Pursuing a World without Kidney Diseases: A Hero's Journey

Throughout history, there have been tales of brave people on epic journeys fighting for good and against evil. These journeys are arduous, filled with trials and tribulations. Through these endeavors, our hero is tested and transformed, finds fulfillment, and eventually returns triumphant—improved and usually bettering the situations of others. Examples include Joan of Arc, Mahatma Gandhi, Harriet Tubman, and Luke Skywalker. These real and mythic individuals are recognized as heroes.

We are fortunate to have plenty of heroes in the medical field. Dr. Willem Kolff, a Dutch physician and 1938 graduate of University of Leiden medical school, is one example. His life's mission crystalized, during postgraduate training, while witnessing a young man die of kidney failure. Because no treatments existed, he decided to create a machine that would do the kidney's work. Helped by his mentor, Dr. Leonard Polak Daniels, Kolff created an artificial kidney using cellophane for membranes. Others had tried, but Kolff was undeterred by prior failures or the seeming impossibility of his task.¹

Kolff's quest would be difficult under any circumstances, but he lived during a particularly challenging period. At about the time that he began his mission to create an artificial kidney, World War II erupted. When Nazi Germany overtook The Netherlands, Polak Daniels died by suicide to avoid persecution.

Because supplies were scarce, Kolff improvised. The aluminum for the drum of the artificial kidney came from an airplane shot down nearby. The conduit through which blood was pumped was from a Model T Ford cooling system. The enamel tub that the dialysate sat in was secretly made by an enamelware factory ordered to only make pots and pans for the German army. In 1943, Kolff piloted his artificial kidney to save patients dying of acute kidney failure.

Kolff unsuccessfully treated 16 patients. Colleagues lost faith in his program. As the war progressed, working conditions deteriorated. The supply of cellophane used for the diffusion membranes ran out. He substituted German sausage casings. Transporting patients to his hospital was increasingly dangerous.

Despite the challenges, Kolff continued perfecting his artificial kidney. Finally in 1945, his 17th patient, a 67-year-old woman in uremic coma, regained consciousness after 11 hours of hemodialysis with Kolff's dialyzer. She lived 6 more years.

Kolff's story is remarkable, but he is not nephrology's only pioneering hero. Others include:

• Dr. Belding Scribner, who made long-term dialysis possible through creation of a durable dialysis access, the Scribner shunt.

• Ronald Herrick, who donated a kidney to his brother Richard, making history with the first successful living donor kidney transplant.

• Edith Helm, the first woman to receive a living donor kidney transplant from her sister and successfully deliver a baby after transplant, paving the way for transplanted women seeking pregnancy.

• Shep Glazer, who in 1971 dialyzed before the US House of Representatives' Ways and Means Committee, helping produce the Medicare Program's coverage for dialysis for every American.

These heroes and pioneers are well known in nephrology. We have many more who are not. People contributing meaningfully through patient care, research, teaching, and administration. Individuals who are part of one epic journey to an audacious destination: a world without kidney diseases. As nephrologists and kidney-focused researchers, we are all part of this journey.

For years, the US Government focused nephrology spending on dialysis, with relatively little investment in research. Treatment options were limited with few effective therapies, little new to offer, and few innovations on the horizon.

However, new and effective innovative therapies are now available. Examples include flozins,² finerenone,³ and glucagon-like peptide-1 receptor agonists⁴ promising added years of dialysis-free life. There are many more advances, such as silencing angiotensinogen,⁵ aldosterone synthase inhibitors,⁵ and inaxaplin.⁶

Progress in kidney transplantation is another advancement to celebrate. Through legislative and regulatory advocacy, we are transforming transplant on many fronts. We now routinely transplant people who would never have received a transplant before, and xenotransplantation is emerging as a clinical reality.⁷ We are making transplant access available to even more individuals.

To help facilitate these and other advances, the American Society of Nephrology (ASN) has worked with the Obama, Trump, and Biden Administrations. These bipartisan efforts have expedited government reforms necessary to maximize patient access to transplant, enable the use of more organs, establish transparency, ensure that access is equitable, and reduce barriers in the kidney health ecosystem.

Biden Administration's Organ Procurement and Transplantation Network Modernization Initiative implements reforms to help more patients receive a transplant. The bipartisan legislation that came from Congress supporting it—the Securing the U.S. Organ Procurement and Transplantation Network Act—was signed into law by Biden in September 2023. Consequently, we are at a pivotal juncture in the nearly 40-year history of governmental regulation of transplantation.

However, such progress does not mean this opportunity will be easy. Change is hard. In this critical moment, we have had a choice to make: to look backward nostalgically or move forward to improve the transplant system. ASN has chosen to move forward, working with governmental agencies and officials to help shape the changing system to one that better helps patients.

We are also making progress in workforce and training, although challenges remain. Over the past 14 years, interest in nephrology careers has declined. Nephrology applications fell by 30%, while nephrology fellowship slots increased by 34%.⁸ Given this reality, we must re-evaluate how to best make the case for nephrology as a career.

We need to expose trainees to the excitement, joy, and fascination of our field. Many of us, me included, entered nephrology because of mentors. I believe each of us could identify mentors who made a difference and are our personal heroes. It is up to all of us to make clear why we love our field and why the next generation should invest their futures with us in nephrology.

One half of US nephrologists and nearly two thirds of our future workforce completed medical school outside the United States. Consequently, ASN—in concert with the American Nephrologists of Indian Origin—is engaged in helping international medical graduates seeking to train and work in this country. ASN is also working to pass the Healthcare Workforce Resilience Act, legislation aiming to recapture unused visas and provide them to physicians and nurses at the system level.

In 2023, we reinvigorated training, worked with the entities responsible for regulating training and certification, and implemented proposals set out by the ASN Task Force on the Future of Nephrology.⁹ For example, ASN and the American Society of Transplantation jointly recommended that the Accreditation Council for Graduate Medical Education accredit fellowships in transplant nephrology. The Accreditation Council for Graduate Medical Education has approved this recommendation.

ASN has also been addressing sustainability. The relationship between nephrology and the environment is bidirectional and complex. Our medical treatments affect the environment, and the environment affects kidney diseases as well as our ability to provide care. Climate health is an equity and social justice issue in nephrology but on a global scale.

We must reduce the environmental footprint of tools to manage kidney failure and foster resilience among people living with or at risk of kidney diseases. Globally, dialysis uses an estimated 265 billion liters of medically pure water every year.¹⁰ We also consume and discard a tremendous number of disposable plastics.

ASN is collaborating to address that huge environmental effect. In 2023, ASN joined the Medical Society Consortium on Climate and Health. We also joined International Society of Nephrology's Global Environmental Evolution in Nephrology and Kidney Care initiative.

With climate change–related alterations in weather patterns, we are seeing more intensified natural disasters, such as hurricanes and wildfires. These catastrophic events can pose insurmountable barriers for patients to receive dialysis treatments. Through its Emergency Partnership Initiative, ASN works closely with the Kidney Community Emergency Response Coalition, Direct Relief, the European Renal Association, and International Society of Nephrology to ensure that kidney patients have access to care and kidney health professionals can provide it.

Among people with kidney diseases, professionals who treat them, and scientists finding new paths forward, the kidney community is full of heroes. Those I have named are remarkable but not unique. There are heroes in all cultures and from all eras. Nephrology heroes are on the journey of care, discovery, and innovation that is the pathway to a world without kidney diseases.

Each of us in nephrology, whether well known or not, is united in being part of this journey. As a clinician, the route you take is a different one than the researchers, or the educators, or the administrators, but we are all in this quest together. We all have different strengths and skills. To make a difference, use what you are good at and enjoy. Persevere if you believe in what you are doing, even if others do not. Never give in to the naysayers. Keep moving forward, building on what you and those who came before you have accomplished. Never stop fighting. Our colleagues and the next generation of nephrologists will build upon what you, the extended family of nephrologists, and I have done and are going to do. Together, let us keep moving forward and never stop fighting.

Disclosures

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/JSN/E910.

Funding

None.

Author Contributions

Conceptualization: Michelle A. Josephson.

Data curation: Michelle A. Josephson.

Investigation: Michelle A. Josephson.

Writing – original draft: Michelle A. Josephson.

Writing – review & editing: Michelle A. Josephson.