Teachers' notes - Professor Priscilla Kincaid-Smith, nephrologist

And your careers were going to converge on the field of kidney medicine.

Yes, they did. We both, interestingly, trained in cardiology – I trained in pathology and cardiology. There was no nephrology as such at the time, but I had been lucky enough to work with Malcolm Milne, as I said.

Ken was coming back to Australia to an appointment, but you had to begin your career over again, essentially, in Australia. You came from being senior registrar. What happened then?

I'd been senior registrar and I'd been offered a consultant position at Hammersmith, but when I came to Melbourne nobody wanted me. Married women were unemployable, virtually. In Australia, when women married they lost their jobs. You couldn't be a married woman and employed in a university or hospital position. So to my absolute amazement and dismay, I was jobless. I did do a bit of research, but I had no status and I had no base or patients or real responsibility for a number of years. I was really frustrated in those first few years, because I had a lot of things I was interested in and wanted to do but I had no way of doing them. It was very, very disappointing.

The question of analgesic nephropathy

Ken got a position at the Royal Melbourne at that time. It took a long time, until 1965, before I got into the Royal Melbourne Hospital. McMichael teed up a position for me at the Baker Institute with Tom Lowe, who was the then director of the Institute, and I worked there for a couple of years. The position was very ill-defined. I was a part-time research assistant – I was having children all this time, so I wasn't full-time – and I had no status. But I was able to do research, and the most interesting thing I got into, almost immediately, was the question of analgesic nephropathy.

You were to make yourself quite well known in Australia, although not always popular, by highlighting an enormous misuse of analgesics that you hadn't seen occurring anywhere else. Tell us about that.

The beginning of the story for me was going to the autopsy room at the Alfred Hospital. My practice had been to go every day to the autopsy room to see what the pathology was. On my very first day going in there, I went to have a look at the kidneys, which of course interested me particularly. There on the table were three sets of kidneys with a condition that I'd never seen in six years in London, even although I'd gone to the autopsy room every day. When I asked the pathologist about it, he said, 'Oh, it's terribly common. It's a papillary necrosis. You get it with infections.' I said, 'Well, it's funny, you don't get it with infection in London.' And that was really the beginning of it. I was convinced this was a completely different condition, one that I had never seen in London.

Ken was the first person to recognise the association with analgesics. He, as a very careful historian, had found on questioning some of his patients who were developing kidney failure, particularly after operations – the same group of people had tended to have gastric ulcers – that they were taking vast quantities of analgesics, of Bex and Vincents powders, essentially aspirin-phenacetin-caffeine. Then, because some of these patients passed little bits of black material in the urine, I sectioned those and found they were papillae. I realised these were the same things I'd seen on the autopsy table. So that was how the connection first came up, and it followed on from there.

These patients were taking incredible amounts of analgesics. For example, we had a doctor patient who was taking 100 doses a day. That would kill a person who suddenly took it, but if people get used to it gradually they can get up to that sort of amount. Many people took 30 or 40 doses. What they described was that as soon as they woke up in the morning, with their Bex powders by the bedside, they'd feel they had to have one to 'start the day'. So they'd slug back a couple of Bex powders…

They'd have a dependence on it.

Yes. They had powders, largely, believing they were much more effective than the tablets. They'd toss a couple back and swallow that down with some water, and then they'd feel they could start. It was like people who are addicted to cigarettes and can't start the day without one. Then they would just go on – every couple of hours they would feel that they had to have some more. Often they got a headache, probably a caffeine withdrawal headache, and so they'd reach for the powders again. And so it went on. Many of them took very, very large quantities. In all the factories the powders were provided free of charge.

Was this a peculiarly Australian thing?

At first it seemed to be, but it was similar to the addiction pattern in Sweden at that time and it probably still exists to a certain extent in countries like Switzerland and Belgium, where there hasn't been much control. It was very much a community habit. If you went into the supermarket, every second trolley that you saw people wheeling out would have two great big gross-boxes of Bex or Vincents on top as their week's supply. I couldn't believe it.

Your deep involvement with that massive social problem went beyond clinical medicine. How did you approach it?

I talked about it a lot at lectures and so on, and the medical community were quickly informed about it. We got together as groups of nephrologists and by the mid-1960s the Nephrology Society was founded. We started going to government then and saying, 'Look, you've got to control this.' Then the Kidney Foundation was formed and managed to persuade the NH&MRC, who eventually – in about 1970 – were able to persuade government to put on some controls. And the disease has disappeared. You never see a case anymore.

Renal transplantation

Eventually you did begin to get further, reasonable work in Australian medicine.

In about 1962 I got a Wellcome Fellowship, my first substantial grant, to work as a senior research fellow in the Department of Medicine at the University of Melbourne. After that I got an NH&MRC fellowship for a year, and that led on to the years when, finally, married women could be employed.

You were a catalyst in the development of kidney transplantation, as early as 1964. Was that program the first in Australia?

It was the first in Australia to use cadaver transplantation, although Adelaide had a living-donor program going in the mid-1960s. I was very much involved in the setting up of the renal transplant program at the Royal Melbourne Hospital. I was a research fellow, with no real status, but nonetheless I was a key person in the process and looked after the patients. The operations were done in those days mainly by vascular surgeons, and the Professors of Medicine and Surgery, Lovell and Ewing, were both very supportive of transplantation.

I was desperately keen to start it. Dialysis was just starting but we had no facilities, we had no machines – at most we'd only have a machine for one person – and so transplantation was always what I thought we should do. We never seriously tried to set up a dialysis program, except to dialyse people for a very short period of time so they'd be fit for transplantation. Then, if you do transplantation successfully, you treat those patients and you've got room for the next ones and so on. Even by 1967 we had only a couple of renal dialysis machines, but we had set up a very successful transplant program.

Up to that time in the early '60s, kidney transplantation was not going well, despite the efforts of people like Roy Calne, in London.

Transplantation had a very bad name round the world. Several units were doing a little of it. At Hammersmith, my old school, results in transplantation were uniformly bad, but some very good work had been done in Boston in a series of twin cases, and David Hume had done some excellent work. Mary's Hospital had a good program just starting, and Tom Starzl was starting in Denver. I went on a trip in 1964 to look at the transplant programs round the world, and when I came back I decided that we could do it, and how we should do it.

Were you sponsored for that decisive trip?

Yes. I didn't have any money. Somebody invited me to speak and I was convinced. Our program got off the ground very well indeed, and in 1967 we published in the Lancet that we had had 80 per cent success – after two years. People could hardly believe it, because around the world the possibilities for cadaver transplantation had seemed quite dismal. But it did work, and it still works. The results we got then were almost as good as the results that we're getting now.