John Dique: dialysis pioneer and political advocate.

John Dique (1915-1995) epitomized the internationalism of medicine, the intellectual and manual dexterity of many pioneers of dialysis, and the social concern evinced by many nephrologists. Born in Burma of French, German, British and Indian ancestry; educated in India; an Anglo-Indian who described himself as British without ever having visited Britain; he moved to Australia in 1948 to escape the murderous inter-ethnic conflict that befell multicultural India as it and Pakistan became independent. Settling in Brisbane, he pioneered several novel medical techniques. After inventing some simple equipment to facilitate intravenous therapy, he established a neonatal exchange blood transfusion programme. Then, between 1954 and 1963, he personally constructed and operated two haemodialysis machines with which to treat patients suffering from acute renal failure, the first such treatment performed in Australasia. His patients survival results were, for the era, remarkable. He subsequently helped found the Royal Australasian College of Pathologists and went on to establish a successful private pathology practice. The latter years of his life, however, saw him become a social and political advocate. He fiercely opposed the emerging ideologies of multiculturalism and social liberalism that, he predicted, would seriously damage the national fabric of Western society. Public vilification ensued, his medical achievements disregarded. It does seem likely, however, that in none of the areas that he touched - whether medical, social, or political - has the last word yet been said.

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. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study of patients commencing renal replacement therapy (RRT) in Australia. We compared patients with LiN with all other RRT patients between 1 January 1991 and 31 December 2011, using Australia and New Zealand Dialysis and Transplant Registry data. MAIN OUTCOME MEASURES: Numbers and characteristics of incident RRT patients, primary kidney disease (LiN or other, based on clinical diagnosis). RESULTS: LiN contributed to 187 people in Australia commencing RRT between 1 January 1991 and 31 December 2011. The incidence rate increased from 0.14 cases/million population/year (95% CI, 0.06-0.22) in 1992-1996 to 0.78 (95% CI, 0.67-0.90) in 2007-2011. This increase is unlikely to be attributed solely to demographic changes in Australia. LiN patients were more likely than non-LiN patients to be women, to be white, to smoke, and to have a higher body mass index, but were less likely to have undergone renal biopsy. CONCLUSIONS: Rates of ESRD attributed to LiN are increasing rapidly. Currently accepted lithium dosages and duration of treatment might induce ESRD in a large cohort of patients. We encourage clinicians to exercise discretion when prescribing lithium, check renal function regularly, stop lithium if there is a deterioration in two consecutive readings, and consider substitution with other drugs.

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.

Home haemodialysis in Australia - is the wheel turning full circle?

In the mid 1970s, home haemodialysis accounted for nearly half of all patients on dialysis, both in Australia and elsewhere. The advent of both peritoneal dialysis (itself a home therapy) and satellite haemodialysis resulted in a gradual attrition in the use of home haemodialysis. Since 2000, the introduction of nocturnal home haemodialysis has begun to change this pattern in Australia, with a sharp growth in the uptake of home haemodialysis. Home haemodialysis, which enables longer hours and more frequent treatments than facility-based (hospital or satellite centre) dialysis, appears to offer improved patient outcomes in observational studies; randomised studies are necessary to confirm these findings. Home haemodialysis is also a cheaper form of therapy than facility-based dialysis. As newer, simpler and more user-friendly equipment is emerging that will make home haemodialysis even more accessible and attractive to the consumer, we believe that this trend toward a greater uptake of home haemodialysis should and will continue.

Blackwater fever: the rise and fall of an exotic disease.

After several descriptions by Hippocrates and a single possible medieval description by Gilles de Corbeil, a severe febrile illness accompanied by the passage of dark urine burst upon the medical scene in West Africa in 1819, described by an English surgeon named Tidlie. Most of his patients died within a few days. Further reports appeared from tropical regions until the turn of the century, J. Farrell Easmon having given the condition the name blackwater fever in 1884. Controversy raged about its relationship to malaria, as well as over its treatment with cinchona bark and quinine. Evidence evolved that it was a complication of falciparum malaria in which hemoglobinuria causing acute renal failure resulted from massive quinine-induced lysis of red blood cells. People with red cell abnormalities such as glucose-6-phosphate dehydrogenase deficiency proved particularly prone to developing it. Its incidence fell as more mildly acting antimalarial drugs replaced quinine. Several enigmatic issues bedeviled understanding of it, but a careful analysis of its historical development has enabled resolution of each of these.

Caring for kidneys in the antipodes: how Australia and New Zealand have addressed the challenge of end-stage renal failure.

Clinicians in Australia and New Zealand have developed active programs for the treatment of patients with chronic renal disease, including end-stage renal failure. They became interested in treatment with dialysis and transplantation shortly after the initiation of these treatments elsewhere in the world and have distinguished themselves over the decades by striving to provide comprehensive treatment for all who appeared suitable on purely medical grounds, without patients' personal, financial, or social characteristics entering into consideration, and despite geographic and national economic impediments. They have undertaken all major forms of treatment promptly after the development of these internationally and have conducted significant research locally. Home hemodialysis and peritoneal dialysis have featured more prominently in their repertoire than has been the case in many other countries, whereas in transplantation, they have traditionally shown a strong interest in the sourcing of grafts from deceased donors. Their participation in the field of end-stage renal failure has benefited from long-standing institutional support not only at the level of the governments and legal systems of their 2 countries, but also through the collegiality generated by their active participation in many local and international scientific societies.

From Fahrenheit to cytokines: fever, inflammation and the kidney.

People have used the words inflammation and fever for millennia, but the meaning of inflammation has gradually changed whereas that of fever has remained reasonably constant. Whereas inflammation originally referred to the combination of heat, redness, swelling and pain in a local area, it has gradually evolved to focus upon cellular and humoral processes that occur in tissues when external or internal agents cause damage to them. The classical manifestations are no longer obligatory. Diseases that affect internal organs such as the kidneys are nowadays commonly described as inflammatory despite entirely lacking those classical manifestations, but possessing evidence of cellular proliferation and/or involvement of factors such as cytokines. These conceptual changes have resulted from the application of progressively improved investigational techniques such as microscopy, thermometry, experimental pathology, and tissue culture. The consequence of them has been largely to extinguish the fire that previously epitomised inflammation.

History of home haemodialysis in Australia.

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.

The cellular history of the glomerulus.

Knowledge about the structure and functions of the cells of the glomeruli has accumulated slowly over the past 350 years. Marcello Malpighi originated the work, but it failed to progress far until Schleiden and Schwann developed their cellular theory in 1839. William Bowman linked the glomeruli to the tubules, described the parietal epithelial cells, the basement membranes, and (with Robert Todd) apparently first identified endothelial cells. Electron microscopy contributed especially to an understanding of epithelial and endothelial cell structure. Axel Key first described mesangial cells, but acceptance of these fell into abeyance for many years until Yamada incontrovertibly demonstrated their existence. Techniques such as tissue culture and molecular biological investigations have, more recently, provided much information about glomerular cell function. Progress has, throughout, depended upon the discovery of ever more powerful methods of microscopy, the development of ancillary experimental methods, the formulation of persuasive explanations for observations, and the suggestion of succinct terminology to describe the features observed.