Patient-based continuum of care in nephrology: why read Thomas Addis’ JN

JNEPHROL 2010 ; 23 ( 02 ) : 164 - 167
REVIEW
www.sin-italy.org/jnonline – www.jnephrol.com
Patient-based continuum of care
in nephrology: why read Thomas Addis’
“Glomerular Nephritis” in 2010?
Giorgina B. Piccoli
Unit of Nephrology, Department of Clinical and
Biological Sciences, San Luigi University Hospital,
University of Torino, Orbassano, Torino - Italy
Affectus qui passio est, desinit esse passio, simulatque eius claram
Abstract
et distinctam formamus ideam
The name of Thomas Addis (1881-1949) is linked to
several aspects of nephrological practice: from the
“Addis count” of urinary elements, to the history of
diet in chronic kidney diseases. He was accustomed to
working with limited funds, and developed his theories
with relatively simple means, combined with the careful, long-term observation of single cases. His political
ideas were progressive; his outlook on life was optimistic. This is deeply reflected in his Glomerular Nephritis: Diagnosis and Treatment, a book worth reading in
the era of chronic kidney disease (CKD), as it contains
sharp analyses of the organizational aspects, and accurate comments on the role of the physician – all subjects of interest for the present times and challenges.
One of Addis’ ingenious ideas was to follow his patients
throughout their lifelong disease, thus anticipating the
theories of continuum of care and of therapeutic alliance between patients and physicians. He used to tailor his prescriptions and frequency of controls to each
patient and phase of the disease, thus anticipating the
tailored therapies and the patient empowerment presently considered as fundamental in chronic diseases.
Furthermore, he suggested that physicians should
work outside the hospital in small coordinated teams,
in which volunteers, dietitians and laboratory technicians would play a crucial role. Patient-centered care
and the importance of nonmedical team members are
clear from the first lines of his book. As far as we know,
he was the first physician to stress the role of volunteers in CKD, anticipating by decades nonprofit organizations such as the National Kidney Foundation.
Key words: History of Nephrology, Organizational issues,
Thomas Addis
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—Spinoza, Ethics, part V, prop. 3 (1)
Almost every nephrologist has heard at least once of Thomas Addis (1881-1949). For most of us, his name brings to
mind the “Addis count” of urinary elements, still given great
importance in several medical schools, including ours, up
to the late 1970s.
Furthermore, each comprehensive review on diet in chronic
kidney diseases (CKDs) mentions his name, usually within
the first few paragraphs. Indeed, he was probably the first
clinician to understand the potential benefit of curbing protein intake through the various phases of what we now call
CKD, but which was often considered almost a synonym
of Bright’s disease (1, 2) back in the 1920s-1940s, when
Thomas Addis did most of his work.
What is probably less well known is that he described kidney tissue hypertrophy and suspected the existence of an
“overwork effect” on the remnant functional units, merely
by studying mice models and observing changes in the
morphology of casts in the urinary sediment. In fact, he
could count on minimal laboratory supplies: he essentially
relied on the intuition that CKD history could be described
by long-term observation of single cases. By those relatively simple means, he was able to anticipate by around 4
decades Brenner’s theories on remnant nephron hypertrophy: “in general, then, our subject is the theory of the application of this principle of rest in the case of any patient in
whom any disease has led to a substantial reduction in the
number of functioning nephrons…” (Introduction to (1)).
Thomas Addis’ theories and practical approaches to diet
probably saved the life of Nobel laureate Linus Pauling,
© 2010 Società Italiana di Nefrologia - ISSN 1121-8428
JNEPHROL 2010 ; 23 ( 02 ) : 164 - 167
Fig 1 - Thomas
Addis. Glomerular Nephritis,
a small, simple,
blue book (1).
Fig 2 - The first pages of Glomerular Nephritis: Diagnosis and
Treatment (1).
who suffered from glomerular nephritis, allowing him to become the first man to win 2 undivided Nobel Prizes (3). It is
even less acknowledged that his political ideas were truly
progressive: their potential danger at the time was such
that his wife destroyed most of his papers after his sudden
death in 1950, fearing the implications of being considered
a communist in the McCarthy era (4). Because of these
fears by his wife, Linus Pauling wrote Addis’ biography only
after her death: he felt that the political ideas of this great
physician were so closely linked to his clinical and research
activity that it would be impossible not to mention them.
The biography was then written in the 1980s, in a different
political climate (4).
Thomas Addis died of sepsis, as the result of a nephrectomy, in 1949, soon after finishing his famous book Glomerular Nephritis: Diagnosis and Treatment. The book, published by Macmillan, was probably the first (and possibly
the only) clinical nephrology bestseller. It still has devoted
collectors, and well-preserved hardcover copies are widely
available in Internet bookstores (prices ranging from US $7
to US $20, shipping excluded) (Figs. 1 and 2).
It may be worth reading this book now, in the era of CKD,
when we are being challenged by the growing needs of an
aging population in which the prevalence of CKD is probably as high as 8%-12% (5).
One of Addis’ ingenious ideas was to follow his patients
throughout their lifelong disease. There is obvious evidence
that he never charged his patients more than they could afford (which meant he cared for several indigent people with
glomerular nephritis for free) (3, 4, 6).
He used to tailor his prescriptions and frequency of clinical
controls to his patients and to each phase of the disease:
[B]ut whenever we try to apply the theory in practice, we
find we cannot use it effectively for any individual patient
until we know him and his situation and have learned
from direct clinical observation of his blood and urine
as much as we can about the nature and the extent of
his renal lesion.… Without this knowledge, the application of the principle is only formal and … in detail, very
ill-advised. (1)
Of note, Addis mentions the patient first, and then the disease; for a writer who cites Spinoza at the beginning of his
book, this is not fortuitous, but a deliberate choice.
Following this individualized prescription policy, he
stressed the importance of acquiring profound knowledge
of the clinical and personal history of patients, and suggested that, in the care of this chronic disease, physicians
should work outside the hospital in small coordinated
teams, in which volunteers, dietitians and laboratory technicians would play a crucial role. Cost constraints due to
his choice of not charging the sick and the poor for his
services led him to put together a heterogeneous group
of people: “since no nurses are assigned to the clinic we
asked for help from patients and friends. They were neither
biochemists nor dieticians but ordinary people who liked
to work in a group of ordinary people to help other ordinary
people” (Introduction to (1)).
Patient-centered care and the importance of nonmedical
members of the team are clear from the first line of the book,
which is “dedicated to the patients, laboratory workers, di165
Piccoli: Thomas Addis in 2010
eticians, medical students, and doctors who have worked in
the Nephritis Clinic of the Out-patient Department of Stanford Medical School in San Francisco …” (Dedication in (1)).
As far as we know, he was the first physician to believe
in the role of volunteers in CKD, anticipating by decades
the growth of nonprofit organizations such as the National
Kidney Foundation (7).
Last but not least, decades before the formal description
of the concept of therapeutic alliance, he described, in his
touching – yet devoid of any unnecessary emphasis – last
chapter, “Treatment,” the story of a boy who fell ill with
Bright’s disease at age 8 and died in a uremic coma at
age 28; he clearly established the principles of a holistic,
highly individualized patient-physician alliance, which is
increasingly considered the standard for relationships in
chronic diseases (1, 8-11).
In order to make the matter as objective and concrete as
possible, let us consider a particular patient. An 8-year
old boy has been treated with penicillin for a beta-haemolitic tonsillitis.… [T]wo weeks later his mother rings
up and says that the urine that he voided … looked like
coffee. She is sure that his face is swollen.…
Returning to the boy … He came home from school in
the middle of the day, feeling tired and weak, and did not
want to eat his lunch.… The rates of excretion of protein
[were] four to five times greater than is usual, and we can
see many hyaline and few granular casts with an occasional blood cast.… The boy is not alarmed, because he
has been forewarned.… (1)
Interestingly, this last chapter of Glomerular Nephritis, describing the disease treatment through the clinical and personal history of this young patient, was considered a fundamental piece of art and science by Bending Scribner, Addis’
former student and the inventor of chronic hemodialysis (4).
The detailed technical explanation and the attention to the
daily details of this boy’s life are both part of the same description. No general theory of the patient-physician relationship could better clarify the importance of an individual
approach to each patient, and the responsibility of the physician in sharing knowledge as the disease progresses:
[T]he first question that arises is whether we should show
the patient the centrifuge tube that would tell him at a
glance that there has been an astonishing increase in the
proteinuria. In this particular instance we would not only
not let him see the tube … Nor would we tell his mother
because to tell her would only be an indirect way of telling
him. We would tell no one. The reason is that telling gains
nothing but may lose some of that freedom from anxiety
that is an element in the patient’s well being and a factor
in determining the rate of progression of the disease.…
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What is being concealed is our fear that the change in
the urine may indicate the beginning of the degenerative
stage, but it is a fear that is concealed, not a truth.… Honesty is not easy.… [I]t requires discipline and effort.… But
while we must share our knowledge with them, we must
not ask them to participate to our fears. These are our
burdens and we must carry them alone. (1)
Besides the beauty of his writing and the richness of his
experience, there is probably a deeper reason for reading
Glomerular Nephritis: Diagnosis and Treatment again. All
too often, we get the impression of having to face too hard
a challenge, by treating an increasing number of patients
with growing needs and limited budgets (11-13). This is not
new, and the importance of effective organization and of
rapid and simple approaches is clearly described:
Even so, there will still be doubt because someone has to
do the work. If the doctor cannot do it, who will? The problem has not been solved; it has only been transformed into
a problem of organization that may be equally insoluble.
We were forced to contrive a series of extremely rapid
methods, so simple and mechanical in their operation
that the possibility of large error is excluded, and so direct that the results are presented as pictures whose significance can be read at a glance.
We have said that the growth of efficiency in medical service depends on the development of well-co-ordinated
teams or groups. The truth of this statement has grown
sharper and clearer in the course of writing this book,
which itself is nothing else than an account of the work
of one such group, and an attempt to derive some immediately useful conclusions ... to consider the meaning
of what we have done together. (1)
Therefore, after reading the well-balanced and optimistic
view of this clinical pioneer, underlining so clearly that medicine is a constant and dynamic discipline, we may wonder,
if Thomas Addis held this view 60 years ago, why should
we not do so now?
It would be thus that we should re-establish for ourselves the proper atmosphere of the group, which
lives always at war with itself, no claim being ever advanced that does not meet its counterclaim, no thesis
presented that does not promptly elicit its antithesis.
It will always be so, because the group as a whole is
not interested in anything that belongs to the past or
the present, except to break it up and build, from any
fragments of truth and usefulness that may remain, a
new bridge into the future. The group still carries on,
forever immune to the attempt of any individual within
it to crystallize its meaning or bound its activities within
the confines of a dogma (Introduction to (1)).
JNEPHROL 2010 ; 23 ( 02 ) : 164 - 167
Acknowledgements
To my father, who followed Thomas Addis’ example throughout his life. To my friend Pietra Selva Nicolicchia, theater director, who made me read his pages as a piece of art. To Dr. Peter
Christie, for his careful language revision.
Financial support: No financial support.
Adress for correspondence:
Giorgina Barbara Piccoli, MD
Unit of Nephrology
Department of Clinical and Biological Sciences
Azienda Sanitaria Ospedaliera Universitaria San Luigi
Regione Gonzole 10
University of Torino
10043 Orbassano, Torino, Italy
gbpiccoli@yahoo.it
Conflict of interest statement: None declared.
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Received: June 29, 2009
Accepted: July 24, 2009
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