Peter Robert Uldall 1935–1995: A Personal Tribute

I was fortunate enough to know Rob Uldall first as a clinician and teacher, then as a researcher, and finally as a colleague and friend. I am delighted to provide this brief overview of how my life was enriched by the relationship I had with this unique role model (Figure 1). Figure 1: A portrait of Peter Robert Uldall.I have a vivid memory of my first meeting with Rob Uldall in July 1985. I was a brand new nephrology trainee at what was then the Toronto Western Hospital (TWH). I knew Rob by reputation. In those days, all dialysis catheters were known by medical residents (in Toronto at least) as “Uldall lines.” Imagine meeting such a giant that a device was named after him! Indeed, TWH in those days also had Dimitrious Oreopoulos championing peritoneal dialysis, and the world’s first home based continuous ambulatory peritoneal dialysis (CAPD) program which Dr. Oreopoulos had created. It was an exciting time and place for a nephrology trainee. On rounds that first day with Rob, our discussion involved a very passionate and extended monologue, in which he described to the new house officers his plans involving studies of hemofiltration and hemodiafiltration. I remember that I had no clue exactly what these new techniques were; however, I was impressed with the energy and drive to push the barriers that he displayed. Rob had many exceptional qualities. He loved procedural nephrology. He performed percutaneous biopsies, 1 inserted temporary and semipermanent dialysis catheters, acute peritoneal dialysis catheters, and in a makeshift procedure room he declotted ateriovenous (AV) grafts and created his own AV fistulas. 2 He seemed happiest in his procedure room and trained many young nephrologists to do some of these procedures. He knew first hand what worked well and what did not, and loved to tinker with equipment to better the design of procedurally related devices. One project grew out of Rob’s frustration with the semipermanent vascular access devices available in the early 1980s that could not be inserted percutaneously, and were too difficult for most nephrologists (however, not for Rob) to perform themselves. Furthermore, once these catheters were removed secondary to infection, the site was lost to future insertions. Working with industry (Cook Critical Care, Bloomington, IN), he designed and perfected a percutaneous, semipermanent access device that is easy to insert and can repeatedly be replaced on the same site (Figure 2). It is so successful, durable, and easy to insert and remove, that it has largely replaced the use of acute temporary subclavian or internal jugular catheters, even for treatment of acute renal failure or while waiting for permanent AV access to mature. Figure 2: Photo of Rob Uldall with Bill Bobbie taken August 1993, on a flight to Cook Critical Care in Bloomington, Indiana, when they were developing a new catheter.When it came to patient care, Rob was inspiring. He would crusade tirelessly against the use of dorsal veins for routine IVs in hemodialysis (HD) patients or in potential HD patients. He would personally establish and complete a medication list for his office and HD patients, update it himself, and give the patients a clear plastic envelope with which to protect it. Some of these former patients of his still dutifully present these cards for me to update during each visit. He also designed a plastic “catheter cape” for patients with catheters to wear so that they could take a shower. He never missed the weekly staff meetings in which his patients and their problems were discussed. His high standards and technical expertise were transmitted to every trainee, nurse, and technician in the program. With his strong British accent, tall stature, gray hair, and high standards, Rob could be an intimidating figure. However, his nurses thought so highly of him that they lovingly called him “Dad.” He or his wife Shirley would personally greet new trainees from the United Kingdom or India at the airport; and they shared Rob’s home until they got settled in Toronto. He had a comical side that probably even he couldn’t fully see. Every Christmas, the Uldalls hosted a large party. Rob was not good with cameras; however, he would insist on a group photograph. It always took several shots for him to figure out how to set the automatic timer and scramble into position before the shutter clicked, to the hilarious laughter of his guests. Rob was also an immensely supportive colleague. He was willing to help with procedures anytime, day or night. A phone call to Rob because of difficulty in a procedure would bring him to the bedside within seconds to help out. I always wondered if he had a Star Trek type transporter to beam him there that quickly, no matter what he was supposed to be doing at the time. Rob was a unique and encouraging mentor, who got many trainees involved in starting, and even more impressively, in completing and publishing their first study. I was no exception. Rob had me do a retrospective chart review of outcomes of autosomal dominant polycystic kidney disease patients who had undergone nephrectomy before transplantation. When I missed a deadline, he encouraged me to continue, exhorting me that this would be an important study, indeed the definitive manuscript in the field! At the time, I was naive enough to believe him. The irony is that in the 11 years since this definitive study was published, I have not even once seen it cited. So, in memory of Rob’s mentorship, I will cite it here. 3 Rob’s generous mentorship was expressed in other ways. When I was a young staff doctor, he was invited to present his pioneering work on continuous renal replacement therapies (CRRT) at the ASAIO meeting in 1992. In turn, he invited me to accompany him and present one-half of his work. My intellectual contribution to the project was minimal, although with a great deal of suspicion, he allowed me to create new color slides to replace his old blue and white diazos. This kind and small gesture sparked an ongoing interest in CRRT, allowed me to meet several influential people in the CRRT arena, opened doors, and established friendships and collaborations I still enjoy. Rob was a pioneer, who strove to tinker with and improve the technology of dialysis and the outcomes of dialysis patients. He is perhaps best known for his seminal work in the area of first temporary, 4–10 and then semipermanent vascular access devices. 11–15 It is less well known that he foresaw that for the treatment of acute renal failure, pumped continuous veno-venous methods of renal replacement therapy would prevail and come to replace the simpler arteriovenous methods in widespread use in the early and mid-1980s. Indeed, he created his own homemade continuous veno-venous hemodialysis (CVVHD) system, with an ingenious bicarbonate based dialysate delivery system. It was successfully introduced into the intensive care units (ICUs) at TWH in the mid-1980s at a time when most ICU nurses were not willing to operate the intimidating, cobbled together, hemodialysis equipment that CVVHD was in those days. 16,17 Rob’s final groundbreaking vision may well prove to be his most important legacy. In the 1980s, ideas about hemodialysis in North America were dominated by attempts to deliver treatment in the shortest possible time. It was the era of high flux, high efficiency dialysis. However, Rob went against the grain and wondered if the slower, more physiologic treatment technology emerging for pumped, CVVHD for acute renal failure could be adapted to chronic hemodialysis therapy. He began the slow nocturnal home hemodialysis project in the early 1990s, working tirelessly to convince skeptical colleagues and an even more skeptical dialysis industry to support this work. Eventually, he was able to convince the Ontario Ministry of Health to fund it as a demonstration project. 18–20 Its success has been an important part of a rebirth of interest in home hemodialysis. Most successful physicians get where they are through a combination of intellect, hard work, and luck. In Rob’s case, good fortune or good timing just were not part of the mix. Indeed, his stature was never quite where it ought to have been, largely because of political events he could not control or influence. Several examples come to mind. In the late 1980s, the Toronto Western and Toronto General Hospitals underwent a merger. Inpatient nephrology and almost all ICU services were assigned to the Toronto General site. I was involved in attempting to bring Rob’s CVVHD system to the ICUs at Toronto General. It was an era of budget deficits, and the mandate from administration was, “no new or expanded programs.” His pioneering work in CRRT was stopped cold. Ironically, by the early 1990s, industry recognized that pumped CRRT was the way of the future, and began to design dedicated and sophisticated machines, which has lead to rapid expansion of pumped CRRT in the mid- and late 1990s. Similarly, Rob perceived a lack of support for his work at the merged Toronto Hospital. His chief technologist, Bob Francouer, with whom he created the CRRT and slow nocturnal hemodialysis systems, was let go because it was decided that two chief technologists were not needed. This was among the factors that led Rob to leave TTH to accept a position as Division Director at the Wellesley Hospital Toronto, Canada in 1992. The events that shape Rob’s legacy continued to evolve even after his tragic and premature death in 1995. At the same time that Andreas Pierratos, Bob Francouer, and others have very capably carried on the slow nocturnal dialysis project with remarkable success, 21,22 a provincial hospital restructuring committee ordered the closure of the Wellesley Hospital. Dialysis patients were scattered across the city in 1997 and 1998 while the slow nocturnal project was forced to move to the Humber River Regional Hospital. At the very least, these distractions have caused some momentum to be lost. In the meantime, other players have emerged. Industry now sees potential profitability in home hemodialysis and is building dedicated machines. Some groups are advocating short daily home hemodialysis instead of slow nocturnal therapy. Many nephrologists now predict a resurgence of interest in home hemodialysis. Hopefully, Rob’s important contribution will continue to be recognized; however, there remains some risk that its proper significance might be diluted by his untimely death and subsequent events. In Toronto, the value of the slow nocturnal program is now recognized by those initially skeptical local nephrologists, who recently took the initiative to advise the provincial government to end the experimental status of the program and to open it up to all patients who might choose this modality. Rob was a clinician first and foremost. He never had a job description that gave him protected time for research. He used to tell me that he knew he would never be promoted to full professor and did not care. However, he wrote more than 100 research papers and was promoted to Professor during the year of his death. When I travel throughout Toronto, I meet many administrators, nurses, technicians, and others who know about my relationship with Rob. I am constantly amazed at how many still want to reminisce for a few moments about Rob, and how many remark about how much he is missed. The qualities I remember most were his tenacity and idealism, which drove him to create better technologies to improve the outcomes of the vulnerable patients to whom he devoted his life.

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