1992 ASN Presidential Address

1992

ASN Presidential

T

Address

he decision was made to use this occasion to celebrate the Society’s Silver Anniversary. The ASN was actually formed in 1966; the first meeting was held at the Biltmore Hotel in Los Angeles in October 1967, and this is the 25th Annual Meeting because a meeting was not held In 1 972 when the ISN met in Mexico City. Thus, it was somewhat arbitrary as to when the 25th Anniversary should be celebrated. Nevertheless, having chosen this the 25th Annual Meeting as the Silver Anniversary, we have relieved those who follow of the difficult decision as to when the celebration of the 50th anniversary should take place. To commemorate this event, a book entitled a Quarter Century of Nephrology was produced and distributed to the membership. Posters of the past presidents lined the hall, displays depicting the history of dialysis and transplant coordinated by Lee Henderson and C. Bernard Carpenter have been placed in the exhibit hall, and several talks of a historical nature were integrated into the program. To add to the historical flavor of this meeting, I thought it would be fitting in my remarks to you to consider where we have come from, what we are, and where we might be going. To put this in a larger context, I will also try to refresh your memory concerning the world in which we lived in 1967. 1967 was an eventful and turbulent year for both the ASN and the world at large. The Vietnam War was in progress and creating division within the country, and the 6-day war took place in the Middle East. At an ASN Symposium that year, there was conflict to a somewhat lesser degree as Alexander Leaf and Isidore Edelman vigorously debated whether aldosterone increased transepithelial sodium transport by enhancing Na entry across the luminal membrane or by stimulating the activity of the Na pump. This topic is now closing in on a resolution, with evidence supporting a role for both mechanisms, and this year, the world is optimistically hopeful that the Arabs and Israelis may be moving toward a final resolution of their conflict. A more vital conflict in nephrology was addressed by Neal Bricker in the First Presidential Address to this Society in 1967 entitled “Dialysis, Toad Bladders and Social Conscience: A Search for Balance” (1). He took the position that nephrology should use all of its resources to make dialysis and transplantation available to every patient suffering from uremia, whereas others at that time argued strongly that this course

Journal

of the

American

Society

of Nephrology

of action would erode the scientific base of our discipline. As all of you know, the capability to provide care to all patients afflicted by ESRD was subsequently developed, while at the same time, the science of nephrology did not erode but rather prospered greatly, in part because of this course of action. Thus, this major nephrology controversy of 1 967 has been put to rest, as has the Vietnam conflict and its scars. Twiggy was the rage of the fashion world in 1967, and boots were in. Others who frequented HaightAshbury had a different view of what was in fashion. Without question, however, natriuretic “third factor” was “in” at the ASN meeting, with a symposium and multiple free communications on the topic. Hit movies of the year included Bonnie and Clyde and The Graduate. State-of-the-Art Addresses at the ASN meeting by Robert Berliner and Louis Welt were equally distinguished, but the titles of their presentations, “Renal Physiology” and “Clinical Nephrology,” were somewhat lacking in pizzazz. Ronald Reagan was first sworn in as Governor of California in 1967, and this year, with the defeat of George Bush, the Reagan years ended. Reflecting the slow pace of cause and effect in 1967, Thurgood Marshall was sworn in as the first African-American Supreme Court Justice and was replaced in 1 992 by Clarence Thomas, a man with totally different views. In 1967 at the ASN, the entity of rapidly progressive glomerulonephritis was described in one of the free communications sessions. This year, an entire session was devoted to antineutrophilic cytoplasmic antibody and there were multiple presentations on the pathophysiology of cresentic glomerulonephritis. As I am sure is vividly recollected by this year’s superb program chairman, in 1967, the Boston Red Sox, led by Carl Yastrzemski winner of the triple crown, were defeated by the St. Louis Cardinals in a seven-game World Series. Bill Russell and Wilt Chamberlain were the giants of professional basketball, but in 1967, Chamberlain prevailed and led his Philadelphia 76ers to the NBA crown. Meanwhile a member of the next generation of superstars, Lew Alcindor, later known as Kareem Abdul-Jabbar, was leading his UCLA Bruins to the NCAA title. The first Super Bowl was played in 1967 and won by Vince Lombardi’s Green Bay Packers. Little did anyone dream at the time that this game would blossom into the football event of the year. Similarly, the organizers and attendees at the first ASN meeting in 1967 did not envision the enormously successful path that this meeting would follow. They did, how-

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1992

Presidential

Address

ever, create a visionary meeting structure, which in large measure has persisted to the present. Most crucial, it represented an equal blend of basic and clinical science that brought hard-core basic scientists and clinicians together to share their expertences and blend their knowledge. For example, the meeting included six symposia, three devoted to clinical topics including chronic dialysis, renal transplantation, and ureteral reflux and three to basic physiology including mechanism of action of aldosterone, glomerulotubular balance, and natriuretic third factor (Table 1 ). The domination of science by salt and water physiology was readily apparent. However, a glimpse of what was to come in 1 992 was reflected by two of the State-of-the-Art Addresses, “Membrane Transport” by Daniel Tosteson and “Immunologic Pathology of Renal Disease” by Frank Dixon. The 1 967 meeting, which combined State of the Art, Symposia, and Free Communications, lasted 1#{189} days (Table 2). Two hundred eighty-seven abstracts were submitted, and 80 were selected for oral presentation. The six topical areas for Free Communications were also a balance of basic and clinical material, as shown in Table 3. We have certainly grown in size since 1967. Our science has diversified and become more sophisticated, and it has shifted from an overwhelming predominance in renal physiology to a major focus on the pathophysiology of renal disease. Furthermore, our scientific partners from all over the world are now major participants and contributors to this meeting. This year’s meeting lasted 3/2 days (Table 2). There were more than 6,000 participants in contrast to the approximately 1 ,000 attendees at the 1 967 meeting. More than 2,400 abstracts were submitted, and 1 ,94 1 of them were presented in a combination of oral free communications and poster sessions. There were still only four State-of-the-Art Talks, but there were 14 Symposia and 25 Minilectures. We also mitiated as an experiment a poster reproduction process, which we hope will enhance the value of the poster presentations. In 1967, there was an ebullient sense of optimism among nephrologists about their discipline and its future. The field was on the verge of exploding. Strauss and Welt had published the first comprehensive American-authored text of nephrology only 4 yr before and Heptmnstall his book on renal pathology 1 yr before. The feasibility of chronic dialysis had been demonstrated by Scribner and his colleagues in Seattle in the first half of the decade. Murray, Merrill, and their collaborators at the Brigham, along with Starzel and Hume in the United States and Hamburger in France, had demonstrated the feasibility of renal transplantation, and Christian Barnard had

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TABLE

1.

1967

ASN

Meeting

Symposia

Clinical Chronic dialysis: present and future Renal transplantation: science and philosophy Role of reflux in pyelonephritis Basic Science Mechanisms of action of aldosterone Glomerulotubular balance The nature and mechanism of action of the “third factor”

TABLE

2.

ASN

Meetings,

1967

and

1992

1967

Duration (days) Abstracts State-of-the-Art Symposia Minilectures

TABLE

3.

1967

natriuretic

1992

1#{189}

287 4 6 0

Lectures

ASN Meeting

Free

3#{189}

2,490 4 14 25

Communications

Clinical nephrology Pathologic Physiology Physiology, Transport, Metabolism Hypertension, Renin Pathology-Immunology Transplantation and Dialysis

carried out the first heart transplant that year. The world of renal physiology was rapidly advancing with increased sophistication in micropuncture technology and the development by Burg and his collaborators at the NIH of the isolated perfused nephron technique. Membrane transport of sodium, water, and protons was forging ahead with the use of isolated epithelial membrane preparations. New insights were being forged into both acute and chronic renal failure. The application of micropuncture to the pathophysiology of acute renal failure (ARF), initiated by Oken and his coworkers, had spread to multiple laboratories, while Bricker and his colleagues were delineating the impact on renal function of a reduced nephron population using the unilateral reduction of renal mass model. Parathyroid hormone measurements had been developed, and its abnormalities in renal disease were undergoing study. Dixon in his State-of-the-Art Address that year described the phenomena of immune complex and basement membrane-directed immunologic mechanisms causing nephritis. There was optimism for progress on multiple clinical and investigative fronts. Progress in these areas since 1967 was presented in some detail in a series of minilectures by several

Volume

3

Number

10

1993

Tannen

TABLE

4.

1967

HistorIcal

Minilectures

Hemodialysis

B.H. Scrlbner

Sun. 4:00 p.m.

Renal

R.L. Vernier

Sun. 4:00

J. Lemann

Sun. 4:00 p.m.

M.B. Burg P.R. Steinmetz

Tues. Tues.

Calcium

Immunology

Metabolism

Salt and Water Urinary Acidification

p.m.

10:00 a.m. 4:00 p.m.

of our distinguished members who have both witnessed and contributed in substantial fashion to this evolution (Table 4). There was a State-of-the-Art Address on organ transplantation by Dr. Joseph Murray. In 1967, space probes from both the United States and the Soviet Union had reached Venus and were relaying information concerning its atmosphere. Less appreciated but lurking in the background, biologically active DNA was synthesized and the molecular structure of ribonuclease was determined that year. In recent years, there has been a growing concern about the relevance and excitement of our science in nephrology in comparison with other disciplines. We are not doing as well in attracting new talent to the field. Dialysis and renal transplantation are no longer viewed as cutting-edge technologies. This coupled with the difficulties in federal funding transformed the excitement of the 1 960s to a doom-and-gloom mentality in the 1 980s. The 1 990s should dispel these notions, for during the 1 980s,. nephrology was effectively retooling for major scientific impact during the next decade. A look at the free communications In this year’s program should rekindle excitement across the complete spectrum of science that encompasses the interest of the ASN membership. On the basis of the application to nephrology of the revolution In cellular and molecular biology along with the advances in immunology, we are poised to uncover the pathogenesis of multiple renal diseases, to unleash new diagnostic and therapeutic strategies, and to understand the most basic mechanisms of cellular function as it relates to water and ion movement. These are exciting times. To whit on this year’s program, an entire session was devoted to “Molecular Analysis of Native Renal Biopsy,” describing a technologic revolution that should help uncover the pathogenesis and enhance the diagnosis of many forms of renal disease. Transgenic animals are being used to identify pathophysiologic mechanisms. For example, rats with the mouse ren-2 gene have been used to delineate the role of the intrarenal renin-angiotensin system in the progression of renal failure, whereas mice transgenic for bovine growth hormone and an analog have been used to Investigate the mechanisms by which growth hormone accelerates glomerulosclerosis. The genetics of Alport’s syndrome nephrogenic diabetes in-

Journal

of the American

Society

of Nephrology

sipidus, Banter’s syndrome, and polycystic kidney disease are being unraveled along with new insights into the mechanisms of cyst production in the latter disorder. The pathophysiology of diabetic nephropathy, the major cause of ESRD, is undergoing intensive scrutiny with one abstract on the program providing evidence that polymorphism of the insulin receptor gene correlates with those individuals destined to develop diabetic nephropathy. The roles of endothelin and EDRF, along with other vasoactive cornpounds, are being dissected in regard to hypertension and glornerular function, and the mechanisms of glomerular injury and sclerosis are being dissected at multiple fronts including the roles of cytokines, matrix, T cells, and inflammatory mediator mechanisrns. Exciting therapeutic possibilities reported at this meeting include the potential for enhanced recovery from ARF with the use of insulin-like growth factor I administration and the potential for improved survival with ARF by hemodialysis with biocompatable membranes, the efficacy of interleukin1 receptor antagonists in modulating the crescentic glomerulonephritis of anti-glomerular basement membrane disease, and the ability of a competitive inhibitor of CD 28 receptor on T cells to impair graft rejection. The membrane physiology of ion and water transport is being revolutionized by the cloning of multiple transporters and channels, including the CHIP 28 water channel, and the dissection of the intraand extracellular mediators of their action. The list goes on and on and obviously would be generated differently by each of us, depending on our orientation and background. But I would challenge anyone who would conclude other than that these are enormously exciting times for the science and clinical practice of nephrology. The ASN exists to help facilitate this message, to be the vehicle for communicating these new scientific discoveries, and to help get our message out to the public at large. The 18 founders who created this society in 1 966 developed a constitution that has served us well for 25 yr (Table 5). However, we are now a different organization than we were 25 yr ago. We have grown immensely, and we have broadened

TABLE

5.

ASN Founding

Henry 1. Barnett Robert W. Berliner Neal S. Bricker Stanley E. Bradley David P. Earle James F. Glen Robert A. Good Charles R. Kleeman Richard Malvin

Members John P. MerrIll Solomon Papper Robert G. Petersdorf George E. Schreiner Belding H. Scrlbner Donald W. Seldin Daniel C. Tosteson Robert 1. Vernier Louis G. Welt

1641

1992

Presidential

TABLE

6.

Address

Constitution

R.W. Schrler,

and

By-Laws

Committee

Chairman

R.G. Abramson C.B. Carpenter R.W. Chesney

G.H. J.H. AR. T.D. F.G.

Second, the her category dents.

Gieblsch Hostetter Hull McKlnney Sliva

our mission. On this 25th Anniversary, it therefore seems appropriate to reexamine our by-laws and consider changes that might suit us better for the future. To this end, Craig Tisher created an Ad Hoc Committee chaired by Bob Schrier to provide the Council with advice on this issue, and the council itself spent several long sessions examining these issues (Table 6). One obvious problem with the current by-laws relates to the mechanism for changing them. As currently structured, a two-thirds majority vote of those present at the business meeting is required to modify the by-laws. In view of our current size and the number of members who attend the business meeting, this process runs the risk of not truly reflecting the will of the membership. Therefore, we proposed that a by-laws change be made at this meeting that would implement a mail ballot for subsequent bylaws revisions, and the by-law change was approved. The Council will submit to the membership following this meeting a series of additional by-laws changes. Some of these proposals are largely technical in nature and codify certain procedures already in place, such as the requirement for a certified audit, the empowerment to retain counsel, the designation of a chief staff officer, and the provisions for a JASN editor and a process for the selection of this individual. Other proposed changes are of a more substantive nature. They include: First, a change in the statement more closely reflect the current society. The purpose has been

1642

“advance the knowledge and practice ogy,” a view of the Society’s mission ready reflected by Bricker in his initial address (1).

of our purpose to workings of the broadened to state

establishment for Fellows

of nephrolthat was alpresidential

of an Associate and postdoctoral

Memstu-

And finally, a revision in the methodology for choosing councilors. A nominating committee chaired by the past president and including five other active members will place three names in nomination to be voted on by mail ballot. This change has been recommended based on the urging from many to democratize the selection of councilors. There was substantial discussion concerning the suggestion that the size of the Council be expanded. For several reasons, the Council decided not to support such a change at this time. The ASN has prospered enormously. However, after a quarter century, it is time for some changes. I hope you will concur that we should, however, proceed cautiously so as not to eliminate those aspects of our structure that have brought us to where we are. I would like to thank all of you for the privilege and pleasure of serving as your president. Every member I have asked to help me this year has done so uniformly and with enthusiasm, reflecting the great sense of pride and commitment to the ASN that all of us feel. Thank you.

University

Richard Department of Southern School Los

L. Tannen of Medicine California of Medicine Angeles, CA

REFERENCES 1.

Bricker NS: Dialysis, conscience: A search 16:177-181.

toad bladders and for balance. Clin Res

Volume

3’

Number

social 1968;

10#{149} 1993