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In January 2018 @Silvi Shah of ASN's Media and Communications Committee interviewed new ASN President Mark Okusa. Below is a transcript of their conversation, lightly edited for clarity and length. If you have other questions for Mark Okusa, you can ask them here. 

Silvi Shah, MD, FASN
I am very excited to kick off the Leadership Spotlight Series. As a member of the Media and Communications Committee, I have the honor of interviewing Mark Okusa. How did you became interested in nephrology and who inspired you to pursue nephrology?

Mark Okusa, MD, FASN
Early in medical school, I wandered through various courses including biochemistry and microbiology. I didn't like to follow the labeled carbon or to study microbes and fungi. Physiology was much more interesting to me especially studying various control and regulatory systems. There was no memorizing, but rather there was the need to understand concepts. To me, nephrology was "physiology on steroids". In medical school I was exposed to noon lectures in nephrology conducted mostly by Dr. Dominic Sica who unraveled the complexities of acid-base and electrolyte disorders. I bought every edition of Burton Rose's "Clinical Physiology of Acid-Base and Electrolyte disorders" (at the risk of dating myself….the green covered version) to help reinforce what I learned in these lectures. During residency I realized that many of the nephrologists were also the best internists. Being a good internist was important to me as I didn't want to sit in front of an Xray box (at that time) or look at skin lesions all day long. I thought that if I became a nephrologist I would become a good internist.

Clearly good mentors are important and can be very influential in your career choice. In this light, Dom Sica, Douglas Landwehr and Don Oken, all nephrologists at the Virginia Commonwealth University (formerly Medical College of Virginia) were most influential. Dr. Landwehr assigned me a dialysis research project in medical school on the differences between acetate and bicarbonate dialysis on hemodynamic instability, which I presented at the ASAIO meeting in Chicago – another indelible experience during my formative years. This experience gave me the drive to pursue research. Don Oken was an outstanding clinician and basic scientist who taught me the importance of understanding the biologic basis of kidney disease. Of course Dom Sica, a die-hard NY Yankee fan taught me to dislike the NY Yankees, but in spite of this shortcoming, he unraveled the mysteries of the kidney. Good role models need to be accessible and visible to trainees.

Dr. Shah
How have you made nephrology less of a "black box" for trainees and potential researchers in your institution? Are there other institutions or other specialties that do this well that we can learn from?

Dr. Okusa
Your question gets at the fundamental issue of our work force in nephrology. It seems that nephrology has become an area where residents (more so than students) avoid because they have less understanding of how the kidney works. My approach to teaching and unraveling the "black box" is to do more bedside teaching to discuss pertinent real-time issues. Rounding in the ICU, we discuss the patient's acid-base electrolyte disorders and I try to emphasize the pathophysiological basis of renal disorders. We discuss pertinent issues such as hypercalemia, metabolic alkalosis in those patients who are on citrate regional anticoagulation during CVVHD. Less and less do I do sit down and have didactic sessions that may not be relevant for cases of the day. We often make trips to radiology to look at angiograms with the interventional radiologist or abdominal CT with CT radiologists as they often have so much more to offer than reading a report. I always learn something new when I make the trip to radiology. We always look at urine samples together so that trainees know what they are seeing through the microscope. I am amazed to hear "muddy brown casts" frequently by students, residents, and fellows, but when you look at the urine with them you may see an occasional granular cast or 2. But importantly, I try to challenge trainees by asking probing questions to stimulate their thinking. My hope is that they will go beyond reading web-based reviews. You can tell those interested in nephrology as they will rise to the challenge.

There are contemporary approaches by outstanding young clinician educators including the William and Sandra Bennett Clinical Scholars @Jane Schell (U. Pittsburgh), @Joshua King (UVA) and @John Roberts (Duke) who have created innovative teaching tools for trainees. Their approaches will undoubtedly help breakdown the complexities of the kidney and increase interest in nephrology.

As a physician scientist I try to excite trainees to the life of a physician scientist. Too often we dwell on funding issues and less on the virtues of the academic physician. For me, the opportunity to teach trainees in the hospital and clinic and then return to the laboratory after a grueling two weeks on service to find new discoveries made by lab members is what inspires me. I am excited for my postdocs who present at national meetings or see their publications in print. If you show them that you are passionate about their work, then hard work and long hours are less concerning. Perhaps this is the problem with the work force and interest in nephrology; nephrologists face long hours and hard work with less reward (not necessarily monetary) - leading to less passion. Can we do something about that?

Dr. Shah
Innovative education tools has been one of the excellent resources for learning in the field of nephrology. I think, going forward, it may remain challenging for our field to strike a perfect balance between passion, and career satisfaction. What new initiatives is ASN pursuing this year? What is ASN's partnership with HHS (Kidney Innovation Accelerator), and why should patients and physicians be excited about it?

Dr. Okusa
You are absolute right Silvi, it will be challenging, at this time, to balance passion and career satisfaction. There are three articles that have just been published on line in CJASN: 1) Jeffrey Berns and Mitchell Rosner, 2) Amy Williams and 3) John Roberts that address these challenges. In the overview article by Ian De Boer, he indicates that we can either accept this fate or we take a new direction that brings passion back into our profession. The articles are insightful and offer solutions.

With regards to the accelerator. There is an excellent article in the January issue of Kidney News that describes the Accelerator (a.k.a. KidneyX). KidneyX is a public-private partnership to incentivize accelerated development and commercialization of novel technologies to reduce the number of patients with ESRD and improve the experience of patients on dialysis. There are a number of areas where KidneyX could support including: diagnostics and therapeutics (e.g. real time GFR), next generation dialysis (e.g. bioartificial kidneys) tissue engineering (e.g. vascular access technologies), medications (e.g. drugs to slow progression of, reverse, or even cure kidney disease) and patient-centered tools (e.g. electronic health record tools, like nutrition apps).

What is exciting for patients and nephrologists is that this program will pull together various partners to accelerate the breakthrough in dialysis technology and treatments. Rather than work in silos they work as a team, ensuring financial resources and expertise. Through key partners including HHS, FDA, CMS and NIH the path to commercialization will be faster.

Clearly progress has been slow in the past with regard to innovation with incremental changes in dialysis technology. Our patients deserve better and I am hopeful that KidneyX will be a game changer in improving the lives of patients with kidney diseases.

Dr. Shah
You have conducted significant research on acute kidney injury (AKI) during your career, how do you plan on incorporating that interest into your presidency, and what is your pitch to MD or PhD researcher to look into AKI?

Dr. Okusa
A major interest is in AKI including basic and clinical research in AKI as well as the clinical practice of AKI. Although my dream is to be able to impact the care of patients through discovery, there are immediate concerns regarding clinical aspects of acute kidney injury that I will try to focus on during my presidency. I hope to work with knowledgeable nephrologists with similar interests to demonstrate the impact of nephrologists in the care of patients with renal disease and in particular AKI. I think it is important to demonstrate the value of nephrologists by obtaining data to show that we can make an impact on outcomes. I will provide 2 areas that I hope to engage in this year.

1. 1. CRRT is very important to our profession and we see that in Europe and in some parts of the country, non nephrologists are performing this procedure despite the lack of formal training. This year I hope to work with expert nephrologists to: 1) begin to develop a necessary tool kit through the development of a curriculum to ensure that nephrologists are the experts in this area and 2) begin to develop quality measures to provide quantitative data to colleagues and hospital administrators.
2. AKI-D - these are AKI patients that are discharged from the hospital and continue to require dialysis, which is currently being done in ESRD units. Since up to 40% may recover it is imperative that we ensure that these patients receive appropriate (not necessarily ESRD) care tailored for patients with AKI. I would like to ensure that we obtain data from collaborative research initiatives so that we can develop best practices for the care of these patients and inform CMS and advocate for necessary regulatory changes.

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