Marc De Broe – Antwerpen, Belgium
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Marc De Broe – Antwerpen, Belgium |
Prof Zoccali: Professor De Broe, how did you come to be interested in nephrology?
Prof De Broe: Well, as a student I think. When I was a student I saw the first treatments of acute renal failure with a Kolf dialyser in ‘64-65. Every patient who had to be treated with an artificial kidney, the surgeons came to put a catheter in, did the dialysis, the day after another catheter and when all the veins and arteries were used and the patient either died or survived. So that was the beginning and also because the chief of nephrology was at that time a young motivated Professor. So I was attracted by this challenge in this discipline of internal medicine. Nephrology was a brand new discipline with a lot of new avenues and new ideas, that was the reason.
Prof Zoccali: You have organised a diversified research oriented renal department in Antwerp. Could you briefly tell us the story of your department?
Prof De Broe: When I came to Antwerp it was 1977. I was my own assistant in an old hospital in the centre of the city with 20 patients on dialysis and that was it, that was my department. 25 years later we had a full clinical department with transplantation and every facility of renal care and research team made of 20-25 people, that was 25 years later. The research budget from 1.5-2 million euros a year, which was necessary for doing all that research with all those young people because the University was/is not supporting us. Instead you have to pay and I think this is the problem in Europe, all over Europe. European universities have no good policy for research. They do not support our research, they gave us some facilities and some surface in a building, but I have to pay for it. I pay 17% taxes on every grant I receive from outside, so at 2 million euros, 17% it is a lot of money. I regret that because it’s not a good policy. Clinical research is becoming a drama in Europe. There was a paper in Science and Nature describing the disappearance of the MD PhD species. Research in our department is coming from the bedside, from our patients, the patient has acute renal failure due to a toxic drug because, the patient has hyperphosphatemia, the patient develops proteinuria and hypertension etc. and then we translate that in the lab and I think only the physicians can do that. It is normal that an MD has to bring clinical ideas into the lab. You need the medical education of 7 years with emphasis on physiology and pathophysiology, and exposure to clinical medicine to have good ideas and research. I think what is happening now is that a lot of research is performed in labs when not a single doctor is coming anymore. We have to fight against that and it’s one of the good things of EDTA, of the organization EDTA. If he can help in raising some grants for MDs doing research, it’s excellent. I have seen over the years, over 25 years of my career, in 30 years of my career the decline in time of MDs in charge of the department, working in the research labs. The decline, the dramatic decline in time they can spend on research because the demanding of the hospital, of the direction of the hospital for taking care of patients is so increasing for budgetary reasons or for whatever reason that the time they spend on research is becoming negligible.
Prof Zoccali: Yes, this is a problem that we have all over Europe.
Prof De Broe: It’s all over Europe.
Prof Zoccali: Perhaps, a sort of alliance at a European level should be created because we are at risk of losing the best stimuli.
Prof De Broe: Absolutely and particularly I’d like to discuss also about the fact that the clinical research in Europe and particularly in nephrology is becoming almost completely controlled by industry, which is far from optimal. We have to still have at least a certain percentage of freedom and independent research. Look at this EDTA, I’m not saying this program isn’t a nice program, but the impact of the industry is enormous. I always had one rule: never may the support from industry exceed 50-60% of our budget because I want to remain free. Here, I make a plea to create an industry independent structure within Europe which allows to test particular clinical research hypotheses, obviously based on well written protocols evaluated by experts in the field.
Prof Zoccali: You have a variety of interests, of scientific interests from let’s say epidemiology of analgesic nephropathy, a paper that you published in the New England Journal of Medicine to the treatment of bone disease. You are the lanthanum man now. How did you manage to put together all these projects?
Prof De Broe: We always were at least with 20 people in our research group, most of the time 7 PhDs, between 6 and 10 predoctoral students and some lab technicians. I have supervised together with my PhDs of the group, 42 PhD-theses, which are almost 2 a year. If there was an interesting clinical problem in some of our patients, we considered if we could solve it in the lab. That is what I call translational research. The lab was able to capture some of these ideas and to develop animal models and in vitro set ups. We were obviously not always successful but some cases we were. I like a certain diversity. I was fortunate to have a lot of young people who were interested in particular aspects. Overall the mainstream was that everything we do, has as much as possible a mechanistic approach. For lanthanum we looked for all the mechanisms involved in the metabolism and subcellular localization. For aminoglycoside nephrotoxicity we discovered to way to prevent nephrotoxicity by disclosing its renal handling. For analgesic nephropathy I had the luck to have in the group an outstanding epidemiologist (M. Elseviers). After 10 years of clinical epidemiology there was law voted in the parliament putting all analgesic mixtures on prescription. For acute renal failure we found a role for lymphocytes at the early phase of the injury. Thinking in a mechanistic, physiologically and pathophysiologically way, is the product of the medical education. I think we can’t lose that because if we lose that we lose our identity.
Prof Zoccali: So the energy behind this in a way can be, let’s say, the exciting from the bench to bedside approach because this is very exciting.
Prof De Broe:That’s it.
Prof Zoccali: Which is the study that you would have liked to do and could have done at least until now?
Prof De Broe: I will give two examples of studies I would have liked to do. First an epidemiological study. I was 2-3 times in Taiwan where they have an incidence of 350-340 new patient dialysis every year, which is the highest in the world. It’s even higher than in the United States. We in Europe, Belgium is the incidence is 170 and in Italy I think around 200. So I put forward several times the hypothesis that this was due to the traditional medicine in Taiwan. I said that 5 years ago and every year, I have been there, 3-4 times and I always repeated do a simple epidemiological study to prove that indeed your high incidence is related to Chinese traditional medicine. I’m not saying that the traditional medicine of China has no value, it’s part of the Chinese cultural patrimony. However, nobody knows exactly what happens with those herbs/plants in the human body. The number of patients on dialysis with adenocarcinoma, with pelvic carcinoma in your dialysis patients was unbelievably high and this is well known that aristolochic acid in Chinese herbs induces the famous carcinoma of the epithelial carcinoma. My second example is a cell biology one. We found a few years ago a role lymphocytes in ischemia. We should have gone further in that direction and explore more in debt this fascinating observation. However, at that time the labo had no experience in fundamental immunology.
Prof Zoccali: Which is the article that influenced you most?
Prof De Broe: There are a few. In the last years there has been first of all an impressive increase in the knowledge of what we learn in nephrology because if I compare my time 25 years ago and now, it’s another world because the way science is progressing is going so quickly and so fast. What I found an important publication is the paper of Wayne Border in Nature. He described that TGF-beta was playing a role in renal fibrosis. I think that was the first article which really showed the role of this important protein in fibrosis. A recent very interesting article demonstrated that fibrosis is reversible. It was a paper in the Journal of Clinical Investigation not related to kidney disease but to liver fibrosis where you have a reversal of the fibrosis. There are so many related to genetics and nephrology and in recent years, I must say I follow that very carefully. The boom, the famous boom that the stem cells has been jeopardized by 3 basic articles. Three of them in JCI by 3 different groups clearly supporting the evidence that stem cells probably is maybe a marginal phenomenon and that we have to rethink their function and how they may play a role in regeneration of the injury. So, that’s for me and also for the next future a very interesting new challenge. What is really the truth? Is it worthwhile to do the next step etc? I’m really looking forward to that.
Prof Zoccali: What book have you been reading recently?
Prof De Broe: I read a book every two weeks. I’m interested by the North-South problem in the world because I lived for 4 years in Africa when I was a young student and I go back every other year (ISN-Comgan). If you go to black Africa now and you were in Africa 20 years ago, there is almost no progress. So this is so shocking compared to the progress of humanity in Western Europe, America and Asia. We have to rethink the way of our economic behavior. I’m reading books about that. Six months ago, I read an interesting text “The Wealth and Poverty of Nations, Why People are Rich, Why People are Poor”. It’s an analysis of the facts of why certain countries became so poor and others not. Cultural, intellectual, educational, and several other factors all play a role and the author was able to dissect them and bring new integrated views. There is the recent book, two months ago which deals with “The End of Poverty” by an American economist from Harvard with a positive note. Maybe things are not so bad and he’s describing the first light in the tunnel. I think it’s wonderful to see that. I am a member of the ISN research committee in Africa and we will try to develop a living related donor transplantation program in Mali. I’ve been to Mali three times in the last 12 months and I would like to do that because I found in Mali a surprisingly favorable background at the local university hospital. There are some excellent nephrologists there, their motivation is impressive, the government wants to do something. It will be an important achievement for ISN/OMS and - if the EDTA can help us, why not - to prove that even in very difficult conditions you can achieve something.
Prof Zoccali: Which advice would you give to a young doctor about entering or not entering a nephrology-training program?
Prof De Broe: I still believe that kidney disease and all that surrounds it is challenging. From an intellectual point of view I think our discipline is one of the most attractive because even more than cardiology which, to a certain extent are redirected surgeons/interventional radiologists. Nephrologists are one of the best physiological physiopathological reasoning doctors in the medical community because it’s a complex disease. Furthermore, physiology-pathophysiology of the kidney is very well developed. You can transplant the kidney, you have its excretion product for free at any time, which is impossible with most other organs. So I think from an intellectual point of view still I’m convinced that nephrology is an extremely challenging discipline and very attractive but again provided the societies can stimulate clinical and fundamental research.
Prof Zoccali: Which hobbies do you have?
Prof De Broe: One of my hobbies is Romanesque art. I’m reading books about that and I visit them in remote areas of Italy, Spain, Catalonia and France. I have to walk sometimes 3-4 hours to these small churches. Reading about philosophy, social-economic behavior of the human species of time. There’s one man that I respect enormously, Petrella is his name. He’s a professor of Sociology, Political Sociology and he brought together 25 people with a totally different background in Lisbon. He is an economist and he invited a doctor, an engineer; a Buddhist, an artist coming from several places in the world to think about the future of our society and he wrote some books on new models of economic systems. I really believe that the economic system imposed to us by the American economy, can be maintained as such. I cannot accept that the human society is governed by shareholders. Nowadays, companies are so proud to announce; our shares have increased by 20% and we have decreased the number of our workplaces by 15%. In my whole life I have tried to create jobs for tens of people, young PhD students. All those young persons have wonderful jobs, are productive and create themselves new jobs.
Prof Zoccali: Thank you very much.