working in Charles Dinarello's laboratory.

Prof Zoccali: As an Indian you have a strong spiritual background. What do you think about the present scientific interest of the healing power of praying?

Prof Pereira: I believe that religion and spirituality have a strong role in healing. While the scientific basis is being studied, there is no doubt that religion and spirituality contribute to a better state of mind and help deal with disease in a more balanced way.

Prof Zoccali: Which is your favourite hobby?

Prof Pereira: I enjoy all forms of physical activity – biking, work-outs, tennis, just about anything that is physical. In addition, I enjoy reading, writing and politics.

Prof Zoccali: What advise would you give a young doctor entering a career in nephrology?

Prof Pereira: Nephrology is an exciting field – it has something for everyone. For those who wish to pursue a research career, nephrology is at the cutting edge of genetics, proteomics and molecular biology. For those who wish to be teachers, there is nothing more fascinating than explaining a complex acid-base or electrolyte case. For those who choose a clinical career, the growing CKD population is certain to keep you busy and the satisfaction of slowing progression of kidney disease, managing difficult dialysis patients and seeing a patient through transplantation is immeasurable. Finally, those who choose the industry-track, the next decade will see a rapid growth in novel therapies that will improve patient lives.