The Oxford Kidney Unit 1967-2016
Dr CG Winearls, 1st November 2022
Oxford was one of the pilot sites chosen after the deliberations of the Rosenheim Committee and the de Wardener Working Party report recommended in 1965 that the NHS should provide haemodialysis for end stage renal failure (ESRF)(ref). These units were to provide treatment by haemodialysis and or transplantation for an estimated 30 adults per million population under 50 years of age suffering ESRF. This early phase in Oxford has been charmingly described by EJR Burrough, a contemporary Administrator of the United Oxford Hospitals. (Appendix 1)
In Oxford in the early 1960s patients with renal failure were generally the responsibility of the Department of the Regius Professor of Medicine, Sir George Pickering FRS, whose key interest was high blood pressure. He eschewed the word hypertension. He had no special interest in renal failure.
In 1966, one young woman with what was called terminal renal failure, Jean Tarver, was kept alive by weekly IPD, and in 1967 the Artificial Kidney Unit (AKU) was opened on the Churchill Hospital site, three miles out of town from the main acute hospital, the Radcliffe Infirmary. The unit was located in a temporary prefabricated wooden structure used as a place to experiment in ward organisation. It had been scheduled for demolition, but still stands today, 56 years later, under-maintained as it continues its wait for demolition. The unit was to be run by two consultants, one a general physician with expertise in endocrinology and renal hypertension , Dr John Ledingham, and the other appointed to set up the Unit, Dr Desmond (Des) Oliver, a New Zealander who had come to England to take the MRCP and had never returned to his home country.
Oliver had been exposed to acute renal failure managed by PD at the Hammersmith Hospital, working for Professor Oliver Wrong, who was not interested in renal failure. He was later appointed First Assistant to Sir George Pickering in Oxford, and then to the new NHS post. The other candidate was Dr Tony Wing, who was later appointed to a post at St Thomas’ Hospital.
The first patient of the Oxford AKU was Ruth Lupton, who had already been established on dialysis in London by Dr Stanley Shaldon. Jean Tarver, a secretary at Ruskin College who suffered from Henoch-Shonlein purpura, was the second. She lived for over thirty four years on haemodialysis, never having had a transplant. (Figure 1). She sat distraught at the front of the small Butterfield church of St Barnabas, in Horton-cum-Studley, at Desmond Oliver’s funeral in 1997.
The AKU had four dialysis stations which were for the treatment of new patients and training for Home Haemodialysis. There was one futile attempt to do a renal transplant, after which patients who chose this, then high-risk option, were referred to Birmingham or Cambridge. They fared scarcely better, and transplantation got a bad name, while demand for dialysis grew rapidly.
Patients were kept on PD until a HD training slot became available. The fluid was made up in the pharmacy and sometimes cramelised. Travenol Twin Coils were used at first, then KiiI dialysers, which were tricky to set up and apt to leak. Patients were referred from six counties, Oxfordshire, Berkshire, Buckinghamshire Northamptonshire, Wiltshire and Gloucestershire – a population of about 2.5 million. Patients were only accepted if home haemodialysis was feasible.
Vascular access was by Scribner shunt until Brescia-Cimino fistulae were fashioned by a kind plastic surgeon Mr Tom Pattison. The Unit was not allowed to have a British registrar who might compete for the rare jobs, so relied on “colonials’. Faroukh Wadia was from India; George Nicholson from the West Indies; Jo Adu from Ghana, and Mike Pascoe from South Africa. The Nuffield Department of Medicine loaned its lecturer post to help staffing. An NHS senior registrar post was only created in the 1990s.
By 1973 there were >120 patients on Home Haemodialysis – a huge logistical exercise involving the placement of Portacabins in gardens, house alterations, dialysis machine with RO water treatment systems, generators in case of electrical supply failure, delivery of disposables, social support, training of helpers.
The patients were mutually supportive and set up a group called the Six Counties Kidney Patients Association (SCKPA) which is still thriving. There was much fundraising to buy kidney machines, and they established holiday dialysis cabins on the South Coast and in France, so they could holiday while continuing their thrice weekly sessions.
The AKU team grew to include a team of dialysis technicians who fixed and serviced the dialysis machines, a dedicated renal social worker who helped with benefits especially the “Attendance Allowance” paid to carers who assisted with the home treatments, dieticians and AKAs (Artificial Kidney Assistants) who helped with setting up of machines and “building” the Kiils.
Demand for dialysis increased and the strict rules on home haemodialysis and age were breached. Every year Dr.Oliver had to go to the Regional Health Authority to ask for more money. They grimaced but usually paid, knowing that he was parsimonious and deployed the limited resources carefully.
The Oxford Transplant Unit was opened on January 1975 under the direction of the new Nuffield Professor of Surgery, Professor (and later Sir) Peter Morris. In the late 1970s a new Transplant Centre and shared outpatient facility was built after a substantial fund-raising campaign. It was opened by Sir Peter Medawar, the Nobel Prize winning immunologist who had predicted that organ transplantation would never work. In his speech he said that this building was a testament to how wrong he had been. (Figure 3).
CAPD was started in 1980 and usually offered to the more elderly or comorbid patients deemed unsuitable for HD. A satellite dialysis unit was opened in Northampton in 1985.
Dr Ledingham had been appointed May Reader in the Nuffield Department of Medicine and returned to his role as a general physician and teacher. Dr Oliver remained single-handed until August 1988, when a second NHS consultant Dr Chris Winearls (a Cape Town graduate trained at the Royal Postgraduate Medical School, Hammersmith) was appointed.
In 1995 the Buckinghamshire Health Authority asked for local treatment of its inhabitants. Satellite units were opened, in Amersham and in Milton Keynes. The Amersham Unit was closed when a High Wycombe facility was completed.
Later when the RAF Unit at St Mary’s Halton was closed, a new unit was opened in Aylesbury on the Stoke Mandeville Hospital site. Swindon too had a satellite unit run by a private provider but this was closed and a new unit was created in the new PFI funded Great Western Hospital. All these units are run from the Oxford Hub with a single management structure and clinical protocols.
Two new consultants were appointed – Dr Paul Altmann (trained at the Royal London Hospital) and Dr Philip Mason (trained at Guy’s Hospital and the Royal Postgraduate Medical School, Hammersmith). There are in 2022, 12 WTE consultant nephrologists, and three academics with clinical sessions. The Kidney and Transplant Units forged joint working when Prof Peter Friend moved from Cambridge to take up chair of Transplant surgery in 2002.
After three medical Clinical Directors, the fourth was a nurse, Sr Alison Thornley. Vascular access is provided by surgeons working in the Transplant Centre.
Clinical research thrived from the beginning, inspired largely by John Ledingham but supported by Desmond Oliver.
The Unit had a few famous patients including the first MP on haemodialysis – Sir Michael McNair Wilson; Sir Rudolf Peierls, who had realised the potential of the atomic bomb; and the great actor Sir Michael Hordern.
At the 2017 50th anniversary of the founding of what had been renamed the Oxford Kidney Unit, 1767patients with ESRF were being cared for. The median age of these patients was 57 years. 545 were on dialysis, the majority on haemodialysis in-centre or at one of the five satellites. There were 1,222 patients with functioning transplants. The catchment area had contracted to 1.69 million after Berkshire developed an independent service, but still relies on Oxford for dialysis access and transplantation, and Northamptonshire became part of the Leicester Renal Service. See Figure 5. The take-on rate was 129pmp/ year of which only 12% were late presenters and the median age was 64 years – so very different from the start.
First posted 3 Nov 2022
Last Updated on November 3, 2022 by neilturn