OCTOBER 27, 1995

DA: Dr. Kolff could you recount some of the key events - the things that shaped your thinking and your work on the artificial kidney, perhaps starting from World War II and working forward; some of the early events and things that defined your work and your career.

WK: When I finished medical school at the University of Leiden, I went to Groningen. Groningen is in the North of Holland and I went there because it was the only place where you could be an assistant in internal medicine and also be married. My wife and I had been engaged for five years and I thought that was long enough. So we did get married. I didnít get any salary. I was the youngest volunteer assistant and [my responsibility was for four beds.

In one of these beds was a young man who slowly and miserably died of renal failure. I thought if I could just remove as much urea and other retention products that this man produced, then he could live.

It was my good fortune that at the University of Groningen was Professor Brinkman and Brinkman participated in all the conferences of the Department of Medicine. He was, what we now call, a biochemical engineer - and a wonderful man. He knew about cellophane. Cellophane was mainly produced in sheets. It is actually regenerated cellulose. It also came in tubes. That was artificial sausage skin.

And so from Brinkman I learned about dialysis. I decided that if I could remove from this patient just as much urea as he formed everyday, that he could live. Well, the patient died before I had a useful machine.] When I took a piece of cellophane tubing - artificial sausage skin - and put it in a water bath and put 400 mgs percent of urea in the blood inside that cellophane tubing and shook it up and down, to my surprise saw that in a period of one minute, most of the urea had been removed. Actually, you could not determine the remaining urea in the urine anymore. So the first time then, I saw how quick dialysis could work and established the basic principle that you should have a small vial of blood, that most blood and dialyzing fluids should be in motion and have a large volume of dialyzing fluid. That was the beginning of making artificial kidneys. I made several types of artificial kidneys at the University of Groningen.

Then the Germans, during the war, put a National Socialist at the Head of the Department and I decided that I did not want to work under the National Socialist. So I left the evening before he came out and how all my papers were in order because if I had simply left....................................................... sabotaged then I would have been sent to a concentration camp. Since I had all my papers in order, I went to my parentís house and looked for a place where I could continue to work as an internist.

It was my good fortune that I was appointed in the City of Kampen. Kampen is where the River Yssel which is the branch from the Rhine, where the Rhine comes from Germany. It gives off the Yssel, gives off the Zuiderzee there is the old city of Kampen. When I went there, there were 23,000 inhabitants and there was a small hospital. There was one surgeon and I was the first internist specializing in internal diseases.

II then decided since I made approximately 10,000 guilders per year (divided by 2Ĺ and you have the amount of dollars) that financial considerations should not be in my way. I immediately went to the local manufacturer of enamel. That was Mr. Berk. Mr. Berk was one of the directors. I explained the principle of the rotating drum artificial kidney to him and the first rotating drum artificial kidney was made in the Kampen Enamel Factory. When it came time to charge me for it, they couldnít because a factory could only work for the German Wehrmacht - the German Army. So I never got a bill. So it had been a very profitable arrangement for myself and that was the rotating drum artificial kidney.

DA: About what year was that?

WK: The first patient was treated in 1943. It is almost forgotten but that was a patient in chronic renal failure. Remember, I wanted to remove just as much urea as this patient formed and then I thought she could live. She was treated 12 times and the last time I had to give up because there was no good vascular access anymore and she died.

When it became time for her father to pay the bill, he came up to my office. For the childís dialysis on the bill I charged him 5 guilders per dialysis. I felt he would feel much better if he could pay me something. He immediately thanked me and went down to the office and paid. That was 60 guilders (divide by 2Ĺ and you have the amount of dollars for the first patient).

Dialysis does not have to be very expensive. It is most unfortunate that it is. You could set up the rotating drum artificial kidney and all you needed was tap water, cellophane tubing which is artificial sausage skin (which costs almost nothing), some sterilizing fluid and go ahead. There is no need to be expensive.

In the beginning in Kampen in a small hospital, I had my work during the daytime but I had help from Bob von Noordwij. Dr. Noordwij was a medical student living what we call "underground" which means hidden from the Germans. He would be arrested as soon as they saw him and he set up the artificial kidney during the daytime and the two of us would dialyze during the night. Later he went to London, Ontario and introduced the artificial kidney in Canada. He became Professor of Pharmacology and the Head of the public health system and he still is a very good friend.

DA: Dr. Kolff, why did you have to dialyze at night? Was it because of the Germans?

WK: I was too damn busy. I had to make a living. It had nothing to do with the Germans. I had to work with the German doctors because they referred German soldiers to our hospital. I had to be on the good side of the German soldiers. Also, to protect myself against the very mean Burgermaster who was a Dutch National Socialist but thatís another story.

I would show the German doctors the artificial kidney and I recall one of them who said, "Oh that is the machine that I recognize from having read about it in the medical literature." Well, that was impossible because it had not been published yet.

DA: After the War then, you came to the United States. Who was instrumental in bringing you to New York in 1946?

WK: Professor Isador Snapper was Professor of Medicine at Mount Sinai Hospital. I had never met him in the Netherlands because he was already in China at the time that I graduated but of course I knew his name, being a very famous Professor of Internal Medicine - a brilliant man. I offered him an artificial kidney which I had made by that time. As a matter of fact I had made four artificial kidneys to be ready after the War. I offered him one of these artificial kidneys and he would pay for my stay in New York. I believe I paid my own travel expenses. I wanted to come to New York to teach them how to use the rotating drum artificial kidney and he paid for my stay in New York. So, when I went there the kidney was waiting. That was one of the artificial kidneys with wooden laths. We didnít have aluminum anymore. So the rotating drum was made of wooden laths.

DA: After you stayed in New York for a while, did you return to Holland?

WK: Snapper had me give a lecture and he wanted me to write it down which I never did. So he forced me to write it down and gave it to an editor but I still gave it without using the manuscript. He was sitting next to me. It was the first time Iíd used a microphone and I remember he said, "Speak into your microphone." So, I did so.

That apparently came out rather well because Snapper then organized a trip for me through the United States with my wife and we went all around and the last stop was in Boston. In Boston I was the guest of Dr. Thor at the Peter Bent Brigham and John P. Merrill was a young physician on that service. By that time I had given my artificial kidneys away. I gave the plans for the rotating drum artificial kidney to Carl Walter. Carl Walter was a surgeon at the Brigham Hospital and he built a stainless steel version of the rotating drum kidney and they called the Brigham Artificial Kidney. Working with John P. Merrill has always been wonderful.

Later on, when we had a transplantation program going on, Dr. Gene Putos and I at the Cleveland Clinic decided that we were going to do kidney transplantation. Putos was an excellent surgeon. He could repairs renal arteries. In cases of renal hypertension he would operate on the renal arteries. I was sure that as a urologist he would be able to do the vascular anastomosis.

Since Iím on that subject, the Cleveland Clinic was mortally opposed to doing kidney transplantation. I had a young resident go around to poll the various authorities and they all said "We can wait. Then, if it is later proven that it works, we can get on the bandwagon." Putos and I had a different version and we decided to do six kidney transplantations in very rapid order, one after another. We would do it so fast that we would be done before they could stop us. At that time we thought that the remaining kidney might influence the transplanted kidney. So all these patients were bilaterally nephrectomized, maintained with dialysis and then in rapid succession were given donor kidneys. That first series was from living family members. At the last meeting of the staff - on Saturday morning we had meetings (they were excellent) and all the staff of the Cleveland Clinic came to that one. I spoke to the Chairman of meeting and said "Give me that last meeting before the vacation." We had on the podium six patients all bilaterally nephrectomized, all with working kidney transplant and all in radiant health. Now this was rapidly enough after the transplantation that no rejection was present yet. Those who had been against us had no other choice than to congratulate us. Of course they tried to get back at us with a vengence but they couldnít stop us after that. That approach is not quite original because you may recall that Bailey, who introduced the .commisurotomy, organized three patients in Philadelphia at three different hospitals and when he did the third patient, somebody came in and said, "Dr. Bailey, you cannot do that." He said, "Itís too late, Iíve already done it." That was the only patient that survived from commisurotomy and that established commisurotomy as a treatment of mitral disease. So our approach wasnít original. We just followed the technique of Bailey.

Six weeks later the first patient, a young lady, began to reject. It was very significant that when we did the renal biopsies that the report on the renal biopsy which showed rejection was circulated through the staff and they all knew it before we knew it. So if weíd had only one patient they would have stopped us right there. But since this one patient who died after 8 months was offset by the four other patients who continued to do well, we were praised???

DA: What year was that?

WK: This was probably in 1955. No, I take it back. I started back to work on the artificial kidney in Cleveland in 1955, so it must have been a little later. Any time between 1955 and 1960. We immediately published so you can tell.

DA: What encouraged you then to return to the artificial kidney? Why didnít you continue to pursue transplantation?

WK: My aim is not to make apparatus. I make apparatus when they can improve human happiness. It was quite obvious that the patient with a successful transplant can have a better life than a patient with an artificial kidney. So there is no contradiction in my overall view of what doctors should do. I have a very simple philosophy ever since I started. If there is a reasonable chance that this patient is know to be improved and can have a happy existence should determine what you should do. If there is a reasonable chance you should do it, if there is no reasonable chance, you should not do it and you should certainly not prolong life if it means prolonging misery. I recall that in my experience I refused to further dialyze two patients. One was very interesting.

He was a man about 20 years old who had recently married a very beautiful woman of whom he was extremely proud. He developed renal failure, was taken to dialysis (rotating drum artificial kidney). We attempted four times a kidney transplant and he rejected all of them. At a certain moment he began to bite the nurses. He became very mean. I decided that we had tried enough and that we would not succeed. He was not brought down to the dialysis room. He never questioned it. He never asked to be taken down. He became friendly, nice to the nurses, he behaved very well and all of them came to me and said "Dr. Kolff, we should dialyze him." And I said, "No." It took much longer than we thought. It took 14 days and he died quietly and I would say happily. He didnít vomit much, he was not very miserable. He just sat. And then his beautiful wife came to see me and told me he had bought a Thunderbird automobile - a beautiful automobile - on a life insurance clause so that when he died she would have the last present. So I thought Iíd made a wise decision.

DA: Now that weíre in the 1950s can you comment briefly perhaps on the work of Homer Smith and perhaps some other important individuals that may have influenced you and the direction of your work.

WK: Snapper, Isador Snapper from Mount Sinai, organized my trip through the United States and he also introduced me to everybody he thought to be important. So I also met Homer Smith. He was extremely gracious and I only heard by the grapevine that he was not in favor of dialysis. But if he wasnít, he never mentioned to me.

Another man that I met then was Jean Oliver, I think his name was. He would dissect kidneys and spread out the whole nephrons and all the tubules on a glass plate. I loved that. He showed it to me in great detail. When I went back to the Netherlands, I was riding in my car and in front of me there was a horse-drawn buggy and I saw the horse wobble and I knew enough then to know that this horse had myohemoglobinuria. If you have a heavy-built horse, no fat and it is suddenly put to work, its muscles begin to break down myohemoglobin that shuts off the kidneys and I knew the symptoms and I saw the horse and sure enough. I sent one of these hemoglobinuric kidneys of the horse to Jean Oliver and I hope that he spread it out on one of his plates but I never heard the results.

DA: Where was he working at the time?

WK: He was in New York somewhere.

I also met Necheles. I think they call him Nicholas here. He was a Jewish doctor who fled from Hungary early enough and he landed in New York and at Mount Sinai. He was immensely pleased when I mentioned his name, not knowing that he was there, as another way to treat renal failure by peritoneal dialysis. He was the first that got it right but could not perform, anyway. He invited us to his house. He was quite prosperous. I remember he had a Chinese servant, who served an excellent dinner.

DA: Did he continue to work on peritoneal dialysis?

WK: Yes, he continued to work but not with outstanding success.

The people that had done the most outstanding work at that time on peritoneal dialysis were in Boston. Frank Zeligmann, and .................................................... There were three of them. I know that in publications they changed their names - Frank Zeligmann and so and so, so and so and Frank Zeligmann, etc., and I met them there. In a little booklet that I published, "New Ways of Treating Uremia", in the last chapter there is picture of the peritoneal dialysis tank that we developed in the Netherlands. All you need for peritoneal dialysis is a large volume of fluid that you let in and out of the peritoneal cavity. You could heat this tank on the kitchen stove. One compartment had everything in it and the other compartment had the glucose in it, with some hydrochloric acid. If you did it that way you could keep the calcium in solution and you did not caramelize the glucose. So that one was worth it to do peritoneal dialysis that way. In our hospital we decided for each patient - what do we do - peritoneal dialysis or hemodialysis?

CSM. Kopp wrote the first good book about peritoneal dialysis. It has been greatly ignored and then another book about peritoneal dialysis was written by a Dutchman called Boen in Amsterdam. There was nothing new in the book of Boen that was not in the book by Kopp.

DA: A number of people have characterized the 1960s as being a very crucial time in the development of dialysis machine. What are your recollections of the 60s, particularly in terms not just the work of Scribner but also the work toward the ESRD (endstage renal disease) program in the United States - the amendment to Social Security that eventual paid for dialysis.

WK: In 1955, I went to the Chairman of the Department of Research. That was Dr. Irving Page - a great scientist - but not particularly interested in artificial kidneys. I said, "Dr. Page, will you give me three weeks because I think I can make a disposable artificial kidney." He gave me three weeks and in that time, with the help of Wachener, who came from Austria to work with us, we made the twin coil artificial kidney. The twin coil artificial kidney made dialysis possible worldwide. The twin coil artificial kidney consists of window screening, the screening that you use to keep the flies out of your house, wound around a fruit juice can and then between the bindings there is the artificial sausage skin - the cellophane tubing. When I bought the various parts of it in a hardware store, the total cost was $16.25 and Baxter Laboratories, to which we gave the twin coil artificial kidney sold them for $62. But they did succeed in making dialysis possible worldwide and they paid for it from the beginning and they built their entire artificial organ division on that twin coil artificial kidney. That was Baxter Laboratories. The Division that did it was Travenol.

I offered it to Abbott and it after six months I said, "If you donít give me a reply now, Iíll go to somebody else." So they invited me to come over to Abbott and at that time Abbott had a Board of Directors who made all the decisions. I gave my presentations, they all applauded, they were very polite. But the guy who had invited me over to give the presentation didnít dare to tell me the result until 11 oíclock. He took me to every nightclub he could find in Chicago, trying in vain to get me drunk and then said that the Board of Directors had decided that theyíd never made an apparatus and there were not going to do it now. There reversed themselves 11 months later and invited me to come over. I saw no use doing that. So its not always been easy.

So then I called somebody at Baxter. I canít think of his name right now. He immediately accepted. Then they gave it to an engineer and in their department they were able to make it but to my dismay they came to Cleveland and they brought various new dialyzers made by Mr. Gunica??, was a nice man. I think he is still alive. He had a wooden leg which bothered him and he had to go down slowly on a slant but he was a good engineer and he of course has made numerous variations on the twin coil kidney all of which he thought would be better than what we had. So we spent a whole long day testing his artificial kidneys and proving that what we had was better. And then my technician overheard Gu.....? and the Chief standing near the sink and the Chief said, "Why donít we do it Kolffís way?" And that was the way they finally produced the twin coil artificial kidney. But he was still somewhat stubborn. At that time Baxter didnít have any injection molding equipment and the President was forced to buy injection molding equipment. So I called my friends at Abbott who had made my injection molding the attachment where you attach the cellophane tubes so that they couldnít twist and Abbott then made a few hundred of these which I gave to Baxter and those kidneys worked well but then being the nosy neighbors, they put their regular nylon connectors that you use for intravenous tubing and of course they twisted the cellophane and then the blood wouldnít go through. That was one of my early experiences but Baxter did do the marketing well.

DA: That machine was the one that eventually that was used around the country and is it the one that Scribner first used also in Seattle.

WK: Scribner used an artificial kidney made by Dr. Kiel which was a flat plate kidney and Scribner used flat sheets of cellophane that were more permeable, were thinner than the thinnest artificial sausage skin that I could buy. That was probably an explanation why Scribnerís longterm results of dialysis were better using the permeable membrane than those with the relatively thick artificial sausage skin which I used. So I wanted patients that did not do well on my coil dialysis program sent to Scribner in the hopes that heíd do better with them. But Scribnerís machine was too cumbersome to set up for worldwide use. As you know now, both the Kiel and the twin coil machines have been replaced by capillary dialyzers which have any kind of capillary membrane now that you wish. There are a number of patients that are sensitive to cellophane or regenerated cellulose and they should have another type of membrane. It is one of my great frustrations that since most dialysis centres are for profit, they object to the use of more expensive membranes which would actually be much better for the patients.

DA: I heard that from someone at NIH who told me that research into new membranes has really slowed down because the dialysis centres donít want to take the chance of buying

WK: Dialysis centres are for profit and moreover the dialysis centres connected with large hospitals and universities are a great source of income for nephrologists and they are the greatest source of income for the nephrologist in most departments so they also look very carefully at what they will use and will not use. Apart from that, if you have a routine operation and the physician is not particularly interested in dialysis and it is left to the dialysis technician, who is course sensitive to the hospitality suites that you see at all the meetings, there is no incentive for this man to bother with using a more expensive or difficult or cumbersome artificial kidney.

Another thing that has been well proven by a young lady who was a kidney patient herself in Torino, Italy. If you use the same artificial kidney several times in the same patients, the reactions during the second and third dialyses are less than during the first dialysis. Thatís also a little more cumbersome. It saves money though but not very much because the cleaning and sterilizing.

Before the Public Health Service financed practically all renal disease - by the way only patients that are covered by Social Security (but thatís the majority of them) - before that time we had virtually no money to dialyze patients. Nakamoto, my long time coworker and I reused the same kidney we started with a little extra heparin in it. So you had the twin coil artificial kidney which at that time needed two pints of blood to fill and I added a little extra heparin and stored in it the refrigerator and after three days used it again and again. Nobody did that. We reused this 40 times. We saw something weíd never seen before. Patients began to bleed from their gums. Why we donít know.

One thing that is very interesting is that the rotating drum of the artificial kidney - I now go back to Kampen in the Netherlands - was extremely effective. If you have blood urea coming in from one side at 400 mgs percent and your dialyzing fluid of 100 liter was clean, the blood urea of the blood coming out of that kidney was practically gone with the old ............... method which we use it is hard to find it. So it was an extremely effective artificial kidney. Since gravity moves the dialyzing fluid from one end of the cellophane to the other side, there was no pressure gradient. So I had to add extra glucose to the dialyzing fluid so the extra water was removed by the glucose gradient of Professor Bott in Amsterdam and immediately said that the glucose will probably go inside so it probably wonít work. I told the machine to prove that it did work. You could remove water so well that I remember a patient that I dialyzed one night in Amsterdam and her hands were lying on the sheets and you could see the edema being removed from her hands and the skin would shrivel up. There was no doubt about it. But there was one thing that saved us and we didnít know it. When you remove urea with such ferocity or velocity, you would probably get the disequilibrium syndrome but since I added the glucose that compensated for the disequilibrium syndrome. So we didnít see it. I recall blood sugars of 700 mgs percent. We gave them insulin to take care of the blood sugar.

DA: Dr. Kolff did you have the opportunity to work at all with Dr. George Schreiner from Georgetown and participate in the 1960s period where they were attempting to get funding for dialysis patients.

WK: I wasnít really involved in that. [I know Schreiner very well and have a great love and admiration for him. He is a wonderful physician and he has done an awful lot. He has also trained a lot of physicians. I recall he himself was also in Korea. As you know from M*A*S*H, the rotating drum kidney was used in Korea. There is a basis of true in M*A*SH accept that it was a rotating drum artificial kidney that was made in the United States and not in Korea but he used water from the rice fields that he sterilized in the drum and he used dialysis and such a lot of physicians rotated through that unit that it brought dialysis to the experience of a lot of young physicians. ]

An outstanding man who was there was Paul Teshan who went to Vanderbilt. He later developed a method so that you could use the cannulas in the arm several times which was different from the shunts that was introduced by Scribner. The important thing was that Scribner had a meeting of the Society of Artificial Organs and took his shunt to the meeting and demonstrated to all of us how you could make it. So I immediately talked to him and within a week after the meeting we had patients with Scribnerís shunt on dialysis and this opened the possibility for repeated dialysis without running out of vascular sites. I always simplified things, so we didnít like this Quinton Scribner arrangement. It was very complicated and on the arm. We made a simple loop which was almost nothing and we sent the patient home. The first patient had that shunt for I think eight months without any problems and died in a taxicab from either heart failure or stroke, one of the two.

DA: Was the reaction to Scribnerís shunt at the meeting generally positive or were people very skeptical?

WK: Everything that is new is always received with disbelief so this is probably no exception but I immediately adopted it so it was a very great contribution.

DA: What do you think of the contribution of the endstage renal disease program has been to renal dialysis. Obviously it paid for dialysis for most people. Do you think there have been some negative things associated with it?

WK: By the way, [this was the first instance where a disease was recognized as a financially catastrophic disease. Consequently all the costs of the disease were adopted by Social Services and the great flaw in this has been that there was absolutely no control. It was assumed that all physicians were honest and there was an enormous difference, for example, between the remuneration for a physician of a patient who is in a dialysis centre. You can look up the figures because I have published them. I think the remuneration for a physician for a patient sent to dialysis was $14. The remuneration for a physician for a patient sent to hospital for dialysis was $150 or $300. The difference was just too great. The difference in remuneration for the hospital for a patient was $300 and for the dialysis it is a fraction of that in a dialysis centre. So everywhere in the country you saw that patients were maintained on hospital dialysis who had no good reason being there except for the financial rip off of the Government and this is basically because at that time the American Medical Association and every medical organization in the United States I know of had been basically opposed to every control of what a physician does.

Now let me tell you the difference. I worked in a small hospital in Kampen in the Netherlands. Twice a week the two controlling physicians of the insurance companies that provided the money for a patient came and sat opposite me and they would say, "Kolff, what about Mr. Johnson? You have had him for a week now. Do you really need to him to stay any longer?" And I would say to the controlling physician, "Yes, give me one more day. I want to do stomach x-rays. Iíve been too busy to do them. I promise you I will do it tomorrow and then he can go home." In other words, I worked with the physicians and had to justify everyday why the patient was in the hospital and when we didnít agree and that happened very rarely, I could go to a higher office and I could appeal to a panel of professors of medicine and go over the dispute. The controller physicians didnít want that so we always came to an agreement or a satisfactory solution. If you donít have any controlling body that looks at how the government money is spent it is wasted.

At one time we made a washing machine artificial kidney. So we built a little rolling device that the patient could wind up his own artificial kidney. We could send a patient home with a Maytag washing machine! Thatís a little rolling machine so that he could roll his own kidney and enough cellophane which cost almost nothing and enough salts for a month and all of this would cost $265 and would be all the supplies he would need for three months of home dialysis. We would train a member of the family - $265 for three months of home dialysis. That included everything.

Then, at this time if there are no complications when a patient is dialyzed in a dialysis centre, the cost is $15,000 but in some cases it is $25,000 per patient per year and it is an absolutely ridiculous situation.

DA: Why do you think the price has escalated so much?

WK: Now I know this is going to be reviewed by nephrologists - because if nephrologists get high salaries, everybody gets high salaries, the companies make money, it is easy to have a whole row of patients lying there and a doctor sticks his head around the door once a day and thatís what he gets paid for. Itís a routine. If you send patients home and they have a problem at night, they call you. That is a real pain in the you know what! When they pay you they call you. And there all kinds of negative incentives for home dialysis. So instead of increasing, it is decreasing. Also to be honest about it, the dialysis population is getting older and so the wives and husbands of the patients are getting older and it is more difficult for them to treat them at home. So letís be fair about it too. There are other reasons. I do want to state that dialysis does not have to be as expensive as it is and it will remain expensive unless you have a controlled system that really looks at every patient and sees if it is necessary. In a town not far from here (Ogden to be exact), we noticed that in a short time a lot of patients on the dialysis program died - a lot of patients, whereas actually, they very rare die and only after ..................... Well, finally a government organization that was supposed to review this bore down on them. Since we were the organization that had the products to dialyze patients outside the confines of the hospital because we had the "dialysis in wonderland program". In the "dialysis in wonderland program" we sent patients out on rafts on the Colorado River and they had a wearable artificial kidney and dialyzed themselves on the shore of the Colorado River. And we saw them on houseboats on Lake Powell. And they had a wonderful time and it has been the most powerful rehabilitation program we ever had.

I recall a little girl about 12 years old, who was willing to stick out her arms so that her mother could dialyze her at home. But otherwise she was totally passive. She went to Lake Powell, was induced to swim with the shunt. It changed her whole life. She got an interest in life again and it has been wonderful.

I remember one trip on the Salmon River, where two gentlemen fell overboard but they were fished out and how they came back to the community. Now they have something to tell! They were looked at with great admiration by everybody - that notwithstanding being on dialysis they could be fished out of the river.

So we had this "dialysis in wonderland program". Therefore we were the only organization that could dialyze and so we sent to Ogden to dialyze the 40-60 patients they had on dialysis. It was a beautiful building in which they were being dialyzed.

So I went to see the head of the hospital and the Ogden dialysis program is now owned by the patients. It is a very interesting situation. So I went to see the head, Madison or whatever it was, in the hospital where this physician connected with this unit and I basically thought that he was a crook. I was immediately contradicted in polite terms and they thought that he was a very good physician. He was protected by everybody. He was not removed. He was not punished. My associate, Bob Stevens, agreed to review the charts of his patients on the condition that the names of everybody would be removed so that he would not know where they came from and what they were. Well, it was quite obvious that there were dialyzed patients who did not need it and that they did not dialyze patients enough because they could have three shifts on dialysis that were dialyzed for only two hours. However, you can do short time dialysis (Iím against it) if you have a very powerful blood flow, 500 ml/min, and if you have a very good dialyzing membrane and then may be you can get away with 3 or 4 hours on dialysis. They only dialyzed 2 or 3 hours per patient so they under-dialyzed all their patients to be able to do 3 dialysis shifts per day. So this was my personal experience. Iím sure it happens all over the United States and I havenít heard any protests against it.

Anyway, let me finish the story about the washing machine. One day, the lawyer of the Maytag washing machine came into my office and I knew I was in trouble as soon as I saw that lawyer. He pointed out that if one of my patients died on his washing machine the nuisance value of the law suit would be of the order of magnitude of $22,000. Now this is many years ago. It would be now $50,000. He said that the Maytag Company was not in this kind of business and from that moment on I had to buy washing machines on the black market because the dealers were not willing to sell them to me at their own risk. I didnít like that, so when I came to Salt Lake City, I induced Steve Jacobson, who is a very excellent biomedical engineer, who developed the artificial arm and robots and many other things, he was very young at the time. He got the nose cone of a rocket which was a wonderful tank. Instead of the Maytag washing machine, we used a nose cone in the artificial kidney. I think we sent out about 28 patients home with the nose cone artificial kidney. But it was too inexpensive. No commercial company can make a profit on something that is too inexpensive. It is a very sad thing. It became an orphan.

We had another device. Itís called the spad The spad was a device that you put under the skin and a button through the peritoneal cavity and for each peritoneal dialysis you just put the needle in this spad. But the total price for which you can sell a spad would be no more than $350? and no manufacturer can recover the cost of 3 or 4 million dollars to get approval from the FDA and make a profit.

DA: It sounds like youíre saying that itís not just the profitability of the device but its the FDA requirements.

WK: It is the FDA requirements that prevents the companies from going into the incredible risk being taken. If anything in any piece of equipment goes wrong, unless we change the legal system. I have an ironclad agreement signed by the patients that must be adhered to by the lawyers but this time it was not. The costs in the United States will continue to increase until we all go broke.

DA: A couple of last things Dr. Kolff. I wonder if you could comment at all on the role of the International Society of Nephrology and some of the professional organizations that grew up during this time - from the 1960s or so.

WK: I was invited to give a talk by the International Society of Nephrology. I knew nothing about it and the man who asked me was an extremely nice man. He said he would give me an honorarium and first class Travelling expenses. He told me he had 12,000 members. I had very little grants and whatever money I have for research I have to scratch together. I said "Well, if you 12,000 members you can charge every member one dollar to pay for my research and I will come if you pay me $12,000." Well, something like that in those days you couldnít do legally. He was a very nice man, as I said before. So in the first place, they gave me an honorarium of $10,000 which was nice and then they induced the various companies that make artificial kidneys to contribute $5,000, so I got $15,000. I gave them the talk which I was supposed to give and we made ?three rotating drum artificial kidneys. One went to Mount Sinai, one went to Montreal and one went to Poland.

I had not realized at the time that when industry was changing from wartime industry to peacetime industry, no industry had the time to fool around with something like an artificial kidney. Of course we didnít know that before then but it worked out very very well. I made a few more which were sent to other places. These were hidden during the war in various places in the City of Kalpen. So that the bombs would fall on Kalpen, they would not all be destroyed. As it happened, no bombs fell on anything. Very few fell on Kalpen. I had all these kidneys to give away.

Also, to make these artificial kidneys during the war, when officially nothing could be made except for the German Wehrmacht, it was a wonderful experience. Everybody falsified papers.

DA: Do you have comments about the role of the NIH involvement in the 1960s and 1970s?

WK: The NIH held back. It was the Hartford Foundation that promoted dialysis in the United States. They had a wonderful manager, who was one of the managers of the Hartford stores. He dealt with the Board of Directors of the Hartford Foundation. One of them was a very strong anti-vivisectionist and who was particularly opposed to the use of dogs. So to deal with them, we had a photo album that he showed and the old ladies would say "Is that a dog?" He was a wonderful man. He did a lot more for the promotion of dialysis than the NIH ever did. Then Benjamin Bartonb has been very good at that but he was frustrated. There has been no connection whatsoever between the amount of money spent by the Public Health Service in the treatment of endstage renal disease which is between 2 and 3 billion dollars per year and the amount of the money that is spent by the NIH to build dialyzing machines. If they did it could result in much less expensive dialysis. I told you earlier that industry is not particularly interested, just like the automobile industry is not interested in building small inexpensive automobiles. They want to sell you large expensive Cadillacs. So industry is basically opposed to building less expensive machines unless they could beat the rest of the industry.

DA: In closing Dr. Kolff, would you care to comment a little bit on your work today with the artificial heart.

WK: Well, the future for the artificial kidney if you look at it that way, is not very great because most of us have two kidneys. We can give one away and the results of kidney transplantation improve all the time. So you can assume that the artificial kidney will be reserved for patients that are either very old or that have rejected transplants so often that they are no longer candidates or have some other reason why they are not suitable. I think that the number of artificial kidneys will stay about the same, will probably decrease a little bit in time but in whole areas of the world, it is just beginning and China has come out very strongly. Japan already dialyzes more people than we do. Countries in the Pacific Rim such as Indonesia and India are coming up. We also know that the results of dialysis in Japan are much better than they are in the United States.

Now for the artificial heart the situation is quite different. We have only one heart and we cannot usually get it away. Iíve had a request from a man in Bangladesh who said,"the only way I can take care of my family is if I sell my heart to you and then my family can live." I have refused that offer. I also have a prison doctor here who has a whole list of prisoners convicted to death, who wanted to donate their kidneys or their hearts. I havenít wanted to do anything with that either. He never understood that but I refused it. There is some talk of genetically changing apes so that they become even more like humans than they already are. If you do that you can probably transplant effectively into a person.

Do you know how long the life is of a pig before he meets the butcher? Five months is the date that you have for your bacon at this moment. A three year old pig is a very damn old pig. So if you transplanted pig kidney, unless we also change the aging process of the pig, which is not so simple, you can expect that a pig modified transplant kidney will work for three or four years and then be very old. Nobody talks about that because they are not farmers. I have had a lot to do with pigs in my life so I know. I have also had a lot to do with human pigs but thatís another story.

The future then for the artificial heart is excellent. Even if you succeed in delaying death by coronary artery surgery and creating new pathways by little laser beams in the heart, thatís all ..........................................................(French) Go a few steps forward then jump back. The number of deaths that will occur in patients with heart disease is not going to decrease. It may come later but not now. There are no more than 2,000 donors in the United States and it will not increase because the longer we keep an accident victim alive, the greater the chances that he will get infection and other problems and his organs are no longer acceptable. So you are limited to those few brain-dead patients who have been shot. The number of donors is not going to increase.

The future for the artificial heart then is enormous but in the United States it will be very slow because the FDA wants security in an insecure world. The FDA is also used for political purposes. Compare it with the French pill which has been used for four or five years. I mean the abortion pill. The Head of the Utah State Medical Association to which I belong called the FDA and said "Donít give permission for the artificial heart because we cannot afford it." The FDA was not established to be an expense control organization but they are used for it willingly or unwillingly. Also the artificial ear? developed here in Salt Lake City, which is great, has had no complications, no deaths, has been held up for nine years. After they had an IDE and a year ago the company said, "We can no longer make them for an Investigated Device Exemption. We need approval." They didnít get it. So it took 22 months to get approval for implantation of the first Utah type artificial heart in Dr. Barney Clark. You can easily calculate that during those first 22 months, 60,000 people died in the United States from heart failure. The only way we will get progress with the artificial heart is to go to other countries.

DA: Is that happening now? Are you going to other countries?

WK: Iím getting some funding from other countries. Not in the U.S.

One final statement. I said earlier that I have only one philosophy which has always been very simple - if you can improve the quality of life and you can return a patient to happiness, a reasonable expectation is the best you can do. You can apply a heart artificial heart or whatever else you want to do. If that is not the case, you should not apply. You have made a mistake in your evaluation. That is the thing that you should try to do. There are a few exceptions. For example, General Franco was kept alive with the artificial kidney. He had several dialyses by one of my pupils. Until they sorted themselves out and there has been a good transition of the government. The guy, Andropov - not such a nice guy - was the head of the KGB in Russia. His life was prolonged for I believe 9 months with dialysis and until the time when there was an orderly transition of government. Gorbechev was the result. Very good result! Then there was a really good guy, Kreski? Kreski was a Chancellor in Austria. When he came up for re-election nobody in the campaign ever mentioned that he was on dialysis. There are few exceptions to the rule but occasionally you may want to keep a patient alive until the family come to say good-bye. Until then you must restore happiness.

DA: That concludes this interview with Dr. Kolff. It was very interesting and I would like to thank Dr. Kolff for his time. Iím David Ahlstrom of New York University.