Dropsy, Dialysis, Transplant: A Short History of Failing Kidneys (review)

At the turn of this past millennium, persistently sick kidneys in America underwent a major—and remarkably calculated—rebranding. What had been called end-stage renal disease (or ESRD for short), a condition requiring meticulous medical care and either renal dialysis or transplantation, was renamed chronic kidney disease (or CKD, an acronym that declares the new brand). Unlike ESRD, CKD encompasses not only the sickest kidneys (which have completely failed), but also all the kidneys that are mildly or moderately affected by disease, or even kidneys that are still functioning at a normal level but that have suffered some damage and are at risk of becoming severely affected. Whereas ESRD affected 0.1% of the U.S. adult population, CKD, with its five stages of kidney disease, affects 11% of U.S. adults, equaling twenty-six million persons, with millions of others at risk. New initiatives to screen for CKD by measuring blood pressure, urine albumin, and serum creatinine, and by calculating the glomerular filtration rate, which is a measure of kidney function, are afoot, along with redoubled efforts to prevent the progression of CKD from one stage to the next.

The transition from ESRD to CKD is only the most recent episode of rebranding recounted by Steven J. Peitzman in Dropsy, Dialysis, Transplant: A Short History of Failing Kidneys, which is the second entry in the Biographies of Disease series. Although the arc of Peitzman’s biographical narrative spans three centuries, from the 1700s to the early 2000s, two of the most potent images are of persons sitting in chairs, both suffering the ravages of failed kidneys. The first is from the era of Thomas Sydenham and humoral medical theory and shows a woman’s grossly swollen belly pierced by the trochars and wicks of paracentesis that drain pints of excess abdominal fluid; the second is from the era of Medicare reimbursement and angiotensin-converting enzyme (ACE) inhibitors and shows the engorged veins of a man’s arm hooked up to a hemodialysis machine while he whiles away the time watching television. The constancy is as striking as the contrasts: the disease process, understood over those three hundred years in perpetually evolving scientific and clinical terms, continues to drain suffers of energy, while the common diuretics and the last-ditch therapies drain them in ways that their kidneys no longer can.

Peitzman punctuates his history of renal disease with short, illuminating biographies of specific individuals afflicted with kidney disease and of physicians and scientists whose work influenced the care that patients received, underscoring how theories and treatments were historically situated but at the same time suggesting long-term continuities. Samuel Johnson, for instance, writes in 1784 of how “a dropsy gains ground upon me; my legs and thighs are very much swollen with water, which I should be content if I could keep it there, but I am afraid it will soon be higher” (p. 6). The realities of suffering from an ill-understood disease process marching upward to drown the lungs in retained fluid is connected, across centuries, with the motives expressed in 2006 by a woman who told her best friend, who was languishing from kidney failure, that “I’ve got two kidneys, I don’t need both so you can have one” (p. 157). When the autopsy studies of Richard Bright were surpassed by Thomas Addis’s detailed chemical analyses of urine and blood, and these in turn were then surpassed by the results of electron microscopy of kidney biopsies, the names that the medical conditions bore changed, indicative of shifts in the underlying conception of the disease state, incorporating not only clinical attributes or pathological features (and now, increasingly, molecular or genetic characteristics), but also the “end-stage” or “chronic” realities of patients who were still very much dependent—indeed, over time...