ISN VIDEO LEGACY PROJECT

DR. S. MASSRY
INTERVIEWED BY DR. RICHARD GLASSOCK


RG:

This is Dr Richard Glassock, Emeritus Professor of Medicine at the Geffen School of Medicine at UCLA, and I’m here in Los Angeles and am going to interview Dr Shaul G Massry, the Bernard J Hanley Emeritus Professor of Medicine, Physiology and Biophysics at the Keck School of Medicine at USC and the Emeritus Director of the Division of Nephrology at that institution. Dr Massry has agreed to share with us some of his experiences and thoughts in his long and distinguished career in nephrology. Maybe I can start with a question to Dr Massry about some of his experiences in his early career in Israel after he emigrated from Iraq.

SM:

Well to begin with I started my medical school in Iraq, in Baghdad, in the Royal College of Medicine, in 1947, but after the creation of the state of Israel in 1948, life become more difficult, in Baghdad, for the Iraqi Jews. We all immigrated, my family and myself in 1951, to Israel and soon I enrolled in the medical school, the Hadassa Medical School of the Hebrew University in Jerusalem, to continue my studies. When I arrived at Israel, I was at fourth year medical school and I continued my studies in Jerusalem and graduated in 1951. I then had my internship in Belinson Medical Centre, which is now part of the University of Tel Aviv. After finishing my internship in Belinson, I was obliged to go to the army, and in Israel the rule is that you go to the army for three years without pay. I could not afford that so the army agreed if I signed with them for six years, they would pay me. So I did that and they send me to work on the Dead Sea area, what’s called in the bible Sodom. This is the lowest part under the sea level in the world and probably one of the hottest areas as well. The temperature in the summer used to get to 47 to 50 degrees centigrade. Just to give you an example, if I napped for two hours after lunch, I lost three kilograms of body weight, all in sweat.

When I was there I read an announcement in the New England Journal of Medicine that the Ford Foundation would like to study the effect of heat on the human physiology. So I thought to myself, “What an interesting idea. I can create a laboratory and study these things here on the workers of the Dead Sea factory”, and I teamed up with a Professor Toor at the Belinson Medical Centre. We applied and we got an adequate amount of money to start the study and for three to four summers I conducted studies on the effect of heat on kidney function, on the heart, on the lung, on the brain, on the thyroid. These studies resulted in publication of many articles and the writing of two or three chapters on the effect of heat on the human physiology. And that’s what stimulated me to be a nephrologist.

After I finished my army service, I went back to do my residency in Belinson Medical Centre in the department of Dr Toor. And then I decided to come for two years to the United States, for further training in clinical and investigative nephrology. I applied to both Georgetown to work with Dr Schreiner and to UCLA to work with Dr Kleeman. Both accepted me, so we made an arrangement with them to spend one year at Georgetown and then another year at Cedar Sinai Medical Center with Dr Kleeman. I learned the art of clinical nephrology from the master, George Schreiner, who was a wonderful teacher and taught me everything I know about clinical nephrology. Then I came to LA and started working with Dr Kleeman and with him I learned how to be an investigator and a researcher. All my investigative work really began at that time.

After a year and a half with Dr Kleeman, he suggested that I apply for the investigatorship of the American Heart Association and I laughed and said, “Why should they give it to me? This is a very difficult thing to receive. It’s very coveted. I’m just here a year and a half why should they give it to me?” He said, “You apply and we’ll see.” I applied and I was interviewed by Dr. Robert Vernier.  The interview went very well.  When I left him, he shook my hand and said, “You know, Dr Massry, I sit at the committee which will make the final decision and I hope that you will get it.” I realized that I did get it and a month or two later I received the announcement that kept me for another five years in this country, in addition to the first two years. That’s why I stayed in this country and my journey of two years lasted ‘til now, which is almost thirty-five years.

RG:

Dr Massry was there an event, or person, which sparked your particular interest in calcium, phosphorus, parathyroid, hormone, and bone disease?

SM:

When I joined Dr Kleeman, I really didn’t know what I wanted to do in investigative nephrology. Dr Kleeman’s interest was in calcium, phosphate, and parathyroid hormone, so I joined him in his own work, which stimulated me to further this field.  At that time, the late Dr Jack Coburn was in the VA and I was at Cedar Sinai. Dr Coburn also worked with Dr Kleeman, who facilitated my cooperation with Dr Coburn.  I began to work with Dr Coburn under the guidance of Dr Kleeman. We produced large number of papers published in the most prestigious journals in this country. I would consider this period working with Dr Kleeman and Dr Coburn as one of the best years of my life.

RG:

During that work you did with Dr Kleeman and Dr Coburn, you evolved a theory on the pathogenesis of some manifestations of uremia, which was often referred to as the wheel of toxicity, which considered parathyroid hormone as the hub of the wheel.

SM:

Yes.  In 1968 we had a patient, who was a transplant recipient, who suffered from tremendous itching. She had other problems with calcium and bone disease.  She underwent parathyroidectomy and suddenly the itching disappeared the next day. That was a peculiar observation, which I thought…I couldn’t understand, but during that year we did parathyroidectomy on  another five uremic patients who all had severe itching. And the itching disappeared after parathyroidectomy.  We submitted this observation in an abstract for presentation in clinical meetings in Atlantic City.

At that same meeting, the group of the late Professor Merrill also presented a similar observation. The editor of the New England Journal of Medicine asked both us and them to send papers describing this phenomenon and they were published back-to-back in the same issue of the journal. This raised, in my mind, the possibility that parathyroid hormone may be the cause of that itching and I developed the idea that parathyroid hormone may be one of the uremic toxins. I wrote an editorial on this hypothesis  and of course I could not get it published, but I knew the late Dr Berlyne, who was then the editor of Nephron, and I said, “Geoffrey this is a good thing. Can you publish this for me?” I sent him the editorial to look at.  He liked it and published it in Nephron as a theory that parathyroid hormone is a uremic toxin.  Since then, that’s almost thirty years later, the NIH has supported my research in this field continuously. We have developed the idea and explored the mechanisms through which PTH may exert its toxicity. We went into the molecular level. I believe that the idea that parathyroid hormone is a uremic toxin is now accepted and many other laboratories have confirmed it.

With time, we and others were able to show that every cell in the body has a receptor for parathyroid hormone, and that every cell is a target for the action of parathyroid hormone and that excess parathyroid hormone is involved in many of the manifestations of the uremic syndrome. This is a very important observation in my mind because today we can control the blood levels of parathyroid hormone medically, by treating with phosphate restriction or vitamin D, and surgically, by removing at least a major part of the parathyroid glands. So the idea that parathyroid hormone is a uremic toxin is not an academic idea but an idea with far reaching practical implication for the health of uremic patients.

RG:

Over the years, Dr Massry, in addition to your laboratory and clinical research efforts you’ve also been involved as a leader of many organizations, societies; you’ve been an editor of two journals; you’ve been a leading force in drawing attention to the history of nephrology. I just want to ask you to share with us some of your experiences and thoughts about your work…say particularly in the National Kidney Foundation.

SM:

I started as a volunteer to the National Kidney Foundation in the local chapter in Los Angeles and I worked there with them for many years and I became the chairman of the Scientific Advisory Board of that foundation, the local chapter. We were really the first chapter, who started to raise money as physicians for the local chapter.  Before that the lay people used to raise the money and the doctors used to spend it. That created some kind of conflict; we raise the money and you spend it and I said, “Well the doctors will raise money.” So we did the first testimonial dinner in Los Angeles, by the local chapter, which raised many thousands of dollars and that became a tradition that every year physicians create their own testimonial dinner, a fundraising event, to raise money for the Kidney Foundation.

As time went on I joined the national organization of the Kidney Foundation and I was chairman of the Scientific Advisory Board. I was chairman of the Program Committee for their annual scientific meeting. I was then elected to be vice president and then I became the president of the National Kidney Foundation in 1992.  During my presidency, many things happened. One important effort was to continue the idea that Dr Schrier initiated to create an endowment fund of five million dollars for research. When I became president about half a million dollars had already been raised.  Within two years of my presidency, I was able to complete the fundraising of  the five million dollars. That endowment fund, which then was invested wisely, is today in excess of ten million dollars, which supports many research endeavors. I also thought that it was important for the Kidney Foundation to create a clinical meeting to compliment the ASN meetings every year.

We began the first clinical meeting, which took place in Chicago, and it was an amazing endeavor. No one expected the number of people who attended that meeting and now this meeting has become an established event every year that it provides the cutting edge in  clinical nephrology, research and ideas, for the physicians and the nephrologists.

RG:

You’ve also worked as an editor of two journals, and you’ve also been an editor of many international convocations, symposia, and meetings; which have brought together scientists from all over the world to talk about particular topics. How would you measure that as one of your contributions to the overall field.

SM:

I believe that being a scientist and a clinician, is a wonderful thing, but one needs to find ways to disseminate the knowledge to others and one cannot keep that knowledge for oneself. Journals are a vehicle of that. I was editor of two journals: one, Mineral Electrolyte Metabolism, and the other one, American Journal of Nephrology. They were successful journals, and it was a wonderful experience for me to edit these journals and disseminate knowledge through them. 

At the time we were involved in the field of nephrology, the world was divided between west and east. The nephrologists of eastern countries which were under the communist regimes, did not have facilities, and did not have access to scientific journals.  They were really isolated. We tried, with other people in Europe and in the United States, to create contacts with nephrologists in the eastern world, to have meetings and invite them.  These efforts had tremendous effect on the development of nephrology in these countries.

We also, I and the others, gave equipment and laboratory supplies to nephrologists in those countries, which helped them to do research and express their scientific abilities. I take pride in these efforts and I feel that I have done a great deal to the progress of nephrology in those countries.

RG:

Now, as you’ve moved along in your career as many of us have experienced, you got more interested in the history of nephrology, and I think you’re now one of the leading authorities in the history of nephrology; you and Eknoyan and Leon Fine and Stewart Cameron. You must have learned and experienced lots of interesting things about the history of nephrology.

SM:

That’s correct.  This was an idea that Garabed Eknoyan brought forward, and in a meeting in Italy Dr Natale DeSanto, from Napoli, Dr Eknoyan and myself decided to have meetings on this field.  The first meeting took place in Napoli, which then resulted in the creation of the International Association of the History of Nephrology.  I became President of the Association two years later.  My part in this endeavor of the history of nephrology was to examine nephrology in the Bible and Talmud and to examine the contribution of Jewish physicians to nephrology. And it’s amazing when one reads, and searches these issues, one finds many things, which we now think we discovered, were described many centuries ago.

I give you one example, in the eleventh century, a man slaughtered his cow to sell the meat for food.  He found that the cow had  small kidneys. So he went to the rabbi and asked, “Is this animal kosher? Its kidneys are small, can we eat the meat?” The rabbi did not know the answer. He said, “I don’t know, we need to discuss this among the rabbis and we’ll give you an answer.” Unfortunately, it took many decades before they came to the answer. The answer was fascinating; they said if the surface of the kidney is smooth and if the covering of the kidney could be removed easily, it means that the animal was born with a small kidney and therefore it is kosher, and one can eat it. However if the kidney is small, but the surface is irregular and the covering could not be removed from it, it means the kidney is sick and the animal is not kosher. That is the small contracted kidney described by Richard Bright later, but that was described in the eleventh century. Is this not a fascinating observation?

Another example, it’s not really in nephrology, but again it shows you what the power of observation of people was at that time.  In the twelfth century, a Mohel, the man who circumcises children in the Jewish tradition, circumcised a boy and the boy bled to death, so he wrote in his book, “I believe that this boy was born with thin blood”, and that’s all. Next year, the same mother had another boy that he circumcised and the boy bled to death. So he said, “well this mother brings children, boys, to this world with thin blood, we should not cut them.” A year later her sister had a boy that he circumcised, and the boy bled to death.  The Mohel wrote in his book, “No it is not the mother, it is the family, with all its women will bring boys with thin blood and should not be cut.” It’s interesting the daughters of these parents don’t bleed. So in essence this rabbi described hemophilia, its sex-linked characteristic, and its treatment. That was in the twelfth century, not by a doctor but by a rabbi, but hemophilia discovery is credited to scientists later in history. So if you go and read in the Bible and the Talmud there is a lot about nephrology, and in fact in the Old Testament it says, “God examined kidneys and hearts.” God was the first nephro-cardiologist, and that is said in the Bible. So it is fascinating and I believe that interests in the origin and the history of nephrology broaden and widen the horizon of our thinking.

RG:

Fascinating, well let me try and ask some questions that may be a little more philosophical than factual. Allow you to share some events of your past. I’m curious as to what is the best piece of advice that you have ever received personally and from whom did you receive it? It’s a…kind of a…maybe difficult question…

SM:

No, no I have the answer for it. The best piece of advice I ever received was from my mother. You know, my father died when I was four. We had no money; we were poor. My mother worked hard to raise us; we were three children, and I was kind of desperate, disappointed, that life would treat us like this. And she said to me, “Don’t worry, you always work hard, and you will reach places.” That is the best advice. I always work hard, all my life, and I think that the hard work has paid. I do believe that almost everything is obtainable if you really put your mind to it-- people talk about luck in life, there is no luck; we make our luck. We make our luck by working hard, by putting goals in front of us, by trying to achieve these goals. Nobody gives you anything, there is no free ride in this world. You need to work hard.

RG:

Would you give similar advice to a young physician just starting their career in nephrology today?

SM:

Absolutely. Not only to a physician in nephrology, but to anyone and in any endeavor.  There is nothing you can gain without investing efforts in it. If you invest your time and efforts, you will succeed.  I gave my four children the same advice and all are successful.

RG:

What about looking to the future? Where do you think the field of nephrology is going and how do you envision it evolving over the next several decades.

SM:

Well I see two issues. One, the etiology and the cause of many renal diseases, in general are immunological in nature. Now if we can conquer that secret, if we can prevent or find the cure for these diseases then we will not need dialysis and transplantation. How successful will we be? That remains to be seen.  The progress in medicine and in nephrology is so rapid.  To make this point consider the discovery of  proteinuria which took many centuries, compared to the tremendous advances that have been made in the last fifty years. So I believe that in the coming decades we will conquer the cause of renal diseases. If we do that, all the structure we have today for dialysis and transplantation will implode; we will not need it. But if we will not succeed in conquering the causes and the cure of renal diseases, we’re going to be left with dialysis and transplantation.

I don’t believe there is a limit for dialysis because it is a question of money and how society would like to support it, and I believe the public pressure to have society support dialysis would continue and dialysis facilities can expand.

The ultimate success of transplantation will depend on the availability of donors and I don’t believe we will have enough human donors, whether alive or cadaveric to meet the needs We need to go for organs from animals and we know today that the best animal which can provide donors, not only kidneys, but hearts and other organs, is the pig. Xenotransplantation right now is being  thought about and farms are being established to raise immunologically engineered pigs to provide organs. I think with time, not in the very far future, we may have shops, like butcher shops; you go in, you want a kidney you want a heart, you may be able to get it.

There may be one problem with this issue of the pig as a source of donors for both Jews and Muslims because both Jewish religion and Islam forbid to touch a pig, or to use anything out of a pig. Somehow they have not resisted the idea of using cardiac valve replacement from pigs. And all the insulin, in the past, was porcine from the pig and they accepted that, but I wasn’t sure they would accept a total organ from a pig. So I wrote to religious leaders in Israel and the Muslim world.  Amazingly, I get answers which were exactly the same. Two different people, two different religions, the answer was exactly the same, and that answer was, “To save life, all rules are suspended.” In other words, the religious rules would be suspended if you save life because life is so precious because no rule should prevent it from existing and flourishing.

RG:

Many years ago, you and I visited Pope John Paul for the purpose of trying to convince the Roman Catholic Church to produce an encyclical on organ donation. Do you want to share any of your experiences with that monumental move?

SM:

That experience really began before he became Pope. He was the Cardinal in Krakow.  It was in 1976 when I was visiting Poland as a guest of the Polish Academy of Sciences, that I met with him as the Cardinal of Krakow.  It was a wonderful, twenty minutes encounter.  

His physician in Krakow was Professor Kokot, who was a friend of mine. So I contacted Professor Kokot and said, “Why can’t we arrange a delegation of nephrologists and transplant surgeons to meet with the Pope to request him to issue an edict that supporting organ donation by a catholic is appropriate. So we went through negotiations, he agreed to meet us provided we send him a letter telling him what we want to discuss, and I did not know what he thinks about organ donation. So I called a religious Catholic leader  in Los Angeles, and I said, “I may be going to visit the Pope about this issue. Do you know what he thinks?” He said, “I tell you the best thing to do is to call Father Thomas in Boston because he keeps the protocols of meetings of a commision which advises the Pope on technology and science that occur every year in Rome in December.  And in the last meeting, they discussed the issue of organ transplantation and probably Father Thomas has that discussion.” So I called Father Thomas and he sent me the information. This gave me an idea of what the Pope thinks.  So we wrote him and he said, “Alright you can come.” We went there and you were with us, and I presented the group by delivering what we came for, and he was very, very wonderful. In fact he said, “ Organ donation is the greatest gift a Christian can make.” That is a profound statement.  But his concern was that we must be sure that the person we were going to take the kidney from is dead before we take the kidney.  He really supported organ donation. It was a marvelous experience as you remember.

RG:

One last question, Dr Massry. As you look back on you forty years of distinguished achievement in the field of nephrology; one, is there anything you would have done differently? And two, what are you most proud of?

SM:

I tell you, if I was born again, I would do the same thing. I enjoyed it very much. In fact, I laughed with my wife and said, “How lucky I am.” She said, “Why?” I said, “They paid me for my hobby.” All my life, medicine was my hobby, I would have done it without money, without pay, but I was lucky they were paying me for it. So what a fortunate person to be paid for his hobby. That’s a great thing.

What I am proud of…before I am proud of my career, I am proud of my children, and those children would not have come where they are without the support and dedication of their mother, because I wasn’t home; I was traveling, I was working, I was absent. She was there, she raised them, and I am so proud of them. We have two doctors, two lawyers, very successful by themselves and that is the greatest achievement and reward.

After that came the profession, and of course I am proud of the profession. I am proud of the people I taught, we have trained almost 160 nephrologists.  Many of them practicing nephrology in Southern California. They call themselves the School of Massry. Many of them are leading figures in academic nephrology, so this is a great feeling to have your disciples successful; you get the greatest pleasure from them.

The other thing, which I am proud of, is that I was able to help alleviate the suffering of patients in my own way. Each time I see a patient that I can help, that I can talk to him, that I can calm him, it is a great gift that God has given me.

RG:

Thank you very much Dr Massry

SM:

- Thank you Dr Glassock