Interview with Dr J.J. Weening

Dr J.J. Weening ISN President AMC, Department of Pathology Amsterdam, The Netherlands

Zoccali: You are the President of the ISN. The ISN is seen as a society of high ethical stature in world nephrology for helping young nephrologists and scientists of less developed countries in the early stages of their career. Which are the most recent programs in favour of these countries?

Weening: The continuously expanding programs for the emerging countries is that of our Commission on the Global Advancement of Nephrology, chaired by John H. Dirks from Toronto. ISN-COMGAN has developed a network of global activities and contacts, supported by regional committees and specialty committees which all contribute to regular CMEs and Updates in over 100 countries, reaching some 11,000 physicians in 55 cities and 35 countries annually as listed on our website www.isn-online.org.
In emerging countries, we work through our fellowship program directed by Rashad Barsoum, offering short term (3 to 6 months) and long term (12 to 24 months) fellowships in the country of choice. This program has an annual budget of about $750,000 which is largely coming from ISN itself, with generous help from the ASN, NKRF, Baxter and Fresenius. Furthermore, we have a senior scholar program, allowing established nephrologists to spend 1 to 3 months in one or more centers in an emerging country. ISN also supports libraries in the emerging world through journal subscriptions and books. In this respect, ISN collaborates with HDCN and UpToDate.

Zoccali: The main scientific congresses gather 10.000 attendees or even more. Do you feel that in the Internet era the way congresses are organised should be re-thought?

Weening: The web-based technology will assist us in sharing the most recent information in basic and clinical research and guidelines to interested colleagues, related health care workers and patients throughout the world, but the personal contact remains crucial and therefore, I do think that large scale congresses still have a lot to offer. However, also small scale, targeted conferences have great value and will allow greater interaction.

Zoccali: Do you think that the time and space allotted to Clinical Science (as opposed to Basic Science) can be (or ought to be) increased?

Weening: Currently, at the congresses and also in our journal, Kidney International, the balance is about 50-50, and I think that it is a good one.

Zoccali: Uremia is a rare disease but mild renal failure is fairly frequent in the general population and seems to have important clinical implications, particularly for cardiovascular risk. Do you think that this may be an opportunity for nephrologists to enlarge the territory of their specialty?

Weening: Absolutely. Nephrologists have always been involved in the diagnosis and treatment of systemic diseases such as hypertension and diabetes. Urinalysis has become recognized as an important tool to diagnose and monitor patients at risk for progressive systemic vascular disease. It seems to me to be very important that the nephrologists emphasize their central position in this complex field. The ISN feels we have a mission in the prevention of progression in early renal failure.

Zoccali: Which are the scientific papers that influenced you most?

Weening: That is not easy to answer. In the beginning of my career, the work of Philippe Druet, Michel Goldman and Ernst Gleichmann. Thereafter, experimental and clinical observations by Helmut Rennke and most recently podocyte work by Tryggvason, Antignac, Kriz, and colleagues.

Zoccali: In your research projects you utilize renal cell culture, immunologic techniques, and molecular biologic analysis and other modern laboratory techniques. In a way you are a "basic science oriented" clinical nephrologist. Is it a challenge for you to maintain a balance between clinical medicine and basic science in your training programs?

Weening: It is true that as a clinician, I am basic science oriented, but that is partially due to the fact that I am a renal pathologist. In that position, I am always at the crossroads of clinical diagnosis and scientific questions and therefore it is relatively easy to maintain that balance also in training my residents and fellows.

Zoccali: Both in the USA and in Europe, nephrology is presently attracting less trainees than before. What initiatives should be undertaken to reverse this trend?

Weening: Reversal of this trend calls for a number of actions which should focus on establishing a clear, interesting and rewarding career development program in which challenging clinical and scientific targets are offered, attractive in contents and compatible with current day expectations as to time and financial management.

Zoccali: The population of dialysis patients is growing at a rate of about 5%/year. In the near future do you think that it is possible that even the affluent countries will not be able to guarantee treatment to everyone?

Weening: This is probably the most important challenge for current day nephrology, which the ISN tries to take up through the efforts of its COMGAN Research Committee led by Beppe Remuzzi. By combining studies on primary and secondary prevention with large scale epidemiology the committee is developing a strategy which will contribute to preventing or delaying end stage renal failure and at the same time will stimulate the public, doctors’ and patients’ awareness.

Zoccali: You have an interest in diabetes and renal function. Which is the most urgent measure to be taken to halt the epidemic of renal disease in diabetics?

Weening: My interest in diabetes and renal function stems from our own work in connective tissue growth factor and from the work of Remuzzi, Atkins, Ritz, Brenner, Dirks and colleagues in their global program focusing on the epidemiology and the study of progressive renal disease, in particular as a consequence of diabetes. The most urgent measure to me seems to be a public awareness campaign involving global organisations, policy makers and the press followed by concrete plans for early detection and treatment of renal vascular complications of diabetes.

Zoccali: How do you envision nephrology, dialysis and transplantation in 2010?

Weening: Nephrology will be recognized even more than today for its importance in the early detection, prevention and treatment of the most frequent and costly non-communicable disease: atherosclerosis. In this respect, the therapeutic possibilities are no longer the limiting factor, but more so the awareness of patients, doctors and policy makers. Furthermore, a number of renal diseases which are still a puzzle today, may be better understood by 2010, e.g. idiopathic nephrotic syndrome and IgA nephropathy. For other diseases new molecular interventions may have become available or are being developed, aimed at restoring tubular cell function in adult polycystic kidney disease, inhibiting endothelial injury in ANCA-associated vasculitis, and restoring phagocytosis and apoptotic pathways in lupus. In general, interventional nephrology may be an important field to be incorporated at least partially within the domain of the nephrologist.
In dialysis, my colleagues inform me that more frequent sessions may improve health and rehabilitation to a great extent, and further technical improvements may lead to better compatibility, both in hemodialysis and in PD. In transplantation, progress may be considerable: on the one hand, due to the introduction of stem cell technology, to improved immunotolerance by protecting the graft by perfusion of molecular reagents prior to implantation and to improvements in immunosuppressive regimens with development of therapeutics that are no longer toxic to endothelium; on the other hand, progress will be achieved due to expansion of live donor programs allowing better kidney survival and shortening of waiting lists, provided that ethical and medical provisions are taken care of.