In The Body’s Keepers, Dr. Paul Kimmel presents a compelling exploration of the kidney, unraveling its intricate role as the regulator and metronome of the human body’s delicate equilibrium. With a meticulous examination of the kidney’s daily task of purifying the body from various toxins, Kimmel guides readers through the scientific, medical, and health evolution linked to our understanding of this extraordinary organ. Delving into the history of kidney disease, dialysis, and transplantation, the renowned nephrologist sheds light on the advancements in treatments and technologies that have transformed the care of patients facing kidney ailments.
Beyond the medical narrative, Kimmel exposes the harsh realities of inequities within America’s healthcare system, unveiling stories of exploitation and injustices. Through case studies, personal histories, and firsthand accounts, the book uncovers the shocking truth about the consequences of disparate access to care and the medical industry’s profit-driven practices.
In contrast to the brain, the heart, and perhaps the guts, all we usually think about the kidneys is that they make urine—a bit of an inconvenience for older men and women, caretakers of the elderly, and travelers as well as for parents of infants and young children.
But when the kidneys don’t work, whether we’re old or young, we die unless we receive heroic treatment and therapies based on new, expensive technologies. These were not available until about seventy years ago and were then crude, experimental, and relatively scarce. Kidney disease affects a huge swath of the population—variably estimated in the United States to involve from 9 to 15% of adults, or up to 37 million people. For much of the world, kidney disease is the culmination of the endemic scourges of humankind—tuberculosis, malaria, schistosomiasis, HIV, and other parasitic as well as viral infections. These are often diseases of poverty and lack of public health interventions. But ultimately societal factors play dominant roles in determining health outcomes, including the consequences of kidney ailments. Many low-income countries do not have the resources to provide expensive life-sustaining treatments to their citizens who suffer from advanced kidney disease. And now we know that the new plague, COVID-19, causes kidney disease as well.
In the U.S., kidney disease is also often the result of indigence, poor sanitary conditions, and lack of access to adequate medical care. The two most common causes of chronic kidney disease (CKD) are hypertension and diabetes. Hypertension (or high blood pressure), although quite common, is often undetected and untreated, especially in underrepresented, underserved minority populations. An epidemic of obesity has fueled a striking increase in the number of people developing diabetes in the U.S. and globally, a byproduct of the economic success of the Western world that has provided easy access to food and diminished our reliance on physical labor. Both conditions markedly increase the risk of developing kidney disease in those who are already ill, magnifying personal losses as well as burdens, not to mention increasing healthcare costs. In the U.S. end-stage renal disease (ESRD) program—which provides, at the cost of tens of billions of dollars, dialysis and kidney transplantation for those who have contributed to the Social Security system—African Americans are three times more likely to be enrolled than White patients. This inequality, however, is not the sole result of poverty or lack of access to care. Over the past decade, as a result of advances in the science of genetics, exemplified by the federally funded Human Genome Project, we have learned that people of African descent have inherited gene variants that magnify their risk of developing kidney disease by extraordinary levels. These adaptations, which may have protected people from parasitic diseases on the African continent, have become extremely maladaptive in Western societies, rendering those at risk susceptible to developing end-stage kidney disease (ESKD) as they age. Yet paradoxically, African Americans in the U.S. continue to have less access to kidney transplantation, the most desirable ESRD treatment, compared to patients of other races and ethnic groups.
The Historical Significance of the Kidneys
The kidneys have been part of our collective consciousness since at least biblical times. The kidneys are mentioned eleven times in the Five Books of Moses, as both sacrificial items and the seat of some of humankind’s most profound emotions. As biblical scholar Robert Alter opined, the kidney was the “organ of conscience.” That was long before classical, medieval, and Renaissance physicians and scientists identified the ureters as the connection between the kidneys and the bladder. These early investigators realized that the bladder was not the source of urine but merely its penultimate destination after its creation by the kidneys and subsequent transport through the ureters. The understanding of the excretory function of the kidney worked against its previous spiritual standing. The loftier aspects of emotional life were then assigned by the authors of the King James Version of the Bible to the “reins,” after the Old French name for the kidneys. That ancient notion of the deep importance of the kidneys to an individual’s personality persists in somewhat older bits of the English language. Shakespeare’s 17th-century Falstaff is dismayed by the treatment he receives from the Windsor folk, treatment that “a man of my kidney” (in effect of his temperament, disposition, or standing) should never experience. In the 19th century, James Fenimore Cooper’s and Benjamin Disraeli’s use of the phrases “pretty much of the same kidney” and “but all of the right kidney,” respectively, meaning the same sensibility or the right set of people, conveyed similar ideas. (We might now say, as the kidneys have lost their clout, that “she’s a woman after my own heart.”) Meanwhile, in Italy and England, investigators elucidated some of the less romantic inner workings of the organs.
A Brief History of Kidney Disease & The ESRD Program
Kidney disease, however, couldn’t be easily or widely diagnosed until the latter half of the 19th century. Dr. Richard Bright, in Victorian London, linked anatomical disease of the kidneys with patients’ symptoms, an important advance in medical science. Until then, how kidney disease manifested itself was unclear, really a conundrum of swelling and other complaints and maybe, if the doctor looked, or had the tools, abnormalities in the urine.
Since the diagnosis of kidney disease was difficult to make—and therefore its presence so obscure—we know little about pre–Victorian era people who had kidney disease. The legend of Mozart’s death from uremia (or poisoning resulting in kidney failure) stands out in this regard. We do know Emily Dickinson died of kidney failure (because her death certificate so states), although how the diagnosis was made remains unknown. As kidney disease became better understood as a common affliction, however, the number of people who died with or from the illness has been astonishing. They include actresses Sarah Bernhardt, Jean Harlow, and Veronica Lake, showman Buffalo Bill Cody, playwright George Bernard Shaw, composer Cole Porter, pianist Art Tatum, and General Douglas MacArthur. For those who expired before 1973, the diagnosis of uremia was typically a death sentence. The End-Stage Renal Disease (ESRD) program was enacted in the early 1970s through the joint efforts of Belding Scribner and other physicians in the new specialty of nephrology in coordination with patients who raised their voices in public, as well as through advocacy groups and specialty societies, with the help of politicians and considerable legislative legerdemain. The U.S. led the way for the entire world in providing therapy to patients with advanced chronic kidney disease. Since then, using differing implementation strategies and levels of commitment in different countries, therapies for ESRD have diffused across the globe, usefully allowing affected patients to live to a ripe old age.
More contemporary people who survived through ESRD care include Greta Garbo, Sandra Dee, Erma Bombeck, and Marion Barry, to name a few. Bobby Fischer and Bernie Madoff were among those who declined to start dialysis, resulting in their deaths. Howard Hughes, the seventy-year-old billionaire entrepreneur, aviator, and filmmaker, who endowed a medical foundation in his name that currently finances, among other endeavors, ongoing sophisticated research on the causes and treatment of kidney disease, paradoxically died in 1976 of kidney failure, with classic features of uremia, seemingly without taking advantage of contemporary strides in ESRD care. His kidney disease was attributed to the use of licit and illicit nephrotoxic drugs, including painkillers.
The death of the prolific and popular novelist James Michener in 1997, at the age of ninety, who voluntarily and of sound mind withdrew from dialysis after many years of successful treatment, brought to the attention of the public key considerations in the care of elderly ESRD patients, including the issues of participant quality of life and the high rates of discontinuation of therapy as a cause of death in the program.
Twentieth-century physiologists, such as Homer Smith, figured out the chemical measures of kidney function. Physicians found the appropriate laboratory tests and working with pathologists, using renal biopsies (where a doctor sticks a needle into the flank of a patient, engages some kidney tissue, pulls it out, and puts it on a slide for examination under the microscope) defined the various kinds of kidney diseases. Since the 1960s, the quest to establish diagnosis and define appropriate therapies has been in motion, as physicians and scientists have sought to determine the best treatment for the individual patient with a specific disease.
Many advances have subsequently been made over the last several decades. For instance, the HIV epidemic in the 1980s and 1990s shed much light on the ways in which kidneys may be injured, and these studies underpinned the understanding of genetic factors linked to kidney disease. Similarly, we learned from the coronavirus pandemic that the kidneys may become collateral damage of infection from that virus, in part because of a ubiquitous human protein that provides a portal for its introduction into the lungs while simultaneously playing a role in determining blood pressure levels and kidney functional changes. The pandemic has wreaked havoc on ESRD patients—halting kidney transplantation, delaying entry into dialysis programs, killing patients with advanced kidney disease, and magnifying the disparities in favorable outcomes between patients of different groups.
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