2000 Presidential Address

This is the Society's first meeting outside the United States. However, the organization was and still is chartered to accept membership from all of North America. Thus, we have numerous members from Canada as well as Mexico and Central America. My thanks go out to our host country. I am sure you will enjoy this lovely city. I would also like to thank those who have helped to make the organization run over the last year and who have helped to make my job easier. First, thanks to my fellow members of the Council who provided advice and hard work for our organization. Numerous members of committees of the Society have also worked diligently on many facets of the organization, only some of which will I have time to mention. To them, my thanks as well. The permanent staff of the Society stationed in Washington has had a trying year with a move of their offices and some turnover in staff. They remained cheerful and hardworking. We owe them a great deal. My colleagues at the University of Minnesota have shouldered responsibilities for me during this year, for that I am grateful. Patty Johnson has been my right hand in this job. She has been superb. Finally, family and friends have provided counsel and encouragement during this year. The meeting depends on corporate support. I want to acknowledge these most generous patrons. A special thanks goes to the Program Committee members who were responsible for most of what you will be enjoying over the next four days. This committee worked hard, as always, but with remarkably good humor. They showed judgment and taste in constructing your menu for this meeting. They are the Chair, Tim Meyer, Sharon Anderson, Joseph Bonventre, Michael Caplan, Ricardo Correa-Rotter, Allison Eddy, Jonathan Himmelfarb, Charles Jennette, Christopher Lu, Victor Schuster, and Stefan Somlo. There are some key changes in the staff of the Society at our Washington office. First, Julia Janko took over as our Executive Director in the Spring of this year. I am grateful for her committed, strenuous effort. As Bill Bennett announced at last year's meeting, Bob Narins was chosen for a new position, Director of Postgraduate Education. Bob is now charging ahead in that job. Craig Tisher's tenure as the Editor of the Journal of the American Society of Nephrology will be coming to a close next June. We are in the final phases of a search for his successor. However, I am quite sure that no one can replace Craig's determined advocacy for the Journal or his thorough-going concern for its quality. During his editorship, the Journal has prospered magnificently. It is one of the treasures of the Society. Craig and his editorial group deserve tremendous credit for maintaining and enhancing the quality of our Society's journal. Finally, Jill Rathbun, Director of Government Relations, will be going back to graduate school next fall. She has been tireless in her efforts, unfailingly cheerful, and highly effective. I thank her as well. The Society is extremely broad in its scope. Any report I give to you will necessarily overlook certain features of the previous year's accomplishments. Thus, I apologize at the outset to those who have worked in areas that I will not have time to discuss. In addition to our core emphases on providing a forum for scientific interchange and continuing education at this meeting and the dissemination of the information through the Journal, the Society sustains a government relations advocacy program. A number of important issues have been addressed through this program over the last year. First, in response to the National Institutes of Health's (NIH) decision to reorganize their review process, an integrated review group dealing with kidney and urologic diseases was included. One of the Council members, Bill Mitch, has been particularly active in this area and we are now at the forefront in submitting proposals for actual new study sections in the next phase of this process. Bill and the staff with the Government Relations group have done a tremendous job in getting us ahead in this effort. A consistent theme of the Renal Research Retreat, organized 2 years ago by Wadi Suki, was the need to harness the burgeoning harvest of genetic information and bring it to bear on kidney-expressed genes. In this regard, we have advocated for a kidney genome initiative within our institute at the NIH, the National Institute of Diabetes and Digestive and Kidney Diseases. That initiative is moving ahead. Indeed, at this meeting. Robby Starr from the NIH staff will be holding a meeting to obtain thoughts on needs for genomic research and related bioinformatics. In the past, the Society has not reached out extensively to patient groups. We have rather viewed ourselves as a professional and scientific group. Our government relations have focused on research interests. Indeed, those are still the primary lobbying interests of the Society with practice issues shared and lead through our affiliation with the Renal Physicians Association. However, it is abundantly clear that advocacy for research is most effectively carried to Congress by those who are most affected by research, namely, patients with kidney disease. For this reason we have developed a mail campaign to establish a cadre of patients willing to support kidney research at appropriate times. For the remainder of my time I will be discussing two topics. The first is the National Kidney Disease Education Project, an effort championed not only by our society, but the affiliated societies of CAKS, especially the President of the National kidney Foundation, Joel Kopple. The final point, to which I will also return in my later remarks, is a proposed Loan Repayment Plan for physician investigators embarking on investigative careers. This proposal was spearheaded by Lance Dworkin and our Government Relations Committee. The rationale for the Kidney Education Program is simple and direct. We are in the midst of an unabating crescendo of renal disease (1). Indeed, these data from the U.S. Renal Data System of 2000 show that the incidence of kidney failure has been increasing at a rate of 6 to 8% over the last decade. (Figure 1). At this compounded rate of increase, the number of patients coming into renal failure has doubled. Furthermore, over 300,000 people live with renal failure now, and nearly 100,000 U.S. citizens will develop it this year. Indeed, in certain areas of the United States and within particular ethnic groups, the disease is, without hyperbole, epidemic. It is only within the last few years that we have obtained some idea of the size of the pool from which they derive. Data extrapolated from the 1990 National Health and Nutrition Examination Survey (NHANES) were published by Jones and colleagues not quite 2 years ago (2). The NHANES is a periodic survey of 18,000 people selected to be representative of the demography of the United States. A full 10.8 million, nearly 6% of the adult population of the United States, have a serum creatinine of greater than 1.5 mg/dl. Of course, the numbers decline with increasing cutoffs. However, it is a dauntingly large group who are at some point on the road to end-stage renal disease (ESRD). We don't know how many of these people will progress to ESRD or their distinguishing characteristics. Indeed, many may succumb to other vascular complications perhaps bound up with their reduction in kidney function before reaching kidney failure. However, it is from this population that the huge burden of ESRD derives. Probably, most of these people have no idea that their kidney function is depressed. Like hypertension, renal disease is largely a silent disease. However, the public awareness of hypertension has changed over the last several decades. Data gleaned from the last report of the Joint National Commissions on High BP point out that of the individuals with high BP only about 50% of them knew they had it in the 1976 to 1980 period, and successively smaller protions were under any treatment and adequate control for that treatment (3). Those disturbing percentages were markedly enhanced by the next phase of this examination from 1988 to 1991; by which time, nearly three quarters of people with hypertension knew they had the problem, most were on treatment, and 29% were receiving adequate treatment. Those who have followed this trend have been concerned that improvement in awareness, treatment, and control has not continued in the last survey. Nevertheless, the numbers are much better than at the start.Figure 1: . Prevalence and incidence of treated ESRD since 1984 and projected to 2010. From USRDS, 2000.What was responsible for improved awareness and treatment of hypertension? Probably several factors, but beginning in 1972 the Heart, Lung, and Blood Institute of the NIH began a high BP education project. One of our members, our Secretary-Treasures, John Stokes, was instrumental in launching that effort when he was at the NIH. The effort is ongoing, and much of the increase in awareness and treatment of hypertension can be attributed to the program. Furthermore, if one simply follows the incidence of stroke and coronary artery disease over the last 25 to 30 years, there are dramatic reductions (Figure 2). No one claims that the initiation of the High BP Education Project was the sole reason for this decline. Indeed, the decline began somewhat before, but it probably helped. But, undoubtedly you will not have failed to note that in stark contrast to the relentless increase in the incidence of kidney failure, both stroke and coronary artery disease are on the decline. As you all know, treatment attenuates the course of renal insufficiency. If properly instituted, it may even prevent kidney failure in some individuals. Overall, the rates of loss of kidney function measured as a decline in GFR per year as reported in a number of studies conducted in the late 1970s and into the 1980s was about 14 ml/min per yr. By contrast, the rate of decline has been cut by more than half in studies conducted during the 1990s. Most but not all of the patients studied had diabetes and proteinuria and were treated with angiotensin-converting enzyme inhibitors. However, the point, I hope, is clear that, at least in studied populations, we can do something quite substantial.Figure 2: . Change in age-adjusted death rates for cardiovascular disease (CVD), including stroke and heart disease (CHO), between 1950 and 1996. The vertical line marks the beginning of the National High Blood Pressure Education Program.How are we doing in practice? Bits of data are emerging. Three years a group from by reported on this investigators the in patients in both and They that people with serum creatinine of or greater only about a of those with hypertension and than one with diabetes were treated with angiotensin-converting enzyme a of by many practice Furthermore, of those with only about one out of patients and one out of three patients were on this of We do not know how well their BP was Furthermore, one that patients who have not even been to a but who would these of creatinine proteinuria are treated at even rates than patients who have been for some Thus, these data that we are the for primary hypertension in of treatment and We are now about at the point with treatment of renal hypertension was in the We have They are both silent diseases with is There are for and in Indeed, some have to public awareness of renal disease on their The time has to a effort to the public about kidney particularly individuals at high and them to treatment. We to education to including primary We will need practice as the National Kidney Foundation, and we with the Renal Physicians are may be to increase the rate of treatment. we can to the rate of increase of kidney failure as has with cardiovascular disease. I am that this is a process. issues of in many to the or in the United States to this process, but I do not that we can those and doing what we I have a to I will be and her staff at the NIH to develop an education program by a of from the University of Minnesota to work on this program over the next 2 I will be on many of you to However, as as I in the of to the number of people at we the as one simply to public or to of or to We need to know more at to that, better than years are still from Renal failure still even in many patients We need to even more about how to the and that we have We need to know at an what of people with renal to the are the of even and are the these genetic and from or lead into to these and many that our we will need The continued of investigators is Furthermore, many of these and facets of all of them, will by from in we have a I am that the of the has been a of these of at the late 1970s when published a Journal of on a as an that time, a number of other have this The has been that many of us have to However, a by in last year and more a review by and colleagues in the Journal this I that the is even more From that Journal the data that the number of in has by nearly over the last years from numbers before A trend has been in the number of for NIH over the last to greater for on NIH study sections are reported in the Journal are in with the of investigators than years that the of are than years of Of course, the research still and have to this continued and However, it that a at which progress in research will be by an number of In of in can only in Any have I will not the proposed for these I you to editorial in and the Journal review for more Furthermore, I will not simply this but I want to show you that the Society has been this at several for the last few First, a was in with it was on the needs for an of this has been to in and at least them into this My survey that all of a in the quality and number of over the last several Of was the decision in during Bill to to this meeting more who are in but as To nearly have been to the meeting under the support of Society I want to especially the who are in that program. more at and particularly began with the decision years ago to first of the NIH, the when they were we have provided support for NIH in the of We have developed at now the which a year for 2 years to investigators in In the last year, with and Bonventre, developed a program to support to a year from to work in a research receiving a as well as providing support to the of of and of those Finally, we have the large most when their as a to a in The now for the physician who is by this point 30 or more years of this in moving into a more practice for a We are all that into this but to the for As we advocated with it that other groups, most the of American of had to and were nearly Thus, last we a with other have The proposal would a of The would be chosen by review at the NIH. had quite support for this proposal with the the of a has been in the offices of from We have great that this will be in the but if it in the last to the we have that it will in the next year by and was not in the last However, for for investigators was and the NIH is in of this Furthermore, I that the Society with our from who in the NIH review process. The decline in is a problem, but the Society is to However, in the that the the of ESRD are not simply better and better but the continued on into investigative on more than simply I that a large of this of in from our in the of a loss of to the large still but in of you are in some of these But, I we have and I in this to and how how many of these Indeed, all the of and as largely and simply for better the of into the of their has us to these rather than to the of at all to the and I to the research of the by For that, I you to a rather from of our Research of 2 years ago It areas of as for the few But, I a number of investigators within the Society to their more on research Those I were remarkably and in are a few of their more other particular areas were proposed as well. are to the genetic study of hypertension as well as the for renal disease. in and as well as in and in of hypertension this NIH support has to a for the study of in this area this as a will more about on at the and are also under The of by is something that our this has been instrumental in an to of renal is more but with as and in our of this may the we kidney disease. the most within is the study of and is However, the of these may still It is only within the last that an actual in the a was for or will be and to is But, as one in this area on the he that perhaps examination by of other than the kidney with organization new of and have been of to for decades. However, it is still that nearly a people are no that the simply by and We have no idea what but is the to renal as renal is Finally, many of those with I the of disease and treatment as a that has on by have been in renal disease. I would to that we have failed to develop these simply we have the of patients on or if our are rather for some an organized is to increase our of the diseases and more to their I these to to the and that there are as well as still also to all of us that the If we are to the physician we on these of large issues and to our with as as they 1: of in was as a forum to the most and and issues in but we what I as some in our for these and the core of to our I this will be as something more than a to there may be some to to our I have a from this meeting to your a or the of but also them know that If you don't do the for your practice or the primary who I have in this to two areas that are in some by the one the Society has in support for public advocacy and public education to if for the increase in kidney failure. the other I have us to our in a and on and in we do on the one public and and research on the I we can and the next to I want to close by that of in our to do To do I want to For that will the Journal of of a point of It was a remarkably The lead a that That by the group of the with the first renal was one of the of what has to be or The editorial out that in only about of related were at year and that than half of those from for a year. Of course, the of are better in this year, this reported a for from and an rate for that we still of the or treatment of the of this Indeed, this is now the to The on for was by who has been one of the most of the that hypertension in a in the to the last the of one of the of hypertension, has However, the of the of hypertension is, as I still a work much in process. The that with in but was from It was more like Indeed, the editorial the as in and that it had been than years since the first had been in to the genetic of disease has since these The of the out to be a of The was and they apologize at the without of now a more a special was by an and with in during the phases of that which in the next I review this of the Journal of not of its or to our but also it out the of the first meeting of the American Society of years That meeting took in and about with scientific There were four at that meeting, the number as there are for our meeting We are to for his of the meeting published later in of renal to reported that be in with from the of patients with as the one in that Journal of the and of Finally, an of The at that meeting was by and was and the for The first to the of organized support for for patients with renal failure in as an for the of many of the investigators of the Society in this addressed an that was quite The both and be in providing in a the United States or those were better to Most of you are that it was not that the Government began to for in the United States. the do it on a broad and to in the I as as treatment an for patients with end-stage kidney disease and is of for one or more years, effort be to increase the of these But, we not accept our of we not our broad on renal This was an that many as the of research in the United States. even there as you for to of the for many and a of in we do if we to be by the as and as they Finally, a of an by the this to the in has the for the been the physician is better and better than he was years Disease is more studied more and treated more The of has been in a to make the to our and have the death rate from is to the point, and public have the and the of with its of his our However, the as it may have perhaps even to the that it was is still of our if more of public I the in at the of the Society that and do and research and patient There of course, only through but the both and and the to them, have been greater than It may not be the of but it is from the In the United States, we are at and We enjoy a more than Our of research the NIH, is in the midst of Most an of renal disease both the of our and the of We can still do Our not in but rather in doing by doing something

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