Portal de Periódicos da CAPES

Belding H. Scribner, MD, 1921???2003

2003; Lippincott Williams & Wilkins; Volume: 49; Issue: 5 Linguagem: Inglês

10.1097/01.mat.0000091000.27566.09

1538-943X

Christopher R. Blagg, Eli A. Friedman,

Advances in Oncology and Radiotherapy

Belding Scribner died in Seattle on June 19 at the age of 82. Scrib, as he liked to be called, was one of the triumvirate of great men who had an immense impact on the treatment of renal failure. Pim Kolff will always be remembered as inventor of the first effective artificial kidney; John P. Merrill wrote the classic work on acute renal failure and was nephrologist to the Boston kidney transplant team headed by Nobel prize winner Joseph Murray; Scrib’s name will always be associated with the Teflon shunt that first made possible long-term dialysis of patients with chronic renal failure. Merrill died some years ago, and now only Kolff is left. However, as I will show, the shunt was only the first of the many developments we owe to Scrib and his team at the University of Washington (UW) in Seattle. Scrib was born in Chicago in 1921 and was educated at Williams College, Massachusetts; the University of California, Berkeley; and Stanford University Medical School, San Francisco, where his mentor was Thomas Addis of Addis Count fame. Working with Addis, he developed bedside tests for serum chloride, bicarbonate, and urea. He went from San Francisco to the Mayo Foundation in Rochester, Minnesota, as a fellow and there first made the simple “bedside kit” for measurement of electrolytes that was the subject of his first publications in 1950. This kit and the simple and effective approach to the management of electrolyte and fluid balance that he developed were taught to medical students at UW over some 30 years. While at the Mayo, Scrib heard John Merrill talk about the treatment of acute renal failure with the Kolff-Brigham rotating drum artificial kidney and realized the potential of hemodialysis for treatment and research. Scrib was appointed Associate in Medicine by the UW Medical School in 1951, and 2 years later persuaded the hospital to buy an artificial kidney—a Skeggs-Leonards hemodialyzer that he believed to be more useful than the rotating drum. He was appointed the first Head of the Division of Nephrology in 1958 and Professor of Medicine in 1962. An important step in the process that led to the shunt was the report from Paul Teschan on the benefits of prophylactic dialysis in the treatment of acute renal failure. This led Scrib and his group to undertake continuous dialysis for acute renal failure using a Skeggs-Leonards dialyzer with a Sears Roebuck chest freezer as a container for 300 L of dialysate. This same technique would be used for the first chronic dialyses. The impact of a patient with apparent acute renal failure whose renal function did not recover and who was found to have irreversible disease on renal biopsy and sent home to die weighed heavily on Scrib. He woke from sleep one day with the idea of the shunt and in talking with a cardiovascular surgeon he learned that Teflon tubing had just come to the hospital and was being used around pacemaker wires because it did not cause a tissue reaction. Wayne Quinton, the engineer who ran the hospital’s instrument shop, developed equipment to bend the Teflon tubing by heat, and they put together a shunt with Swagelock connectors that were used by plumbers. On March 9, 1960, David Dillard, a pediatric vascular surgeon, implanted the first Teflon shunt in the arm of Clyde Shields, a Boeing machinist dying of chronic renal failure. Scrib was already on the program of the ASAIO meeting to be held in Atlantic City the following month to talk about continuous dialysis in acute renal failure. As it was too late to submit a new paper, Scrib took Clyde and Emmy Shields and Wayne Quinton to the meeting. He presented his first report on the shunt at a separate breakfast meeting, and Quinton demonstrated fabrication of the shunt in a hotel bedroom that night. The importance of this development was obvious to George Schreiner, so he published Scrib’s paper on the shunt in the 1960 Transactions of the American Society for Artificial Internal Organs, even though it had not been formally presented at the meeting. This paper became one of the most frequently cited in all of nephrology. Clyde Shields went on to live and work for 11 years, for much of the time on home hemodialysis, and died eventually from cardiovascular disease. The shunt went through various modifications, the most important of which was using silastic tubing to replace much of the rigid Teflon. Eventually, the shunt was superseded by the arteriovenous fistula, but it is still in use in India and some other countries for temporary blood access. Scrib brought a four-layer Kiil dialyzer home from Europe in 1961. This was easier to assemble and more reliable than the Skeggs-Leonards dialyzer, and he convinced the Western Gear Corporation to make Kiil boards and sell them at cost. The Kiil dialyzer became the dialyzer of choice in Seattle for both center and home dialysis until disposable dialyzers became available in the early 1970s. Once it was obvious that maintenance dialysis worked, Scrib became concerned as to how this treatment could be made widely available. As a result, he and James Haviland established the Seattle Artificial Kidney Center in 1962—the world’s first freestanding outpatient dialysis facility. This community supported unit was described in Life magazine in November 1962, and Scrib was surprised that the article concentrated on the anonymous lay committee that selected patients rather than on the successful treatment of a previously fatal disease. A vigorous discussion ensued among nephrologists, philosophers, and others. According to Professor Al Jonsen, the Seattle committee was the first bioethics committee and led to the emergence of bioethics as a separate discipline. At a meeting of bioethicists years later, Scrib was dubbed an honorary bioethicist. In 1964, Scrib was president of the ASAIO. His presidential address dealt with patient selection and other ethical problems and is still relevant today, some 40 years later (Ethical Problems of Using Artificial Organs to Sustain Human Life, Trans Am Soc Artif Intern Organs, 1964;10:209–212). In 1963, Scribner and Les Babb, UW Professor of Nuclear Engineering, and their staffs began working on improving dialysis equipment. This cooperation led to development of the world’s first proportioning machine for dialysate preparation using acetate to avoid the precipitation that would have been caused by using bicarbonate in the concentrate. The following year, they went on to miniaturize this to make a single patient monitored proportioning machine that was designed originally for home hemodialysis. This was the prototype from which most of the dialysis machines in use today throughout the world are descended. Early on, Scrib also saw the potential of intermittent peritoneal dialysis for the treatment of chronic renal failure, and recruited Fred Boen and Henry Tenckhoff from Europe to work on this. Their efforts led to development of the first machines for overnight home peritoneal dialysis and the Tenckhoff catheter. From 1960 on, Scrib and his team were learning how to treat the complications that developed in dialysis patients, including hypertension and gouty arthropathy, and treating metastatic calcification by use of phosphate binders. His subsequent interests extended into many areas, including uremic toxicity, adequacy of dialysis, the middle molecule hypothesis, and the use of bicarbonate rather than acetate in dialysate as more efficient dialyzers came into use. He also became interested in total parenteral nutrition, using blood access as the route for delivering the nutrients—he called this the “artificial gut.” This work led to development of the Hickman indwelling catheter that is widely used today for cancer chemotherapy and other purposes. Scrib was always concerned with providing dialysis to all patients who could benefit, and he helped efforts to solve this problem locally in the State of Washington and nationally. He was a friend of Senator Henry Jackson, one of whose childhood friends was on dialysis, and this helped get eventual passage of the legislation that led to the Medicare End-Stage Renal Disease Program in 1973. Subsequently, he became very upset by what he saw as excess profits that were being made as dialysis became more and more controlled by large for-profit corporations. In his view, the results of what he regarded as a noble experiment had become a vehicle fueled by greed rather than by concern for patients. In effect, he had given away the shunt for free, so he became increasingly disturbed by the emphasis on profit in medicine generally and the avidity of researchers and universities to capture intellectual property. Throughout the 1960s and 1970s in particular, Seattle was the Mecca for physicians from everywhere interested in dialysis. Many came to train as fellows; many more visited to see how dialysis was done in Seattle and to meet Scrib. Most of the older clinical nephrologists alive today around the world were among these pilgrims. Once retired, Scrib maintained an active interest in dialysis problems, particularly adequacy of dialysis, control of hypertension with dialysis, and minimal or no use of drugs, and most recently in more frequent hemodialysis. He let his very positive views about this and its patient benefits, as well as his negative feelings about the HEMO study, be known in a letter that he sent to be read at the dialysis meeting in Seattle in March of this year. Scrib was one of the outstanding leaders in nephrology for many years. His many honors include presidencies of the American Society for Artificial Internal Organs and of the American Society of Nephrology, honorary degrees from the University of Göteborg and the Postgraduate Medical School of London, and the 2002 Albert Lasker Award for Clinical Medical Research that he shared with Pim Kolff. He moved into his houseboat about 36 years ago with his devoted and charming wife, Ethel, who accompanied him on most of his travels. As is well known, for years he used to commute across the lake to his office by canoe, but after this was shown on television he had several canoes stolen and so changed to a motor boat. Scrib always delighted in tinkering with equipment, particularly with radio-controlled airplanes and yachts, and delighted his colleagues and their children by showing these off. He also owned a house on the bank above the houseboat where for many years he kept his great wine cellar. Scrib was proud of this and also of the fact that the strict State of Washington law restricting the import of wine was changed after the publicity when he and some of his friends were found guilty of bringing in wines from out of state illegally. One of his proudest moments was when Professor and Madame Hamburger came to the houseboat for lunch and declared that they could not have had better wine in Paris. Why was Scrib so successful? Primarily because when he became interested in a problem he would become completely focused on finding a solution. He persevered, and this was important because in the early 1960s the nephrology establishment generally, both in the U.S. and Europe, regarded dialysis as beneath the dignity of real scientists, and publicly expressed doubt that it would ever be successful on any scale. However, at the same time, the ASAIO, that strange mixture of physicians and engineers, saw the importance of his work early, looked forward to the latest reports from Seattle each year, and elected him president. As all his friends well know, he was a very warm and rather modest person to whom so many of us, friends, nephrologists, and the more than a million patients worldwide whose lives have been prolonged by dialysis, owe so much. He always put patients first and from the earliest days of dialysis encouraged autonomy and rehabilitation. He liked to quote his mentor at the Mayo Clinic, Dr. Randall Sprague, who told Scrib that “A good diabetic should know more about his disease and how it affects him than his doctor.” Scrib said, “The same advice applies to dialysis patients and especially to the question of how much dialysis each patient needs to feel well.” Scrib was my friend for almost exactly 40 years, and I was struggling with how best to characterize his life when I received the following in an E-mail message from Claude Jacobs in Paris: “Scrib was one of the very few ‘Great Men’ whom I have had the opportunity to know personally and appreciate during my lifetime: As a physician, mentor, friend, and man I owe him very, very much and will remain grateful to him to my last day.” I could not improve on that. He was a great man and it was a privilege to know him. Note: A memorial tribute for Dr. Scribner was held at the University of Washington on June 30, 2003. Donations in his name can be sent to the University of Washington Scribner Dialysis Fund in care of the University of Washington Department of Medicine, 1325 Fourth Avenue, Suite 2000, Seattle, WA 98101. How I Came to Love Belding J. Scribner By chance, as a third year medical student, I discovered that a Mayo Clinic investigator, Belding H. Scribner (Scrib), had devised an inexpensive, bedside blood chemistry kit that was perfect for ward use at our city hospital, Kings County Hospital in Brooklyn. At that time, flame photometers had not been introduced, and the best estimate of electrolytes were serum chloride and bicarbonate levels that sometimes took days to be reported. I built Scrib’s kit out of pediatric tetracycline bottles and tuberculin syringes, and amazingly, during my clerkship on medicine, charted “correct” key lab values a day before the “official” lab. Scribner left my radar until my return, seven years later, to Brooklyn. One afternoon, while sewing skin grafts on the ears of California rabbits, I was summoned to the Department Office to meet with an august site visitor, Dr. James Kimmey of the US Public Health Service, Chronic Disease Division. Kimmey asked me, based mainly on my lack of association with Scribner, to accept the commission to establish the first east coast “Chronic Dialysis Unit.” The USPHS was under Congressionial pressure to determine whether “that guy from Seattle” was telling the truth. Every step along the way, Scrib was there to help selflessly. He instructed me in the use of propane torches to bend Teflon external shunts. He made certain that I grasped the concept of using proportioning pumps to mix dialysate concentrate and water (like Coke syrup and seltzer). When our unit opened, and at its twenty-fifth anniversary, Scribner was there. Perhaps my most remarkable patient, Dr. Andrew Peter Lundin, III, M.D., who went through medical school, became a nephrologist, and rose to the rank of full professor, all while on hemodialysis, was referred by Scrib. I dialyzed a real life Maharajah, on his way to the USA’s Mecca for kidney patients, Seattle. When Barry, my late wife, developed kidney failure, it was Scrib’s technique that kept her alive until she received a kidney transplant. Scrib wrote a foreword to the memorial book of Barry’s papers. While I should feel profound sadness and despair over loss of a faithful and wondrous friend and mentor, there is instead a greater sense of relief over Scrib’s finally gaining the peace he so much deserved. Remembering details of every encounter with Scrib is easy because of his electric vibrancy, forthright expressivity, and pervasive brilliance. Whether opting not to gain personal enrichment from his creativity of insisting on what was right for the patient, Scrib was unique among the heroes of my life. I last saw Scrib in March of this year when he cautioned me about accepting the HEMO study’s finding that more dialysis was not necessarily better. As for nearly everything he taught me, Scrib was, as usual, right! My whole adult life intertwined with Scrib’s service to medicine and humanity. Not with remorse, but rather respect, appreciation, and love, do I celebrate all that he has done for the world. Truly, Scrib was Medicine’s Man for All Seasons.