Renal Units: Pride in, and of, place?

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Renal Units: Pride in, and of, place?

Introduction

The category of renal ‘Units’ on the UK Kidney History  website will seem familiar and inevitable to UK nephrologists. Further consideration reveals a complex entity, which appeals to a variety of historical and still-current interests. The term implies a unity, more like ‘centre’ than the typical US ‘facility’, perhaps. It has always been used as a kind of counter, with which to compare national specialty activities, both numerical and qualitative. Modern consumer surveys, like PREMs and PROMs, take advantage of that generalisation. However, the implication of unit productivity, of having products in terms of patient outcomes and laboratory characteristics, did not strike a popular chord when used to characterise whole-unit UK Renal Registry results after 1997; that was more ‘facility-like’ and, in emphasising the sum of many inputs, rather neglected the unique contributions of personnel and policies. The lack of enthusiasm said something about the importance of a consciousness of Unit-hood in the UK specialty culture of kidney disease.

The special pleading of place

It has been emphasised that the technologies of dialysis and renal transplantation developed haphazardly, dependent especially on advances in the available materials and periodic technical adaptations to human vascular biology.1 In the 1950s, the pressures of Korean wartime casualties in men and the risky measures to forestall childbirth in women offered a clinical challenge; to sustain the previously fit through a recoverable renal malfunction.2 The methods originated and were validated in a variety of practical circumstances internationally. The pioneers succeeded by using every advantage they were offered to develop their agenda, including the identification with a place (Leeds and Seattle, for example). The subsequent deployment of kidney replacement technologies for irrecoverable organ failure attracted a further cohort of energetic clinicians and clinical researchers.

Such stories in history always need a recognisable context. As natural storytellers, the originators of the website included ‘Units’ as a recognition of the functional sites of renal-related activities. Pride in place was attractive in the developing specialty, perhaps because simply adopting a familiar topographical name for any activity characterises and consolidates it.  Localisation takes advantage of a linkage with established traditions and reputation – the adoption of local placenames by retail businesses is very common for that reason. Similarly, the organisation of military units according to city of origin by Alexander the Great, and lamentably again in early World War 1 (the Pals), took advantage of a loyalty and connection with place to enhance cohesiveness (until local casualty rates pressed the case for the less emotive Roman routine of deliberately mixing the origin of recruits).

Unit entities

Renal units were established as specially equipped and supervised medical settings for the maintained palliative care of renal failure through dialysis. A unit was the practical home of treatment, workshop support and, often, in-patient capacity; it was a good deal more than a hospital department. Cynics have described renal units as centres of suffering, in that dialysis is not without its patient-paid price. The many trials of kidney support can be seen as a symptomatic disease/syndrome that replaces renal failure! A more generous interpretation is usual. However, one must surely separate the cultural impressions of the ‘doing’ staff and the ‘done to’ patients! An account from the patient perspective will be a necessary complement to this essay (vide infra).

Some early establishments were the outcome of academic and idiosyncratic effort, others a  tranche of semi-systematic NHS provision. The unfortunate need for their persisting role has created useful environments of clinical and research training, which form the backdrop to any career focused on kidney disease in the UK. They are the created, semi-uniform context of a familiar specialty culture and, as such, a trove of material for reflection and nostalgia.

The independent consequences of locus

The topographical placing of the units contributed to specialty development of itself.    Perhaps the clearest case was the consequence of the 1970s chemical effort to clarify the peat-discoloured reservoirs of the North of the UK. Aluminium toxicity in Northern units (Sheffield/Newcastle and Scotland in particular), with dementia, anaemia and bone disease, was a signal that haemodialysis might require yet further technical sophistication (Hepatitis B had already become something of a red flag, of course).3 The health service infrastructures of the South East were important in spreading an awareness of Nephrology, adult and paediatric, through the Guy’s Hospital provision of renal biopsy and subsequent advice for nephrosis.4 The metropolitan geography of the M62 could be said to have determined the models of service provision enacted in Leeds (‘Hub and Spoke’) and metropolitan Manchester (‘Networks’), the latter being less demanding of suitably distributed townscapes.  The 1960s coverage of necessary dialysis provision initially promoted a focus on single-handed consultant-led units, while at the other end of the size spectrum an austerity of senior staffing, in the face of steadily burgeoning patient populations, was an incentive to the clinical computerisation of the 1980s.  Some controversies have had a specific unit focus, like a challenge to iterative Urea Kinetics (Leicester) or twice weekly haemodialysis (Belfast/Withington).There were no medals for distribution after those battles! The locus of the UK Renal Registry was partly determined by the existence and facilities of the Bristol UK Transplant distributor and partly by vigorous local renal unit personnel.

In contrast, the accounts of very early haemodialysis at the Hammersmith Hospital, the proof of the maintenance haemodialysis principle from the Royal Northern by Stanley Shaldon and the Charing Cross (de Wardener) origin of renal clinical computing do not linger except as memorials.

The establishment of units has not been without significant effect on the wider local health services. The placing of the Regional Leeds dialysis unit investment in 1966, and the subsequent addition of renal transplantation, signalled the start of regional development at St James’s, the previous workhouse, despite major resistance from The General Infirmary at Leeds.6 That regional mandate was sustained for more than thirty years.

There will be other examples.

Anecdotes of patient pressure have periodically brought in another dimension. Local unit policies and personnel have often had to become exposed in order to broker uncertainties of clinical management and the consensus restrictions of, for example, the referral for transplantation. The extension of dialysis and transplantation to the elderly and diabetics was a stuttering, local process. It  was based on limited evidence at the start, with every appearance and evidence of doing harm, and remains methodologically controversial.7  For example, retinal haemorrhage on haemodialysis was thought later to have been provoked by ischaemia rather than the most obvious suspect, anticoagulation.

Belonging, for staff

The effort of renal palliation has always been based on team activity, which is a cue for rewarding social relationships. In modern times the experience of lively, effective social experience in the community has gradually declined, except in the unselected citizen turnout for covid vaccination! For that reason, the experience of collaborative training and shared clinical care in renal units stands out the more. It may be an accident that the scale of personnel in many units is comparable to the ideals of the Dunbar number (+/- 150), which would serve incidentally to encourage close personal relationships.8 Multidisciplinary intimacy has been a unit characteristic from the start, although arguably formal, national, recognition came very late.

Formative years in specialty healthcare training are localised typically to units. A term equivalent to alma mater (plural almae matres) has yet to be coined but would be apposite. Striving in the same vineyard is unifying, especially since each unit carries specific historical difficulties and constraints. Unit nostalgia then can be complex and highly personal across individual careers.

Reputational benefit

Close working contact with senior staff is common in renal units, although the typical large scale of UK unit patient populations may not have been helpful. Clinical and research participation with reputable individuals is both practically important and enduring as a credit. Learning ‘how to be’ in the range of professional affect can be transformative of careers. Discovering just what you are good for is revelatory at any age. Intellectual and appointment hand-me-downs, and certain ideological pedigrees, can be discerned in the specialty. ‘On the shoulders of giants, etc…’ An instinct to align to the historical reputation of the unit is inevitable, since it dignifies the individual and ensures some personal existential significance through institutional continuity. Such reputation ranges from the enduring preoccupation with Richard Bright at Guy’s to the consciousness of valuable community support in the smallest regional unit.9

Of course, the benefit of reputational branding by place is manifest in motivating effort and enhancing morale. For those with substantial gifts of intellect and energy a notional career space within which to grow and achieve is priceless. To build an institution comprised of skilled personnel and facilities requires investment, both personal and financial, which can bring great satisfaction. The development and promulgation of novel ideas and approaches can be enhanced by the crowning continuity and ready identification of place.

For many, their training  decade was ‘the (professional) time of their lives’ and they enacted an Aristotelian eudaimonia, a self-realisation, which begs sharing and advertisement in the specialty and peer group, not least on an historical website.

Rehearsals of health service management

The decisive NHS enlargement of renal replacement capacity of 1966 was based on urban locations, assigned to a cohort of energetic polymaths from the young specialty. They had only limited blueprints of organisation and processes to hand, which meant that ad hominem, idiosyncratic, improvisations were built into the developing culture at each site. An engagement with local communities was common for fund raising, as well as the encouragement of kidney donation and respite care. The guaranteed persistence of those established units, and their subsequent enlargement, offered a permanent and dignifying credential to medical staff and trainees, in particular, who legitimately ‘saw their faces’ in them.

Any enormous investment of effort and care is a temptation to assume ownership, to identify with the creation, especially when other professional recognition also depends on it. Unfortunately, enlargement of senior capacity often resulted in stress and division; the formalisation of appointing Clinical Directors from incumbent early colleagues, as secondary care experimented with management styles, was both clarifying and provocative, depending on the stage of unit development. Any  uncomfortable phase  of ‘two dogs and one bone’ was ultimately relieved by the rather delayed, piecemeal introduction of third and more colleagues; that was before large scale consultant grade enlargement was engineered after the millennium.

The incidental management training elements of administering a renal unit led to a ready transition for some colleagues into corporate NHS hospital management cultures. The temptation to influence practice in larger ponds  than even large renal settings could be irresistible. From the specialty start several colleagues grew their careers in the management of both hospitals and other businesses. Consultant expansion after the millennium was in general very loosely managed by Medical Directors, with further sub-specialty interests being indulged at the expense of the anticipated substitution of training posts;  in the demand for clinic cover this was making rods for their own backs. A detailed investigation of the consequences of the reorganisation of medical practice in secondary care seems long overdue, especially given the deficits in morale and job satisfaction that are commonly expressed.

An unsuspected core?

Despite all these pros and cons, there is a persisting sense that repeated dialysis treatments create an experience that goes beyond the biochemically homeostatic. It is apparent that the atmosphere of renal units tends to be more upbeat than the prognoses of the patients might otherwise induce. There could be some artificiality in that, since the work is rather dull and arguably needs the relief of even false optimism. Busy activity and meticulousness reward many of us. Yet, what should we call repeated, uniform ceremonials that are performed in expectation of benefit other than rituals? The recognition that there is a performance of rites being enacted in dialysis makes it likely that there are deeper comforts being rehearsed regularly in the social and practical relationships of a unit.

It is then impossible to ignore the analogy of the sequence of dialysis leading to transplantation as a form of rebirth, which is the basic consolation of religions and other belief systems that also enact rites. It is obviously not infinite, but the deferment of mortality and restoration of physical capacity is a good enough result for those entrapped by the progression of renal disease. Such momentous consequences explain some of the positive aura of renal transplantation and the relief in the hope offered by dialysis.

They are not unique in medical practice but concentrated and repeated in renal unit-based palliation. They are also shared repeatedly by staff and patients, which may account for the yet stronger positivity that satellite haemodialysis is sometimes able to generate. Satellites can condense their small group mutuality into colonies of hope. The interpretation of hospitals as representing modern secular cathedrals is consistent with renal units being secular temples to the enablement of survival and a communal absorption of threats to well-being.

The shared predicament of rescue and deferment of mortality was presumably part of the early experience of dialysis in groups. The family trope, espoused particularly by Stewart Cameron, must have reflected that, unifying staff and patient expectations.9 The character of unit leadership is manifestly important, as part of a high-level continuity that has proved difficult to sustain at the dialysis station-side. Continuity of patient care has been variable and more difficult in recent times, but the solace of accompaniment can be brought to bear from every professional level. One mature human response to adversity is simply a relaxed  acceptance, which can be modelled; others whistling in the gloom can at least be heard. When defeat by loss of life is inevitable, surrender can be dignified and absorbed as the best we can. The conservative management of end stage renal failure is a formal acknowledgement of that.

The late fashion for exercise in renal programmes carries the implicit benefit of enacting partial control of otherwise largely submissive clinical scenarios.

The past caution that others have displayed around renal units, relating to hepatitis in particular, may also reflect a sense of special tasks being performed; an effort to sustain a cohort of threatened citizens through the complicated rituals that modern clinical skills and techniques necessarily deploy.10

The background importance of the health care system in evoking a spiritual dimension to renal replacement may be apparent by comparing the NHS with commercialised treatment in US facilities.  The constructs of Units and Facilities are not necessarily identical, and the titles may be more subtly expressive than is normally assumed.

Conclusion

The six dozen UK renal units can generate a variety of commentaries, focussed on the inevitable range of historical material and professional experience of the past seventy-five years. The opportunity for special pleading around unit performance, of what becomes a reputational brand, is a temptation, although insightful anecdotes probably enrich the specialty culture more usefully. Examples of the specific importance of place can justify the website category, but the hazards of misattribution and inaccuracy may make a comprehensive exercise invidious. One of the inevitable consequences of the rich and complex subdivisions of the specialty is the variety of perspectives granted to participants; each of their experiences will have had a unique personal significance. Marshalling that sort of complexity, an inevitable mixture of truth and opinion, can already be seen elsewhere to provoke half-truths and incomplete accounts.  If unedited that carries reputational significance for the site. Just that conundrum is being actively rehearsed on mainstream social media; a free-for-all Pandora’s vase or (suspect) editorial responsibility with fact-checking? Open Societies have not yet worked that preference through.

The assertion that renal replacement, and therefore renal unit provision, was the bedrock of Nephrology is discussed elsewhere.9

Ultimately, renal units offer uplifting examples of communities rehearsing the hope of well-being and survival, while promoting shared spiritual comfort. Their status as ‘good objects’ is then likely to persist. The recognition in a special website cultural category appears legitimate but will be challenging.

References

  1. Peitzman SJ a. Origins and Early Reception of Clinical Dialysis.  Am J Nephrol 1997;17 (3-4): 299–303.
  2. Turney JH, Blagg CR, Pickstone JV. Early Dialysis in Britain: Leeds and Beyond. Am J Kidney Dis. 2011;57(3):509-515.
  3. Ward MK, Feest TG, Ellis HA, Parkinson IS, Kerr DN. Osteomalacic dialysis osteodystrophy: Evidence for a water-borne aetiological agent, probably aluminium. Lancet. 1978;1(8069):841-5. doi: 10.1016/s0140-6736(78)90191-5.
  1. Sharpstone P, Ogg CS, Cameron JS. Nephrotic Syndrome Due to Primary Renal Disease in Adults: I. Survey of Incidence in South-east England. Br Med J. 1969;2(5656):533-535.
  2. Stein A, Walls J. The correlation between Kt/V and protein catabolic rate – a self- fulfilling prophecy. Nephrol Dial Transplant. 1994;9(7):743-5.
  3. Rosen S. Personal recollection.
  4. Dunbar R. How Many Friends Does One Person Need?: Dunbar’s Number and Other Evolutionary Quirks. 2011. Faber & Faber, London.
  5. Friedman EA. Optimizing care in diabetes: a quixotic challenge. Diabetes Care. 2012;35(6):1204-5. doi: 10.2337/dc12-0345.
  6. Will E. Stewart Cameron: Towards an intellectual history. https://ukkidneyhistory.org/themes/remarkable-people/remarkable-professionals/stewart-cameron/stewart-cameron-towards-an-intellectual-history/
  7. Kerr DNS. The Renal Unit. Br Med J. 1975;4(5995):528.

Authorship

Thanks are due to Dr Andrew Paterson for his remarks on the text.

Last Updated on January 9, 2025 by neilturn