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Wednesday, December 13, 2017
Reflections on Pediatric Nephrology in Canada
(an excerpt from CSN a Millennial Anthology, 2000)

by Lorraine Bell

It’s hard to believe that only 36 years ago pediatric nephrology was in its infancy in Canada. So much has changed in so short a time. What was it like in those early days? It must have been exhilarating! In celebration of the millennium, senior pediatric nephrologists from across Canada agreed to share their memories of the evolution they‘ve witnessed. This section is a collection of memorabilia: letters, photos and essays. I believe it will entertain and inspire.

Canadian Paediatric Nephrology Pioneers 

Nineteen sixty-four marked the beginning of pediatric nephrology in Canada. Keith Drummond returned to the Montreal Children’s Hospital that year and established the first pediatric nephrology unit in the country. He’d spent the preceding years in Minneapolis, working with Bob Good, Al Michael and Bob Vernier. Other Montrealers in the early days included Jean-Guy Mongeau and Michele Gagnan Brunette. Dr. Mongeau came to Hôpital Ste Justine in 1966, after studying in New York. A year later, Dr. Gagnan Brunette began at Hôpital Maisonneuve Rosemont; she'd trained with John Dirks at the Royal Victoria Hospital. In Toronto, pediatric nephrology began

In 1965 with Philip Rance; a few years later, Gerry Arbus and Bill Balfe joined him. Meanwhile, in the west, David Lirenman, lured away from the world of adult medicine in 1966 became the first pediatric nephrologist in British Columbia. Norman Wolfish was the first in Ottawa in 1968 and was joined two years later by Peter McLaine.

The 1970's saw further changes. John Crocker, inspired by Keith Drummond. had gone to Minneapolis for his nephrology training, and returned to rather challenging circumstances in Halifax in 1971. A year later in Edmonton, Frances Harley launched the first pediatric nephrology program in Alberta. In the same year, Robert Walker formally established pediatric nephrology in Winnipeg. In the mid-seventies, Morrison Hurley began in Hamilton; later, in 1992, he was instrumental in establishing the youngest pediatric nephrology program in the country at the University of Western Ontario. Now there are 13 centres of pediatric nephrology across the country.

Here are the stories of some of our trailblazers…

History of Pediatric Nephrology: A Montreal Perspective
by Keith Drummond
 

Pediatric nephrology as a specialty in Canada and the US really didn't get launched until the last half of the 20th century. ln the 1950’s, there were physicians and investigators who were known to have a special interest or “knowledge” of this field, but all had other areas of interest as well. Basic studies on fluid and electrolyte metabolism were being explored - largely by pediatric academicians in Boston - but despite some seminal observations there was limited clinical application of their findings until the mid-1950‘s. Clinical decisions about electrolyte disorders and fluid replacement were governed by several quite different schools of thought. The only available diuretics were mercury-containing compounds, which, by interfering with normal renal function, could induce a mild diuresis; they were used primarily in patients with cardiac disease and congestive heart failure. I remember from my residency at the Montreal General Hospital seeing numerous advertisements in medical journals extolling one or other mercurial diuretic based largely on the reduced degree of nephrotoxicity. I recall the excited response that swept through the Montreal General Hospital when the thiazide diuretics first became available.

Hypertension was not then in the domain of “kidney specialists” at McGill. Indeed as late as 1958, as a senior resident in internal medicine at the Montreal General Hospital, 1 was instructed to “bleed” a hypertensive patient. That is, to reduce the blood volume, by withdrawal of 100 to 200 ml every second day, in an attempt to lower the elevated blood pressure.

After three years at the Montreal General Hospital, I shifted my interest to paediatrics, and in particular to pediatric nephrology. This choice was largely as a result of my exposure to Dr. Michael Kaye - at that time a somewhat taciturn person of few words, but one of the most knowledgeable and effective clinicians and researchers in renal disease at McGill. His skill and academic approach to kidney disease influenced my career choice and subsequent training in Cleveland and Minneapolis in pediatric nephrology from 1959 to 1964. I owe him a great debt for his inspiration and help.

I spent five years in all in the United States. The first was at the Babies and Children’s Hospital in Cleveland where I had the opportunity there to work with Walter Heymann (of Heymann nephritis). I also worked with Drs. Weil and Wallace whose contributions to fluid and electrolyte physiology in children were seminal. I spent the next four years as a research fellow with Robert Good and Bob Vernier at the University of Minnesota where I was the first of a subsequent Canadian contingent to study nephrology. Those Minnesota years were the most exciting and enriching years of my academic life.

I returned annually to visit Dr. Alan Ross, then chairman of paediatrics and physician-in-chief at the Montreal Children's Hospital, and each year he encouraged me to continue my studies at Minneapolis as long as possible. After five years in the United States, I was obliged by US law to choose between becoming a US citizen or returning to Canada. I chose Canada.

Before 1964, the care of patients with renal disease at the Montreal Children’s Hospital was not the responsibility of anyone trained in this field. The metabolism and endocrinology service looked after patients with nephrotic syndrome, in particular Drs. Frances McCall and Donald Hillman. This was due to their responsibility for the use of cortisone and ACTH, which were the only therapies available. Suitable diuretics did not exist and most nephrotic patients were grossly oedematous when in relapse. At that time, the only other paediatrician in Canada with a primary commitment to nephrology was Phillip Rance at the Hospital for Sick Children in Toronto.

On my return to Montreal I set up a research laboratory at the Montreal Children's Hospital and initiated the first fellowship training program in pediatric nephrology in Canada. The research laboratory was constructed in what was formerly the locker room of the female housekeeping staff. My office was small (about 5 by 8 feet) and situated in the former area of the female toilets. Once, while I was explaining the need for a renal biopsy in their child to some parents, the father- an obese man- fainted and started to seize on the floor. The door opened inward and his body was lying against it thus preventing me from opening it. A very uncomfortable 10 minutes passed before we could summon help!

Once, after a presentation at Dalhousie, a resident cornered me and took most of the evening asking questions and vigorously discussing some of the points I had made. I don’t know if this encounter in any way influenced his career choice, but John Crocker went on to become one of the most memorable pediatric nephrologists in Canada.

We initiated immunofluorescence microscopy on renal biopsy tissue in Canada, and for a number of years studied tissue not only from the McGill and the University of Montreal hospitals, but also from centres across the country. We were also interested in glomerular metabolism and a number of publications arose from this area of investigation. We were the first to publish on chronic peritoneal dialysis for children with end stage kidney disease.

From a department of one in 1964 to a group exceeding 30 in the year 2000, much urine has passed under the bridge. Twenty-four pediatric nephrologists have been trained in our program and are now active in Canada, the US, the Middle East and Israel. Virtually all adult nephrology trainees at McGill have studied pediatric nephrology with us and there have been countless pediatric residents and medical students from McGill and around the world who have done electives here. Russell Chesney-now Editor of the International Journal of Pediatric Nephrology-did his clinical nephrology training in our program.

We initiated our hemodialysis program in 1989 and our renal transplant program in 1991, mainly as a result of the dedication and efforts of Dr. Lorraine Bell. We have emphasized living related kidney donation, particularly for our infant recipients who have been as young as one year of age.

In addition to a very successful end-stage renal disease (ESRD) program, we have an active inpatient service and daily outpatient clinics. Some clinics are for general nephrology, but there are special clinics for ESRD, renal genetics and hypertension. We now have six full-time nephrologists, of who three have major commitments to research. These clinical and research programs in nephrology at the Montreal Children’s Hospital have developed exponentially over the past 36 years.

Dr. Bernard Kaplan, now head of nephrology at the Children's Hospital of Philadelphia was Director of our nephrology division from 1980 to 1986 and made major contributions to its development. Under Dr. Paul Goodyer's current directorship we all look forward to continued excellence in patient care and first-class research.

Pediatric Nephrology at the Toronto Hospital for Sick Children
by Gerald Arbus
 

The first chronic haemodialysis began at the Hospital for Sick Children in 1967. At that time, Drs. Rance, Baliya and Koch were the nephrologists, and Dr. Jeffs, the urologist. Rance reports some earlier acute haemodialysis treatments. He had trained with Jack Metcoff, an electrolyte guru in Boston, in 1950, but at that time there was no hemodialysis in that hospital. Sangway Kooh trained later in the same unit, and brought some dialysis experience back. However, he came specifically to do his Ph.D. in bone and calcium metabolism, so he took a very small part in nephrology. In 1967, there was no formal unit to perform dialysis. In 1968, Dr. van Leeuwen, a psychiatrist, joined the team and not only helped negotiate a teacher from the board of education but also encouraged the hospital to consider a single room for dialysis procedures.

Gerald Arbus and Bill Balfe both arrived in January 1970. Gerry had trained in Boston with William Schwartz and Norm Levinsky, and then in New York with Chester Edelmann. When Gerry began in Boston, Dr. Schwartz advised him that clinical nephrology could be learned from textbooks, but for fluid and electrolytes, he would need laboratory experience.

From 1970 to 1980, Dr. Arbus was in charge of both dialysis and transplants. Initially, the majority of patients were receiving 48 hours of peritoneal dialysis every two weeks, and only two or three children were on haemodialysis. In the beginning, the physicians were required to needle the fistulas; the urologists wouldn’t have it any other way. However, they were gradually persuaded to allow the nurses to do it. Until 1973, no children less than six years of age were admitted to either the chronic dialysis unit or the transplant programs In 1973 this barrier was removed for any age.

Early on, all patients were dialyzing lying on a flat stretcher bed with bed scales in place. It was remarkable that children were still able to have schooling and recreation in that position. Fortunately, an early innovation was to introduce reclining chairs, and shortly thereafter, individual televisions for each child.

With the growth of the program and the advent of CAPD in 1980, Dr. Balfe assumed leadership for peritoneal dialysis. In the mid-1980’s Dr. Geary became nephrologist-in-charge of the haemodialysis unit.

The Hospital for Sick Children also had the largest pediatric transplant program in the country. We did the first renal transplant in 1969, and as of April 2000, we had performed approximately 600 more. When Dr. Arbus became chief of the pediatric nephrology division in the mid-1980s, he recruited Diane Hébert and Allison Eddy from Minnesota. Diane assumed leadership of the renal transplant program. Allison developed a stellar research career, and is now head of nephrology in Seattle. Carl Skorecki succeeded Gerry as chief and hired Norm Rosenblum and Elizabeth Harvey. When Carl left to work in Israel, Denis Geary became division chief.
 
Pediatric Nephrology in British Columbia
(Adaptation of a letter from David Lirenman)
 

David Lirenman became the first pediatric nephrologist in BC in 1966. He had started his professional life as an adult nephrologist, training first in Winnipeg and then in Boston. However he had fond memories of Vancouver from a summer job as a porter on the Canadian Pacific Railway (CPR) and had a penchant to return. He was told there would be a job for him in paediatrics if he spent a year with the famous paediatrician, Bob Good in Minnesota. This was arranged and a year later Dave came back to BC. His internist colleagues were perplexed; they couldn't conceive of the need for such a position!

Ten years later, Jim Carter joined him. _Jim had attended medical school in South Africa where opportunities for specialty training were limited. In the early 6o’s, he moved to Vancouver to study paediatrics. Later he trained in nephrology, first with David Lirenman and then in England on a McLaughlin Fellowship. In the early seventies in Vancouver, there wasn’t enough work to support two pediatric nephrologists; Jim became medical director of the outpatient department, the Children’s Aid Society and the Adolescent Program. In the late 7o’s when Lirenman was appointed Associate Dean, Carter joined him in the nephrology division. They were involved in the first pediatric renal transplants in western Canada. Morrison Hurley became part of the team in the late 9o’s.

Today at BC Children’s Hospital pediatric nephrology is firmly established with a busy consultative service, a comprehensive ESRD program and collaborative research with other Canadian centres, particularly in the fields of HUS and CRF.

David has an interesting anecdote of a rather unusual consultation:

I was home, babysitting, when I got a call from Pat McGeer at the Vancouver Aquarium. McGeer said, “Syd Segal suggested I call you. We have two baby narwhals; one died and the other is very ill, and Syd thought there might be fluid and electrolyte problems - could you come down and have a look?” I said yes and got my wife to come home. I told her, “Please don't tell anyone where I am going."

I went to the Health Centre and got a catheter and some intravenous solutions. They took me to the narwhal, which was in a wading pool. The biologist from the aquarium said he thought it was dehydrated. I asked him how he knew and he showed me the concavity behind the blowhole, which they said, should not be concave. I asked how you get venous access. and they said there was a central vein in the fin. They showed me, from the freezer, a section of fin from the baby that had died; it was wide and the vein was tiny and deep- impossible to get into. I thought I might be able to get a catheter in peritoneally -it comes with a metal stylus - but I couldn't get the thing in; the wall was so thick it was impossible. I tried with a 16 gauge short needle and that got some clear fluid, so I knew I was intraperitoneal. I ran in some fluid for about 20 minutes when the narwhal turned up its toes and died.

The electrolytes from the fluid I got were absolutely normal; I guess we didn’t get fluid in fast enough. Finally, when they did the post mortem, they found the narwhal had pneumonia.
 
Pediatric Nephrology in Ottawa
(excerpts from a letter from Norman Wolfish)
 

Dear Lorraine,

I came to Ottawa on February 29, 1968, so in essence I will have been here only eight years this coming February 29, 2000! It seems like 32 years. At that time, there was only a handful of like individuals: Philip Rance in Toronto, David Lirenman in Vancouver, Keith Drummond and Jean-Guy Mongeau in Montreal.

Initially, I was located at the old Ottawa General Hospital in lowertown Ottawa. The Department of Paediatrics was, at that time, split between the Ottawa General and the Ottawa Civic Hospitals. In the first six months after arriving I had two patients with acute renal failure due to haemolytic uremic syndrome. For the first, l performed peritoneal dialysis, never having been exposed to the procedure in my training. However, the adult nephrologists here had plenty of experience, and they peeked over my shoulder as I inserted the peritoneal catheter, wrote orders and began the program of pediatric peritoneal dialysis in Ottawa. This would have been in the spring of1968. The patient recovered renal function and came off dialysis permanently. That summer a second case of HUS presented with anuria, coma, hypertension and uraemia. It became obvious that this child would require haemodialysis. A quick search of the country revealed that there were no facilities for pediatric haemodialysis established and therefore, no one's experience I could call upon for help. The adult nephrologists accommodated us within their unit. This was the age of cannulation, anticoagulation, and assembling large Keil board kidneys by hand. Also, the dialysate was made up in large swimming pool-sized tanks, chemicals added by hand to the water and stirred with large paddles. The sinks to clean the kidneys were as large as bathtubs and all patients received blood transfusions to prime the kidneys because the extracorporeal volumes were so huge. Starting an eight-year old frightened child on such a program was daunting to say the least, but the future was knocking at the door and had to be answered. Keith Drummond actually sent two patients to us for dialysis. One was a cystinotic on whom we attempted peritoneal dialysis, but she died shortly after arrival with uraemia. The second patient was an FSGS (focal segmental glomerulosclerosis — in retrospect, this entity had not yet been described and he was labelled minimal change with extensive sclerosis!) whom we dialyzed for many months but unfortunately died with uremic pericarditis despite the dialysis. I would presume we were the first unit in Canada to dialyze children on a regular basis thereafter (summer of 1968).

camp Papillon 1994I covered both the Ottawa General and Ottawa Civic Hospital pediatric nephrology until 1970 when Dr. Peter McLaine settled back in Ottawa. He then took care of the Civic’s needs and I was solely at the General. There after began a long series of meetings to plan the future Children’s Hospital, when both departments would come together.

When the Children’s Hospital was opened in 1974, the first comprehensive unit dedicated to children’s kidney disease was developed for the Ottawa, Eastern Ontario and Western Quebec areas, with myself as Head of the service. Because of the pervasive nature of chronic kidney disease, we developed a comprehensive team approach to the treatment of these children, the first such team approach for this hospital. We were also instrumental in developing our hospital’s institution-based school program for chronically ill children, which is still in full operation.

The first packaged and compact kidney was a godsend because of the time saved in preparation and the lesser blood volume requirements, well worth the increased price. Since then, the development of dialysis kidneys has been phenomenal and gratifying, a far cry from the old days (I hesitate to label them the “good” old days; they weren’t). The introduction of fistulas instead of shunts was problematic at first. Would young children adapt to getting stabbed at least twice for each dialysis, three times a week? Apparently most do adapt, if not somewhat reluctantly. We have had a 2-year old on haemodialysis for well over a year. Since that time we have developed a comprehensive renal replacement program, from early infancy to late adolescence, with the exception of capturing the renal transplant program from the adult nephrologists.

Peter McLaine and Elaine Orrbine have been instrumental in creating the Canadian Pediatric Kidney Disease Research Centre, which initially was the directory of children’s kidney disease in Canada.

With the addition of Dr. Guido Filler to our division, we feel we have developed a first class nephrology program for the region and for Canada. Only the personnel shortage will negatively affect our future, as it will many other programs across Canada. For the present, we should focus on urging provincial governments to sponsor resident training programs in those specialties that have and will have major manpower deficiencies, rather than lobbying cash strapped hospitals for salary increases.

Pediatric Nephrology in Halifax
(Excerpt of a letter from John Crocker)
 

Dear Lorraine,

Thank you for request for a short history of pediatric nephrology in Atlantic Canada.

Having finished three years of pediatric nephrology training in 1971 in the Minneapolis program with Drs. Vernier, Michael and team, I looked around for a place to set up an academic practice. Actually, there were many openings then, so I had no difficulty in finding a job. I felt that returning to Atlantic Canada might have the biggest impact, as I knew they had no one at all here seeing children with renal involvement. The Medical Research Council of Canada kindly made me an MRC scholar, and I moved to set up my laboratory in Halifax at their new Children’s Hospital. My department head told me that I would have tremendous amounts of time to do research, as they had audited the number of nephrology cases and there was only one or two a month.

I arrived in Halifax to rooms with bare walls, bare floors and no sinks, cupboards or any fixtures; they told me these were my labs, but they were a little slow in getting them built. I had sent drawings for the labs from Minneapolis many months before. I found out that a company in Toronto had the contract to build them. As I was agile in the library, it did not take me long before I knew who owned the company- a kind gentleman who lived in a suburb of Montreal. The contract was several months overdue and because it was a small contract, the company kept delaying it for bigger and more lucrative ones. I not only got the man’s address but his home phone number. Late that night I phoned him; in those days, for me at least, daylight and night hours seemed to mix. Surprisingly the kind gentleman who owned the building company answered his phone. I told him of my distress in not having my lab built. He was sympathetic to my problem and said that he owned several companies but this was the first time in his life he had actually talked with a live customer, although around midnight was an odd time to call. My lab was completed in 10 days. The administrator of the hospital and local subcontractor wrote me letters of complaint. They told me I was somewhat rude to wake the kind gentleman. This experience led me to a lifestyle pattern- some people need to be awakened at odd hours to alert them of reality.

My clinical practice that first year generated two thousand dollars in billings. Gradually the practice grew and more and more patients came. We do over a thousand dialysis procedures a year, see over 2000 consults a year and represent over 20 per cent of the inpatient beds, as patients from all over Atlantic Canada come for pediatric nephrology service. I was informed on arrival that first year that the hospital board had voted against renal transplantation, a decision conveyed to me by the kind, gentle head of surgery. (Then again, has there ever been a kind gentle head of surgery.) At the end of this long, slow meeting, he looked at me and said” You don’t care whether the Board or I are against renal transplants, do you? You are going to do them anyway?” I did not answer, as I was shocked into silence at such a ludicrous suggestion. Several nights later I called my adult transplant colleagues; they brought their own nurses and we did our first kidney transplant together. The operation was a success, so the chief of surgery could not very well remove the organ. I still work with the same group of surgeons and board. As far as 1 know the board still has on its books that they do not allow pediatric transplantation, 150 kidney transplants later.

I can now look back at our program, having seen hundreds of children, (now even 600 gram babies are on dialysis) and realize that we were on a learning curve. The next century is going to see a further explosion of ideas. I look forward to it, though sadly I see the same human characteristics and foibles that I saw in my first year. Medicine and science should learn from its mistakes, but only time proves the truth of an issue, not folks in high office. Pediatric nephrology has always been to me, what medicine is, to do the best for your patient and not to look for personal gain as a primary motive

Best regards,

John Crocker

Pediatric Nephrology in Manitoba
by Robert Walker and Malcolm Ogborn
 

Manitoba has a connection to one of the very earliest North American pediatric kidney transplants. Included in the early group of patients transplanted in Boston was a girl of 13 years of age who, fortunately, had an identical twin sister. One of the twins contracted some form of chronic glomerulonephritis and the other did not. Both the donor and the recipient went on to have full and normal adult lives. Both married and both had children at last report.

Dr. Ken Finkel was the first paediatrician to develop an interest in renal disease in Manitoba. He established the first renal clinic in the Children’s Hospital outpatient department but was recruited away from Manitoba in about 1967 to become one of the first faculty members of the new McMaster Medical School in Hamilton. Dr. Derek Gellman, a specialist in internal medicine, took over the pediatric renal clinic and, with Dr. Ashley Thomson of the General Hospital, performed kidney biopsies at Children’s Hospital. He also offered many consultations for any problems that might require acute peritoneal dialysis. Dr. Robert Walker became the first full time section head for pediatric nephrology. As a resident, Dr. Walker worked in the renal clinic with Drs. Finkel and Gellman. After completing the first three years of training in general paediatrics, he went on to do a two-year residency and fellowship program with Dr. Thomson and his colleagues at the Winnipeg General Hospital. During this training, Dr. Walker continued to be actively involved with the renal clinic and hospitalized renal patients at Children’s Hospital. A “Section of Pediatric Nephrology” was formally established at Children's in July 1972.

A kidney transplant program, initially in adults, began at what was then the Winnipeg General Hospital in November 1969. The first transplant was a cadaveric transplant and it occurred on Grey Cup Day. The first pediatric transplant took place at the General Hospital a few years later. It was an in-family transplant with the child's father being the donor. The recipient, a 12-year old girl, recovered successfully. Pediatric transplants continued at the General Hospital with the immediate, postoperative care performed at the Children's Hospital until the late 1980's when the entire procedure and all postoperative care shifted to Children’s.

Throughout this period, patients requiring chronic dialysis were dialyzed in the central dialysis unit of what is now the Health Sciences Centre. Those on intermittent peritoneal dialysis remained as day—patients at Children’s Hospital. A few patients also used CAPD at home. In the early years, a few children also dialyzed at the St. Boniface General Hospital, but the 1980's brought all pediatric nephrology care (except home dialysis training) to the Health Sciences Centre.

Dr. Walker left Children’s Hospital in August 1989 to take up a new position at the College of Physicians and Surgeons of Manitoba. In September of

1989, Malcolm Ogborn moved from the IWK Hospital in Halifax to take over as section head, with a mandate to develop a pediatric renal research program in association with supervision of clinical care. Dr. Ogborn was a graduate of the University of Adelaide in South Australia who completed pediatric and pediatric nephrology training in Australia, and had come to Canada on a research fellowship. He subsequently joined the faculty at Dalhousie University. Upon his arrival in Winnipeg, he immediately began research operations in polycystic kidney disease with the support of the Children's Hospital

Research Foundation and the Kidney Foundation of Canada. University of Saskatchewan graduate and a former fellow at the IWK, Dr. Paul Grimm, joined him when the latter completed pediatric transplantation and research training at UCLA's Children's Centre in 1991.

As both pediatric nephrology and urology services expanded, the centre began to receive referrals from a wider area including most of Saskatchewan, Northwest Ontario and the Keewatin district of what is now Nunavut. The pediatric team took over all aspects of care and in 1995; home dialysis training was relocated to Children’s Hospital. The program has an aggressive transplant policy that was enhanced by the recruitment of Pierre Williot, a pediatric urologist and transplant surgeon who was recruited to the US at the end of 1999. The team pioneered the use of outpatient renal biopsy and established a stable, multidisciplinary team care approach to renal disease. A University of Manitoba graduate, Patricia Birk, joined the team in 1997. Dr. Birk trained at the University of Minnesota and won young investigator awards from every major North American nephrology and transplant association during her training.

The section has a major commitment to education, winning the “Pediatric Teacher of the Year” award three times in the last decade at the university.

The section briefly operated a fellowship training program between 1994 and 1996, but voluntarily suspended the program when agreement on a second site for supplemental dialysis training could not be reached with the Royal College.

Research really blossomed in the latter part of the decade with Drs. Birk and Grimm receiving multiple grants to explore the molecular basis of chronic and acute rejection, respectively. Dr. Ogborn’s research extended from polycystic kidney disease to the biochemistry of chronic renal injury and dietary modification of such injury and the toxic consequences of uraemia. The centre has also participated in a number of national and international clinical studies in the fields of growth hormone, haemolytic uremic syndrome, and transplantation. An interlocking research network involving researchers in immunology, food and nutrition science, pharmacology, medical physics, and biochemistry allowed the effort to survive even the loss of Dr. Grimm to the US at the end of 1998. The section now holds research awards at both the personnel and operating level from MRC, Kidney Foundation, NSERC and industry.

In 1999, the research programs moved to a 2600 square foot laboratory suite in the new John Buhler Research Centre developed specifically for the section by the Children’s Hospital Foundation. The end of the millennium sees us actively recruiting to bolster our clinical programs and protect our research efforts. We intend to recommence fellowship training in the near future to give the pediatric trainees in Western Canada the opportunity to benefit from our research experience.

Reflections on Pediatric Nephrology in Edmonton
by Frances Harley
 

Pediatric nephrology was not even a gleam in anyone’s eye when I moved to Edmonton with my husband in 1970, as a direct result of avoiding a move back to the Vietnam-involved US. The slaughter of co-eds on the Kent State campus, a few miles from our next university move, was enough to make us reconsider the wisdom and merits of returning to a system we had left during the Martin Luther King riots. Fortunately for me, Dr. John Dossetor had moved to Edmonton to become the Director of Nephrology and transplantation and was looking for fellows. What started for me as a great rotation in pediatric nephrology as the metabolic resident at the Montreal Children’s Hospital, was completed at the University of Alberta as an adult nephrology fellowship. In 1970, a fellow was required to declot numerous external shunts with the dreaded “clot screw," place peritoneal dialysis catheters using a trocar (inserted 2 to 3 times a week on the same patient), and occasionally, build a dialyzer.

When it came time to get a “real job" at the beginning of 1972- the Department of Paediatrics offered me a position, doing the juvenile FTT clinic, preschool deaf clinic, CF clinic, cleft palate clinic, four half days in general paediatrics and they said “in your free time you can do pediatric nephrology!”

Aside from a major commitment to the CF clinic, I spent a large amount of time in adult dialysis, which not only enriched my clinical experience but paid for international study travel to England and California. This training enabled me to ensure northern Alberta’s children would not be deprived of the most up to date and appropriate care. There were frustrations early on, but many exciting triumphs. The first patient on CAPD in Alberta was a child living 200 miles away from Edmonton, attending school every day, until his transplant. A youngster from Edmonton was the very first cycler patient in Alberta. I was able to offer live donor transplants through Seattle and Minneapolis and sometimes even sent cadaver kidneys with the children as early as the late 1970’s. Because I participated in teaching the first two years of medical school, it was exciting for me to see the first haemolytic uraemia syndromes (HUS) in the community diagnosed by former students. In the late 70's, I was able to ensure there was an in-hospital school program; it continues today for hospitalized children (and has expanded to educate children who are frequent visitors to the hospital).

By the early 1990's, the pediatric nephrology population had grown and one of our chief residents, Dr. Verna Yiu, went to Boston to do a nephrology fellowship. She returned to Edmonton in 1994. One of the things Dr. Yiu initiated was the allocation of extra points for children needing kidney transplants within the Edmonton program, so that children now receive priority for renal transplantation. In 1998, Dr. Manjula Gowrishankar joined us from the Hospital for Sick Children in Toronto. Manjula trained under Dr. Mitch Halperin and has brought to us her expertise in fluid and electrolytes.

Things have certainly changed since the early 1970’s when pediatric nephrology was considered something to do in “your spare time!” It has now grown so much that we are going through the process of becoming the division of pediatric nephrology.
 
Pediatric Nephrology in London, Ontario
by Douglas Matsell
 

The pediatric nephrology program in London, Ontario, the youngest program in Canada, was established in 1992. The program operates at the Children’s Hospital of Western Ontario and is affiliated with the University of Western Ontario and with the Child Health Research Institute. In the summer of I992, Dr. Morrison Hurley was appointed Chairman of the Department of Paediatrics at the University of Western Ontario after having served as chairman at Loyola University in Chicago. He recruited Dr. Douglas Matsell from his research fellowship at the University of Tennessee. Together, they built a successful program providing a full range of clinical pediatric nephrology services to the south western Ontario region of 1.5 million people. The program has continued to thrive, and with the recent recruitment of Dr. Tony D’Souza, has developed a balanced and complementary basic research arm.

Pediatric Nephrologists in Canada in 2000

BC Children’s Hospital, Vancouver
J. Carter
M. Hurley
D. Lirenman
 
Winnipeg Children’s Hospital, Winnipeg
P. Birk
M. Ogborn
 
Hospital for Sick Children, Toronto
G. Arbus
W. Balfe
D. Geary
E. Harvey
D. Hébert
N. Rosenblum
 
Montreal Children’s Hospital, Montreal
L. Bell
K. Drummond
C. Girardin
P. Goodyer
I. Gupta
A. Sharma
 
Izaak Walton Killam Hospital, Halifax
P. Acott
J. Crocker
 
University of Alberta Hospital, Edmonton
M. Gowrishankar
F. Harley
V. Yiu
 
Children’s Hospital of Western Ontario, London
T. D’ Souza
D. Matsell
 
Children's Hospital of Eastern Ontario, Ottawa
G. Filler
P. McLaine
N. Wolfish
 
Hôpital Maisonneuve- Rosemont, Montréal
M. Gagnan-Brunet
 
Alberta Children’s’ Hospital, Calgary
J. Midgley
A. Wade
 
Children 's Hospital at Chedoke- McMaster, Hamilton
B. Steele
 
Hôpital Ste Justine, Montréal
M.J. Clermont
A. Merouani
P. Robitaille
 
Centre Hospitalier de l’Université Laval, Quebec
M. Brown

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