2004 Presidential Address

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 of the NIH are a major of for ASN members and nephrology The ASN has addressed this in several the council with leaders of NIDDK and the and to programs so that will be used to continue the remarkable of providing into the of kidney and for Second, the ASN to include in the NIH that NIDDK to create for for the study of clinical of kidney disease. 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