Charles R.P. George

How Australian nephrologists view home dialysis: Results of a national survey

Aim:  Australias commitment to home dialysis therapies has been significant. However, there is marked regional variation in the uptake of home haemodialysis (HD) and peritoneal dialysis (PD) suggesting further scope for the expansion of these modalities.

History of home haemodialysis in Australia (Review Article)

SUMMARY:  Australia has had an active and slowly expanding home haemodialysis programme; however, this has failed to expand as rapidly as some other methods of treatment of end‐stage kidney disease. The technique in Australia has always been a derivative from overseas experience, rather than innovative. It received some minor initial support from the report issued in 1968 by an ad‐hoc Committee of the National Health and Medical Research Council on Rationalization of Facilities for Organ Transplantation and Renal Dialysis, but was ultimately disadvantaged because the report promoted transplantation over dialysis to an extent that proved markedly disproportionate to the number of patients who, in succeeding decades, would need maintenance dialysis treatment rather than transplantation. Nevertheless, each state in Australia established home haemodialysis facilities, but major interstate variations occurred in the uptake of the modality. The subsequent development of continuous ambulatory peritoneal dialysis and limited care dialysis centres appeared to have an important negative impact on home haemodialysis, although the recent introduction of daily dialysis is likely to have a positive influence in the future.

Renal replacement therapy associated with lithium nephrotoxicity in Australia

Objective: To analyse the annual incidence of end‐stage renal disease (ESRD) associated with lithium‐induced nephropathy (LiN) in Australia.

Mercury and the kidney

Humans have had a history of association with mercury since the earliest records. This relationship has had many quixotic elements, but has on many occasions and in many ways impinged upon the kidneys. Arabic physicians used mercury to treat skin infections, urinary infections and urethral stones. The rise of syphilis in Europe in the 16th century saw its application as the primary treatment, sometimes oral and sometimes parenteral, of patients suffering from that disease until the mid-20th century. It also found various other uses. Mercurial diuretics originated from chance observations of such patients, and these received much use in the first half of the 20th century until safer and more efficacious nonmercurial diuretics replaced them. Many physicians viewed mercury as a panacea, but others challenged their views. Its use was always recognised to have potential complications, but realisation of its ability to cause acute kidney injury, chronic renal impairment and nephrotic syndrome gradually evolved, and it was phased out of therapeutics. A further contribution it made to nephrology lay in the manufacture of thermometers, sphygmomanometers and cystoscopes.

Development of the Idea of Chronic Renal Failure

Ancient literature contained suggestions of references to people whom we might now speculate suffered from chronic renal failure; however, the first glimmerings of an understanding of the subject arose out of the clinico-pathological correlations that a number of 18th and 19th century observers drew. The concurrent studies by chemists of circulating and urinary levels of urea, creatinine, urate, phosphate, potassium, sodium and hydrogen ions expanded those correlations to a pathophysiological domain, especially in the late 19th and early 20th centuries. With the subsequent development of ideas about circulating hormones and the development of techniques for their measurement during the 20th century, the contemporary idea of chronic renal failure developed. The development of methods for quantifying tests of renal function enhanced that undertaking. Then, in the latter half of the 20th century, the development of effective dialytic techniques for the treatment of patients who suffer from chronic renal failure brought a renewed focus upon the mechanisms involved and problems posed by existing ideas. Nevertheless, the continuing high morbidity and mortality of patients who require such treatment suggest that existing ideas remain quite imperfect.

The Contribution of Nephrology to the Development of Current Concepts of Disease

Historians and philosophers of science rarely comment upon nephrological contributions to the development of general concepts of disease. In the present study, I examine this topic by starting from the premises that an idea of disease pervades most human societies, that received explanations of disease vary between people, societies and eras, and that an understanding of renal disease has often reflected general explanatory trends. Traditionally, most students of disease have belonged to one of four schools: descriptive, causal, mechanistic, or statistical. Descriptivists have tended to focus on manifestations, be these of a symptomatic, a structural, or a functional type. Causationists have focussed upon identification of the origins of diseases. Mechanists have emphasised pathogenetic processes. Statisticians have calculated mathematical differences of parameters from the mean (‘the normal’), without explaining the reasons for these. Mechanists currently appear to hold the ascendancy in nephrology through their focus upon the links that connect causes with manifestations. As, however, all schools of thought have historically waxed and waned, I question the wisdom of granting any of them hegemony. Rather, I promote an event idea of disease that encompasses the causal, mechanistic and descriptive schools. Such considerations should assist nephrologists both to treat disease and to identify those of their predecessors who most advanced knowledge.