We’ve Lost Another Nephrology Inspiration: Farewell Andreas Pierratos

In October, 2000, having just taken the position of Executive Director of the non-profit Medical Education Institute (MEI), I was in beautiful Toronto for ASN Renal Week. The meeting program is long gone, unretrievable even by Google. But, a session caught my eye, and per my memory, was held in the biggest room and attracted the largest crowd I’ve ever seen at ASN. The speaker? Dr. Andreas Pierratos. The topic? Something I thought had long ago been relegated to the file drawers of history: nocturnal home hemodialysis. It was back!

A soft-spoken man with a goatee, Andreas communicated his enthusiasm for a kidney failure treatment option that enabled his patients to have lives, despite needing dialysis. He explained that nocturnal home hemodialysis was done for about 8 hours during sleep, and showed wonderful video clips of his patients living fully. They had good skin color and were animated and enthusiastic, talking about pets and trips and jobs and sleeping well, despite their treatment. They were able to eat and drink with few, if any, limits. They no longer needed phosphate binders with every meal and snack—those were the first medications to go—and were able to stop taking (and paying for) blood pressure pills.

I had spent the past seven years working intensely on the Life Options Rehabilitation Program, which tried to help people with kidney failure to live as well and fully as possible, using the “5 E’s” of renal rehabilitation: Encouragement, Education, Exercise, Employment, and Evaluation. Seven years of twice-yearly strategy sessions with a stellar crew of cross-cutting experts from nephrologists and researchers to nurses, social workers, exercise physiologists, and more had resulted in educational materials and strategies and stories—but nothing like what Andreas showed the audience at his talk. Sitting in the auditorium, mesmerized, it became immediately obvious that the best strategy for “renal rehabilitation” was Much. Better. Dialysis. Longer dialysis. Gentler dialysis. Treatments that mimicked the function of native kidneys more closely, so people had energy and ambitions and got their dreams back.

THAT was what exactly we had been aiming for with Life Options—done better. And, while Life Options continued in its original form, with Amgen support, until 2008, those of us at MEI could see the future Andreas envisioned and wanted to help get there, despite having not even met him yet! In 2003, we approached stakeholders from across the industry to see if we could pull together a collaboration meeting and funding support to share information and strategies to raise awareness and use of peritoneal dialysis and home hemodialysis. That didn’t work. There was too much suspicion among our target participants to make such a gathering possible. People did not want to give away any competitive advantage.

Back to the drawing board we went, for our own brainstorm session. “Why not do a website to share information?” suggested one of my staff. I called Pete DeComo, from RenalSolutions, and when he said yes immediately, leveraged his support to get others on board—and we launched Home Dialysis Central with industrywide sponsorship on July 1, 2004.

Two years later, I was fortunate enough to be included in an email string by global dialysis luminaries of the International Society for Hemodialysis (ISHD; started by Todd Ing) about a session at the upcoming Annual Dialysis Conference to consider definitions of optimal—not just adequate—dialysis. The group included Chris Blagg, Carl Kjellstrand, Bernard Charra, Andrew Davenport, Amy Friedman, Allen Nissenson, Bernard Canaud, Charles Chazot, Mike Rocco, and Andreas Peirratos. Frank Gotch thought the topic was a poor one, because: “Optimal" and "Adequate" dialysis can only be differentiated by "beliefs" rather then by clinical science.  I think this is a meaningless title for a "strategic planning session."  It will undoubtedly focus on the "beliefs" about "optimal" treatment time.

Not so, countered Mike Rocco, “One possible definition for optimal dialysis is a dialysis therapy where most patients no longer require Erythropoeitin stimulating agents, phosphate binders, or antihypertensive agents and have a hospitalization and mortality rate well below current levels. This is not a definition based on belief but on objective measures.  A debate on defining optimal dialysis is needed and should be performed.”

Andreas supported the session, noting that it would allow the ISHD to:

• Define and formalize the goals of a better dialysis method (what is worth - surrogate for mortality or a scientific society consensus for improved quality)

• Decide how these can be achieved (e.g. dialysis hours per week for phosphate control on HD or HDF).

• Suggest which regimens can achieve these goals and to what extent.

• Suggest studies to validate the claims and test the hypotheses (even correlate with mortality if it can be afforded).

• Suggest cost utility studies so the society at large (and industry) has the tools to make funding decisions on 'optimal' dialysis.

• Debate the very issue of this e-mail exchange.

Sessions like these were what made the ISHD an intellectual powerhouse, even though it has never been as large an organization as the ISPD. (NOTE: Please join! You get the excellent Hemodialysis International journal, too).

A variety of amazing email discussions like this one went by, with other renowned experts like Zbylut Twardowski, John Agar, and Bob Lockridge added to the earlier bunch. Andreas was unfailingly kind and encouraging, and took the time to review our Methods to Assess Treatment Choices for Home Dialysis (MATCH-D*), which aimed to level the playing field by helping dialysis staff systematically evaluate patient suitability for PD or home HD. The MATCH-D became our most viral tool.

Andreas and I corresponded via email about MEI patient education materials, and even though he was very busy, he was kind enough to review John Agar’s and my Help, I Need Dialysis! book, and even to consider having it translated into French for use in the Ontario Renal Network. We couldn’t make that happen due to a leadership change, but it was terrific that he wanted to. Andreas volunteered to help a patient I emailed him about who wanted to do nocturnal home HD, but whose nephrologist didn’t know how to get started, as well as several others over the years.

I didn’t know Andreas well, but credit his innovation and passion for spurring our own. I do know that Bob Lockridge and many others made the pilgrimage to Toronto to learn nocturnal home HD and start programs to bring this life-affirming modality back to their own practices—improving patients’ lives in the process, while creating tomorrow’s expert nephrologists and nurses.

I was so sad to learn that Andreas passed away in November, 2022, and just wanted to take the opportunity to share my experiences with a nephrology giant who was a thoughtful, deliberative, and kind man who inspired countless others to offer optimal care for people with end-stage kidney disease.