2004 Presidential Address
Authors: William E. Mitch
Journal: Journal of the American Society of Nephrology (2005)

It has been a singular honor to serve the American Society of Nephrology (ASN). Since my election to the council in 1988, our society has experienced tremendous growth in critical areas, including expanded involvement by ASN members in different activities of the society, in the breadth of educational programs, and in the ASN′s ability to address matters that directly affect our members and the patients for whom they provide medical care. Fortunately, the growth in ASN activities has occurred while the ASN Council (Table 1) has maintained its focus on promoting scientific developments in nephrology. In 1998, the president had two principal activities: (1) To ensure that the annual meeting contained the most exciting advances in nephrology research and (2) to improve the quality of educational programs centered on the practice of nephrology. These clinically based programs had been initiated as “Short Courses” by 1991 ASN president, Craig Tisher. Because of their popularity and their contributions to the practice of nephrology, clinical programs now occupy the first days of Renal Week and are incorporated throughout the meeting. Still, a principal activity of the president is to organize the ASN meeting by choosing a program director and committee that will continue the great tradition of presenting the most exciting scientific advances. This year’s program director, Jeff Sands, and the committee (Table 2) created a superb program that encompassed the enormous range of scientific interests of nephrologists. To name a few examples, the 2004 program contained new developments in understanding transport processes. Mechanisms by which water moves across cells was discussed by plenary lecturer Dr. Peter Agre, who shared the 2003 Nobel Prize in chemistry. Alfred Goldberg presented a plenary lecture about the ubiquitin-proteasome pathway and how it functions to present antigens and how certain cancers can be treated by inhibiting this pathway. The other plenary lectures were by Barbara Kahn, who discussed how malfunction of the adipocyte leads to type 2 diabetes, and by David Harrison, who described how intracellular oxidation reactions generate atherosclerosis. Besides providing an understanding of molecular events, these lectures covered major problems faced by the nephrologists who care for patients with chronic kidney disease. There also were symposia discussing basic and clinical advances in transplantation, which is especially noteworthy because 2004 is the 50th anniversary of the first successful kidney transplant. The 2004 Annual Meeting offered abundant educational opportunities addressing clinically important topics ranging from the diagnosis and management of patients with chronic kidney disease to advances in interventional nephrology, to vascular biology; there also was a 2-d session for those planning to certify or recertify in nephrology based on American Board of Internal Medicine requirements. These sessions plus clinical nephrology conferences held throughout the meeting were created by the ASN Postgraduate Education Committee (Table 3). Besides clinical symposia, there were two dinner sessions for ASN attendees who are interested in the basic sciences. Goals of the ASN The ASN charter indicates that our society was organized “to enhance and assist the study and practice of nephrology; to provide a forum for the promulgation of research; and to meet the professional and continuing education needs of its members.” In 2003, another purpose was added: “To become the leading professional organization in nephrology.” This is a daunting task because of the range of interests of ASN members, but two items are required to accomplish this goal. First, the ASN must be in position to influence funding and public policy that could affect research, education, and patient care. Second, there must be meaningful input from ASN members to identify areas that should be addressed and a means by which members can provide ideas and talent to solve problems. How has the ASN attempted to fulfill these two requirements? To quote Winston Churchill, “However beautiful the strategy, you should occasionally look at the results.” Active participation of ASN members occurs at several levels: First, advisory committees have been created to provide ideas and leadership in specific areas of interest, including acute renal failure, basic science and clinical science, clinical practice, chronic kidney disease, dialysis, hypertension, policy and public affairs, and transplantation. Second, one of the ASN councilors (Table 1) participates in each ASN activity and reports on the goals and accomplishments of the group to the council, but activities of these advisory committees must be organized so that issues impacting the science and clinical practice of nephrology are addressed effectively. To create such an organization, the ASN Council and 2003 president, Norman J. Siegel, formed the ASN Board of Advisors (BOA). The BOA consists of chairs of the different advisory groups and committees (Table 4). At Renal Week 2003, the first meeting was held, and it quickly became apparent that we had tapped into the ideas and talents of enthusiastic members who were committed to solving problems affecting nephrology. For example, the Practicing Nephrologists Advisory Group, represented by Drs. Arnold Berns and Joan Blondin, pointed out important issues are affecting clinical practice and suggested the ASN should address these issues. Besides offering strategies to address these problems, they suggested how the ASN regional meetings (see below) could be improved. An excellent example of BOA committee activities and how groups work together is the response of the ASN Policy & Public Affairs and Dialysis Committees to new regulations about practice guidelines for dialysis patients. At Renal Week 2003, a session was devoted to reviewing Center for Medicare/Medicaid Services (CMS) regulations that mandate weekly examinations of dialysis patients. This year, CMS is considering methods of adjusting physician payments based on patient outcomes. In dealing with this proposal, Jonathan Himmelfarb, representing the Dialysis Advisory Committee; Don Wesson, representing our Policy and Public Affairs Committee; Paul Smedberg, the ASN Director of Policy and Public Affairs; and Councilor Bill Henrich met with CMS leaders. After a full examination of the pros and cons of the new CMS proposals, the group submitted official comments about physician fee schedules and the proposed guidelines for monitoring erythropoietin dosing as well as the impact of the Medicare Advantage Program on ESRD patients. This group in conjunction with National Kidney Foundation (NKF) President, Brian Periera, also wrote a “white paper.” This document provides a full analysis of issues that should be solved before regulations linking physician payments to patient outcomes are established and was published in the December issue of the Journal of the American Society of Nephrology (JASN). The paper shows how advisory committees, the council, and the ASN staff can function to deal quickly and effectively with problems that face nephrology and ASN members. Addressing this problem included the full participation of our sister organization, the NKF, represented by Brian Periera, NKF president. In addition, a semifinal draft of the paper was shared with the Renal Physicians Association as they were preparing a response to CMS proposals. Finally, this white paper is important not only because it addresses serious issues that impact the practice of nephrology but it also could influence other clinical practices because CMS decisions about payments to nephrologists frequently serve as the basis for how CMS and medical insurance companies deal with physicians providing other medical services. In short, the ASN has been at the forefront in addressing an important issue in clinical nephrology. As a final example of ASN activities, the FDA asked the ASN to comment about the use of an ultrafiltration machine designed to remove fluid from patients with congestive heart failure. The ASN Dialysis Advisory Committee responded quickly using the expertise of members with extensive experience with extracorporeal devices and submitted a critique of the CHF Solutions System 100 machine. They also worked with the manufacturers to improve the safety of this type of therapy. ASN Membership The St. Louis arch, the “Gateway to the West,” indirectly applies to the ASN to function as a gateway to nephrology (Figure 1). For example, the ASN charter indicates that an active ASN member is “any person holding the degree of M.D. or Ph.D., or its equivalent, who has demonstrated a major and continuing interest in nephrology and who is a resident of a country of North or Central America shall be eligible for membership in the Society.” To meet the intent of our charter, Tomas Berl, 2005 ASN president, and I developed a program for nephrologists in Central America and the Caribbean area by working with the leadership of Sociedad Latinoamericana de Nefrologia y Hipertension (SLANH). Our goal is to incorporate young Latin American nephrologists or nephrology trainees into ASN activities. With the help of a grant, the young nephrologist spends the month preceding Renal Week working in a nephrology division in the United States or Canada followed by attending Renal Week. The program is jointly funded by the ASN and SLANH, and nephrology divisions in the United States and Canada have enthusiastically supported a program to host a young Latin American nephrologist. The program will be reviewed yearly to ascertain how it affects the careers of the young nephrologists. During our meetings with the leaders of SLANH, we learned that this program would be very popular with young nephrologists throughout Latin America. Although we plan to emphasize participation by nephrologists from Central America and the Caribbean, we agree with SLANH leadership that colleagues from other Latin American countries could participate, and, not unexpected, there are 2004 grantees from Argentina and Brazil (Table 5). Our plan is to promote interest in the science and practice of nephrology while bringing advances in our discipline to others living and working in our hemisphere. In a related development, the council decided to extend ASN membership to colleagues outside North American as long as they are members of their local/national nephrology society. These new “e-members” will have the privileges of ASN membership including JASN and Nephrology Self-Assessment Program (NephSAP) but will receive publications electronically. Colleagues in the Australian-New Zealand Nephrology Society as well as members of SLANH have expressed interest in this program, and we expect that these interactions will make our society even stronger. The other category of members is nephrology fellows. They are designated as associate members and receive JASN and NephSAP gratis from the ASN. ASN Educational Activities The submission of 4100 abstracts and our attendance of 10,996 colleagues to Renal Week 2004 indicates that we are fulfilling the goal of the ASN charter to provide a forum for advancing research, but this is not where efforts to meet the educational requirements end: As PGE director Bob Narins likes to say, the Annual Board Review Course has become a “right of passage” for many fellows. Approximately 25% of the Board Review Course participants attend to gain an update in nephrology while the rest of the participants are preparing for the examination. A new program, the regional meetings, deserves special emphasis. These meetings last 1.5 d and are directed at bringing the highlights of Renal Week to colleagues who could not attend the ASN meeting or missed certain sessions of interest plus those who want a concise review of Renal Week highlights. Last year, the program was held in New York City, Chicago, and Los Angeles and was enthusiastically received; in January and February of 2005, regional meetings will be enlarged to include three new cities: Washington, DC; Seattle; and Dallas (see asn-online.org). Besides educational meetings, the ASN has several publications (Table 6). With the able leadership of editor Bill Couser and deputy editor Allison Eddy, JASN has maintained the highest ranking among all nephrology publications. Besides nephrology fellows, JASN is sent to nephrology units in the developing world as part of the Library Enhancement Program of the International Society of Nephrology. Our other publication, NephSAP, is edited by Dick Glassock and provides a readable and intensive review of different nephrology topics; it also provides CME credit. I confess that some of the questions are a bit abstruse, but Dick tells me this just requires more homework! Renal Express and Renal Policy Express are electronically transmitted information about national and governmental issues that affect nephrology. Paul Smedberg, Director of Policy and Public Affairs, uses this instrument to keep ASN members informed of important changes in public policy. Many of you know that the ASN will begin “self publication” in 2005 because it will allow the ASN more latitude to craft ways to interact with the membership. This also allows growth in publications. Based on recommendations from the BOA and many members, the council voted to create a new clinical journal. Approximately 50% of this journal will be devoted to publishing peer-reviewed clinical investigation and 50% to educational material. The search committee for an editor of the new clinical journal is chaired by Bill Henrich with a tentative initial publication in 2006. ASN and Research Nephrologists and their patients have benefited greatly from the remarkable advances that have occurred in nephrology. These advances have arisen in large part from the increase in funding that has doubled the National Institutes of Health (NIH) budget. What has been the role of the ASN? In 1988, ASN scientists in conjunction with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) leadership convened a research retreat with the goal of defining areas in nephrology that were ripe for clinical investigation or areas that needed more attention to understand the mechanisms underlying different disorders. The Renal Disease Research Plan (Figure 2) resulted from this meeting and has been used by the NIDDK leadership to plan research strategies. This plan, however, was published almost 6 yr ago, so the council decided to reconvene research retreats but with a more focused strategy. The strategy was to adopt principles of the NIH Roadmap and emphasize “cross cutting” themes that would involve disciplines from epidemiology to basic science. Listed on the right side of Figure 2 are the five areas that were chosen to be the focus of intensive research retreats. Each conference will produce a white paper that identifies specific research goals and formulates new investigative strategies. Besides scientists and clinical investigators, there has been participation by the leaders of NIDDK and input from the National Heart, Lung, and Blood Institute and the National Institute of Allergy and Infectious Diseases. Their involvement is important because the five research conferences will identify critical research areas in kidney disease for the institutes. We believe this will be useful because projected budgets do not include the same generous increases for the NIH. During Renal Week, Dr. Allen Spiegel, Director of the NIDDK, discussed new research directions for the NIH and emphasized the far-reaching changes that are taking place at the NIH based on the NIH Roadmap. He explained the emphasis on integrating expertise from several disciplines and the goal of achieving cross-institute collaboration and funding potential. Budgetary restrictions of the NIH are a major source of concern for ASN members and nephrology trainees. The ASN has addressed this concern in several fashions; the council works with leaders of NIDDK and the Kidney, Urology and Hemotology (KUH) Division to devise programs so that funds will be used optimally to continue the remarkable record of providing insights into the biology of kidney diseases and devising treatments for them. Second, the ASN collaborated to include language in the NIH appropriations bill that urged NIDDK to create requests for applications for the study of clinical aspects of kidney disease. In addition, the NIH appropriations bill urged the National Heart, Lung, and Blood Institute to cooperate with the NIDDK to study the cardiovascular impact of kidney disease and especially hypertension. Finally, Paul Smedberg has been elected to the Executive Committee of Ad-Hoc Group for Medical Research while the ASN continues to promote research in the Renal Coalition and the Council of American Kidney Societies. What other activities has the ASN undertaken to support nephrology research? Only a few years ago, the ASN, in conjunction with NIDDK leaders, devised the Kidney Diseases Concept Development Initiative. The goal was to “prime the pump” by providing start-up funds to address clinically important areas. The funds would be available to design a comprehensive analysis of a clinical problem including mechanisms of disease or treatment strategies. There have been 43 Kidney Diseases Concept Development Initiative applications, and 18 have been awarded, a >40% success rate! These grants have resulted in several high-quality research projects, and similar programs are being considered for other branches of the NIDDK. ASN and Research Funding Finally, there is the critical problem of funding scientific investigations in nephrology. Although the ASN cannot make up for NIH funding shortcomings, the council believes that our society should support advances in the biology and treatment of kidney diseases. This year, the ASN portfolio was raised to more than $2 million in grants and the 4-yr plan is to increase funding even more substantially (Figure 3). The grant portfolio emphasizes funding for the transition of young investigators to progress to accomplished scientists (Table 7). Funding for several of these grants is shared by other groups: The Kidney and Urology Foundation of America and the ASN share funding of the KUFA-ASN Research Award, the American Society of Transplantation and ASN share funding of the ASN-AST John Merrill Award, the Association of Subspecialty Professors and the ASN support the ASN-ASP Development Award in gerontology, and the Halpin Foundation and the ASN support a grant to study membranous glomerulonephritis. Besides these grants, the ASN funds established investigators who are changing the focus of their research and medical students who plan to study nephrology. The applications are reviewed competitively by the ASN Grant Review Committee (Table 8) and by other ASN members on an ad hoc basis. Specific information about ASN grants can be found at the web site (http://www.asn-online.org). Funding of these grants requires careful thought as the grants are currently paid from “operating expenses.” The council recognizes that grants should be funded independent of day-to-day budget demands and has appointed a Development Committee to devise strategies to create a Research Endowment Fund. The committee consists of Mohammed Sayegh, Richard Glassock, Bob Narins, and Raymond Hakim. They have developed a plan that will raise new funds while utilizing current funds to create a Research Endowment Fund. Simply stated, our goal is to support nephrology research in a tangible fashion. Finally, a new program was initiated last year, the designation of ASN members as Fellows, American Society of Nephrology (FASN). This program is quite popular, and more than 1000 applications have been submitted. The ASN staff is carefully verifying the credentials for this honor, and we hope applicants will be patient. The FASN designation is for 5 yr and honors leaders in basic or clinical research, clinical nephrology, or renal pathology. The requirements are detailed in each JASN issue and are present on asn-online.org, but, importantly, FASN status requires Board Certification and obtaining CME credits. We believe that these requirements are important because the ASN is the first medical society to promote continuing education and subspecialty certification. After all, nephrologists meeting these requirements are more likely to remain current in their medical knowledge. Transitions As time marches onward, changes occur for colleagues who have been long-term supporters of the ASN. I would like to recognize the many contributions of Dr. Gladys Hirschman, Program Director of Pediatric Nephrology in the Division of Kidney, Hematologic and Urologic Diseases (Figure 4). Although Gladys was principally responsible for pediatric nephrology grants, she also helped many of us who were studying pathophysiology of kidney disease. I remember her help when I was moving between institutions and found a problem with transferring a grant. She was responsible for the administration of the grant and assured me that “everything would be OK.” Within a very short time, she did indeed make everything OK. I know that many of you had the same experience, and I salute Gladys for her kindness and efficiency. Unfortunately, three senior members of our society died this year. It is with sadness that we recognize some of their many accomplishments. Norman Levinsky was the consummate physician-scientist who was committed to patient care (Figure 5). He and his collaborators provided the basis for understanding the clinical consequences of abnormal salt and water handling by the kidney, and his group was the first to document the reversible nature of ischemic damage to renal tubular epithelial cells. This opened the door to experiments investigating the pathophysiology of acute tubular necrosis. As Chair of Medicine at Boston University School of Medicine from 1972 to 1997, Dr. Levinsky was known as a legendary teacher who was committed to patient care and scientific integrity. His service as chair of the Institute of Medicine’s Committee to study the Medicare ESRD program and ethical issues about xenotransplantation were landmarks for nephrology. Roscoe R. “Ike” Robinson served as president of the ASN in 1982 and as president of the International Society of Nephrology from 1990 to 1993 (Figure 6). With Neal Bricker, he received the ASN′s John P. Peters award in 1991. Besides these honors, Dr. Robinson, as Vice Chancellor for Health Affairs, was instrumental in guiding Vanderbilt University School of Medicine to excellence, but many of us will remember Dr. Robinson as a champion of clear thinking and for his commitment to promoting the careers of young investigators. As a scientist, Jack W. Coburn was the embodiment of the clinical investigator (Figure 7). His papers about the pathophysiology of hyperparathyroidism and vitamin D metabolism were landmarks of translational research. In recognition of his work, Dr. Coburn received the David Geffen-UCLA School of Medicine Award for Significant and Noteworthy Contributions to the Field of Medicine. In addition, he and Jack Lemann received the 2003 Belding H. Scribner award from the ASN for outstanding contributions to nephrology and clinical practice and patient care. Jack was, indeed, a physician’s physician. His colleagues and patients will miss his gentle and scholarly manner. Jack’s family and friends have dedicated a lecture in his honor. It will be presented this year by Dr. Tony Portale. While writing this review, I found that it represents a rather hefty list of challenges. Have we bitten off too much? This question is addressed regularly by the council, and I am confident that we can and will make progress for at least two reasons. First, we have an effective organization created by a very dedicated, talented, and enthusiastic staff who are devoted to the goals of the society. The group is led by our very capable executive director, Dr. Karen Campbell. Second, it has been very gratifying to see how ASN members have pitched in to address important issues in nephrology. I hope you will agree we are paying attention to Winston Churchill’s admonition that strategies must be evaluated regularly.Figure 1: The Gateway to the West arch in St. Louis Missouri is emblematic of the role of the American Society of Nephrology in opening new territories in nephrology.Figure 2: Publication of research priorities developed by the American Society of Nephrology in 1988 and 2004.Figure 3: Past and proposed funding for research by the American Society of Nephrology.Figure 4: Dr. Gladys Hirschman served the National Institutes of Health and is a friend of many members of the American Society of Nephrology.Figure 5: Dr. Norman Levinsky was a superb teacher and academic while emphasizing how physicians should uphold the highest standards of medical care.Figure 6: Dr. Roscoe R. “Ike” Robinson guided the growth of nephrology and the careers of many young investigators.Figure 7: Dr. Jack W. Coburn was a consummate clinical investigator who always strived to provide the best possible patient care.Table 1: ASN Council 2004Table 2: 2004 Program CommitteeTable 3: 2004 Postgraduate Education CommitteeTable 4: Board of AdvisorsTable 5: 2004 ASN-SLANH Mini-FellowshipTable 6: 2004 ASN PublicationsTable 7: 2004 ASN grant portfolioTable 8: 2004 ASN Grant Review Committee