The 1950s and acute renal failure

In 1950 when the Renal Association was founded, doctors interested in the kidney were mostly academic clinicians with an interest in physiology, who conducted long and slow studies of electrolyte and fluid balance, acid-base homeostasis, and the effects of hormones. Apart from an early experiment with dialysis at Hammersmith Hospital, this group of clinicians were generally averse to developing the technique of dialysis. Indeed,  important and influential work on acute renal failure at Hammersmith during and after WW2 suggested that good outcomes could be achieved by obsessional management of fluid and electrolytes without dialysis until ATN recovered [work under the notable leadership of Graham Bull).  The development of dialysis was seen as needing practical engineering skills regarded by some as inferior to the intellectual pursuit of renal biology.

• Dialysis in the UK in 1959 [historyofnephrology]
• Conservative management of ARF in the 1940s [historyofnephrology]

But by the late 1950s the barriers were crumbling. The first sustained unit applying haemodialysis (HD) to the treatment of acute renal failure (ARF) was established in  1956 at Leeds General Infirmary by Frank Parsons  and in 1959-60 a slew of new dialysis operations were set up across the UK for ARF . Almost all of these were academically based, in large teaching hospitals. The need for analytical techniques, and issues with fluid and electrolyte imbalance, perhaps made it natural that it should be so. But dialysis was still viewed with suspicion (or disinterest) by some academics; in the late 1960s the RA Executive Committee were still debating whether dialysis was   a subject suitable for a symposium at one of its meetings.

The 1960s – the start of maintenance HD

1961 – Threshold of the new nephrology.  By 1964, success was being documented using HD as a maintenance therapy for those with irreversible renal failure. A few of  the early renal transplants had also been successful.

In 1964 the Department of Health accepted the recommendation of a working party chaired by Hugh de Wardener that 20 dialysis programmes should be established in the UK. All the designated centres were in teaching hospitals. Some were in academic departments of medicine, where  the professor medicine was a nephrologist – for example Newcastle (David Kerr), Charing Cross (Hugh de Wardener), Glasgow (Arthur Kennedy), Edinburgh (James Robson). Others had lead nephrologists within the academic department of medicine, although the primary interests  of the professor of medicine lay elsewhere – for example Guy’s (Stewart Cameron) and Royal Free, where Stanley Shaldon, a lecturer in  medicine was told by the professor of medicine Sheila Sherlock (a hepatologist) to establish a dialysis unit – he did so.

Growth beyond teaching hospitals

The care model centred on  teaching hospitals made sense in the 1960s given the small  number of patients being treated by new and complex approaches. But, as numbers increased, additional local facilities in non-teaching hospitals were only slowly established (typically on a hub and spoke model) , and in some place lagged badly to the detriment of patients, who still had to travel  long distances for dialysis and transplant, let alone for more conventional outpatient care. In some areas growth beyond the teaching hospital was so slow that some suspected that  delays were intentional to protect teaching hospital influence on referral catchment areas. Only  by the 21st century had service provision increased sufficiently to reduce travel for most patients to reasonable distances.

The growing impact of non-academic nephrologists

A consequence of this service growth was the emergence of a cadre of nephrologists who were not academically inclined, whose job was heavily service orientated, and for whom any commitment to research was likely to be secondary (for example recruiting subjects into clinical trials led by others) rather than primary. The early years had passed when consultant nephrologists were expected to have a substantial track record in research in order to be appointed.

The membership of the Renal Association now  had a majority of full time clinicians as well as academics, although for some time the programmes of Renal Association continued to be dominated by tubular physiology and immunology.

Changes in research agenda

The reputation of research into dialysis and its related issues continued to suffer.  This perception was not helped at the time by the direction taken by the European Dialysis & Transplant Association (EDTA). EDTA had been founded by academics (including David Kerr)  in 1964, but the influence of the dialysis industry and its hospitality on its programmes was felt by some to weaken its legitimacy. At its nadir, cynics dubbed EDTA as the European Dining & Travel Association!

In the UK a variety of factors allowed  a healthy mutual respect to emerge between clinicians and academics. The emergence of the British Renal Society representing the renal multiprofessional team and promoting its ‘near patient’ research agenda. led a to a broadening of research interests at BRS and RA meetings, eventually completed by the merger into the UK Kidney Association into 2019.  In the 21st century Kidney Research UK, which  had been criticised by some for funding a relatively narrow array of academic work, increased the breadth and range of it support.

Balance of research and clinical work for academic nephrologists

The development  of academic medicine in the 21st century has in general encouraged job programmes with a heavy emphasis on protected research time, with reduction in clinical commitment, which is often regarded as a distraction to successful clinical science.  This does not sit comfortably with nephrologists whose clinical work is driven by holistic and sustained care best served by continuity of clinical contact.  While this makes for a heavy combined clinical and academic load for research-orientated nephrologists, it has undoubtedly helped to sustain the mutual respect of nephrologists with different balances of  responsibility.

 

 

Last Updated on January 13, 2026 by John Feehally