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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2005  |  Volume : 16  |  Issue : 1  |  Page : 93-95
My Journey with and in Kidney Diseases

Nephrology and Transplantation Unit, Rizk Hospital, Beirut, Lebanon

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How to cite this article:
Stephan AG. My Journey with and in Kidney Diseases. Saudi J Kidney Dis Transpl 2005;16:93-5

How to cite this URL:
Stephan AG. My Journey with and in Kidney Diseases. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2022 Jan 20];16:93-5. Available from: https://www.sjkdt.org/text.asp?2005/16/1/93/32956
I ended my medical studies at the American University of Beirut, Lebanon in 1965. By then, I had made up my mind. I wanted to go into internal medicine. I felt that any specialty, other than internal medicine, would make me lose a sizeable chunk of the medical knowledge, I had accumulated throughout my academic years. These same, deeply anchored, convictions made me choose the field of nephrology, three years later. I strongly believed then that to be a good nephrologist one had to be a good internist, and had to keep updating his know­ledge of internal medicine. Of course, renal physiology was important and, thanks to the efforts of the late Dr. Raja Khoury, I had acquired excellent notions in this vital field. My decision to train in clinical nephrology was, however, mainly the result of the admiration I had to my mentor Dr. Edmond Shwayri.

During my medical residency training at the A.U.H. (American University Hospital) in Beirut, I had already started focusing on nephrology. Chronic hemodialysis was non­existent at that time, and each session of acute dialysis was a memorable event. We were using the old "Travenol" "Cooker". The bath was hand-made. The hemofilters were huge, and required blood to prime them. Cost, and limited vascular access, led us to prolong the dialysis time to the maximum, ignoring the resulting disequilibrium syndrome.

At the end of my medical residency, I went to the USA to train in nephrology at the Uni­versity of Rochester, NY. By then, "Scribner" had devised the first A-V shunt, making chronic hemodialysis possible. I trained in nephrology at a time chronic hemodialysis was progressing rapidly, but with still unsteady steps. I wit­nessed the fierce battle between the proponents of the Scribner shunt & the Brescia - Simino fistula. We use now, the fistula so routinely, that we tend to forget the difficulties of the labor that led to its birth. Renal transplantation was also rudimentary. Our knowledge of immunology was vague and the immuno­suppressors at our disposal were limited.

When I returned to Lebanon I established my first hemodialysis unit at Rizk Hospital in Beirut. At that time, (early 70's) few states provided adequate financial coverage. In Lebanon, the Ministry of health participated generously, by covering fifty per cent of the cost (since 1972 the coverage was raised by late president S. Frangieh to 100%). I had initially a modest 2 beds unit with one head nurse, one practical nurse and one technician. This unit has gradually grown and developed into a full-fledged dialysis center with more than twenty, up-to-date dialysis-delivery units in regular use and several others kept as potential back-up.

Few years later, the civil war broke, nephro­logists became a scarce commodity. I had to cover several dialysis units spread all over the country. It is during that sad period that I had my first experience with dialysis behind sandbags. But the civil war provided us also with a golden opportunity to develop our creativity. We had to care for a large number of patients with obviously limited means. It is then that we had to call back our "kiils" and learn to reuse disposables. During this period of hardships our dialysis technician, short of "electronic thermostats", devised his own unpatented modification: using the dialysis patient as his own thermostat. It is also during these difficult times that we realized that each of our delivery systems could provide enough dialysate for two hemofilters. As we were short of all sorts of equipments, and overloaded with patients, we made use of this discovery.

In 1985 a lull in the never-ending war made us hope that finally peace had set in. Spurred by a dynamic, permanently optimistic hospital director we established, then, the first trans­plant unit at Rizk Hospital.

The war soon broke up again, often forcing us to transfer a newly transplanted patient from the isolation unit straight to the basement!

We were not wise enough to stop then. Driven by our stubborn enthusiasm we went on and on. Thus we have transplanted around four hundred patients since.

In 1990, we did our first cadaveric trans­plant. In 1997 our dialysis head nurse took our advanced course in transplant coordination and we started an organ procurement organization. She became our transplant coordinator, and the first in the country. With the help of the University of Barcelona "Les Heures" we have been running yearly TPM (Transplant Procurement Courses). The aim was to train a large number of transplant coordinators. We hope to generalize organ donation in the country.

I feel that some progress in organ procure­ment has been made but we are engaged in a long and tortuous road, full of obstacles. I know that reaching our final destination requires a lot of obstination and sacrifices. But our determination is still unshaken.

This will always be our best guarantee of success.

Soon after we started acquiring our own transplant experience, we realized that many of the internationally accepted dogmas did not apply to our local population. We had to define our own doses, and devise our own drug combinations. We had to improvise with our limited means, create our own research unit to guide us in our patient's management. It is then, that our transplant coordinator earned a new title. She became our research co­ordinator as well.

In the early 90's we started objecting to the use of Cyclosporine trough levels as a reliable guide to prescribe the drug. At that time, this was a heresy. It could not be allowed to extra­vasate. The whole team at Rizk Clinic, though outlawed, was, however, convinced of it. This gave us the courage to start implementing it.

Aware of the potential nephrotoxicity of the calcineurin inhibitors, we jumped on the occasion of using MMF when it was made available and we literally begged to obtain our lot of Rapamycin.

The international disinterest in the use of cyclosporine T0 as a guide to CyA prescription was rendered public, several years later, rein­forcing our original doubts. When authorities, in the field of transplantation, started promoting calcineurin minimization, our satisfaction was transformed into justified pride. When the medical community finally recognized that immunosuppressive treatment had to be tailored to the individual, and that racial and ethnic genetic differences governed the successful use of drugs, our satisfaction and pride turned into jubilation.

Backed by an efficient clinical team, I have been able to devote enough time for teaching and hold for more than 20 years the position of head of the nephrology division at the Lebanese University. Since 1994, the nephro­logy unit at Rizk hospital is training interns, residents, and fellows in nephrology. Our nephrology fellows have brilliantly represented our unit in Lebanon and internationally. The unit has been able to publish more than thirty papers in indexed journals and has actively participated in national, regional and inter­national medical meetings.

I have not mentioned peritoneal dialysis in my "memoires". This is surely not because I underestimate this valuable modality of the­rapy. It is only, because my involvement in it was only marginal. It was the responsibility of another member of our nephrology team. To help him carry the load of the peritoneal dialysis patients and train them properly, our transplant coordinator and research assistant and coordinator had to cumulate a new job: that of a peritoneal dialysis nurse. We made sure, of course, that she was duly trained for it.

Yes, reminiscing all these things, makes me feel old. On the other hand, I can not but appre­ciate the chance I had of witnessing the birth of modern nephrology, dialysis, and trans­plantation, not only in Lebanon and the area, but very often in the whole world as well. Moreover, I am proud to say that I have not been a passive witness. My limited means were largely compensated by the massive support of devoted helpers. These devoted people, have fortunately lost the notion of time and just remuneration. They have allowed me to be actively involved in the national progress and promotion of these very important fields.

Correspondence Address:
Antoine G Stephan
Nephrology and Transplantation Unit, Rizk Hospital, May Zahhar Str. Ashrafieh, Beirut 11-3288
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PMID: 18209465

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