Invited editorial: Why physiology?

I became a nephrologist because of Burton Rose. More specifically, because of the “yellow book” – the fourth edition of Clinical Physiology of Acid-Base and Electrolyte Disorders. As I look at my dog-eared and over-used copy I see it was published 1994 and last updated in 2001.

From this book, I learned that renal physiology is relavant to most hospitalized patients and is relevant to all patients in the ICU. Every hospitalized patient is either receiving IV fluids or diuretics. Electrolytes are checked daily, and most have at least a single abnormality. Edema from heart and liver failure are problems directly related to abnormal renal physiology. Understanding fluids and electrolytes is a foundational concept of hospital care, and understanding fluids and electrolytes is rooted in renal physiology.

From this book, I learned that the the kidney is amazing (and smart).  One hundred eighty liters of plasma are filtered every day! The counter-current exchange can concentrate urine to 1400 mOsm/L from a serum a osmolality of 290! The concept of Tm is able to explain the apparently diverse findings in diabetes (glucosuria), proximal RTAs and Fanconi syndrome!

From this book, I learned renal physiology. And I understood how renal physiology related to the entirety of clinical medicine. And that was the most exciting part. Fluid and electrolyte problems and their management could be solved by applying the basic principles. There was logic to it – and I knew what the logic was. I became a nephrologists because it was the only subject that was explained really well and I understood it. Strangely, today a source of the lack in interest in nephrology is because it is “too hard”. Are we suffering from a post Burton Rose funk?

As the years accumulate since the last update to Rose's masterpiece, who is explaining renal physiology now? Who is demonstrating the intricate genius of the nephron? Who is making it clear that if you are interested in hospital medicine and critical care, that you are actually interested in (and need to know) renal physiology? Lots of residents are becoming hospitalists – is it because hospital medicine is so wonderfully accessable and understandable with the advent of UpToDate, another Burton Rose creation?

The editors of CJASN understand the situation perfectly. Understanding renal physiology is the essence of being a nephrologist. At this stage in my career, it is hard to imagine that I will be reading another textbook – thus, the CJASN series is filling an extremely important need for a comprehensive and comprehendible renal physiology resource. Hopefully, it can help inspire future nephrologists as well. 

Sarah Faubel is a Professor of Medicine at the University of Colorado and chair of the ASN AKI advisory group. Her Twitter handle is Doc_Faubel.