Remembering Frank Gotch, MD

Frank Gotch, MD, was the founding director of the University of California Renal Center at San Francisco General Hospital, where he led an early effort to establish national dialysis programs, and the first one in Northern California. In the fall of 1967, he was recruited to evaluate a new product––the hollow fiber dialyzer––that Dow Chemical was developing under contract with the National Institutes of Health (NIH). I was responsible for the pilot plant at Dow to produce the prototype dialyzers for evaluation, and began working with Frank––part of a more than 30 year collaboration marked by both professional synergy and friendship.

The hollow fiber dialyzer design that brought us together became, and has remained, the premier dialyzer to the present day.

Beginnings

Frank was born in Humboldt, Iowa and was named after an uncle, Frank A. Gotch, who was credited with popularizing professional wrestling in the United States (different from the current version of that “sport”). Frank once related that having that name in his youth created playground disadvantages and physical challenges.

Frank attended UC Berkeley and UC San Francisco, where he got his medical education and was mentored by Dr. Izzy Edelman, a formative figure in fluid and electrolyte physiology. It was through this connection that Frank became interested in the issues involved in treating renal failure, which ultimately led to applying quantitative methods to dialysis therapy.

After the dialyzer evaluation project, Frank and I started investigations into how dialysis should be conducted to most effectively address the physiological challenges it presented. Frank was intensely interested in the application of the principles of physical science, particularly mass conservation, to dialysis, which is essential to the mathematical models that we developed. He continued to pursue and define quantification of the delivery of dialysis for the treatment of end-stage renal disease for more than 40 years.

John Sargent, Frank Gotch, and nephrologist George Schreiner at a gathering in the late 1990s honoring Gotch after a book was published by Seminars in Dialysis about his contributions to nephrology.

I believe that one of the most profound results of our collaboration was a unique way of looking at the fundamental problems in dialysis by coupling Frank’s observations and curiosity with the application of basic physical laws and a structured problem-solving approach. In addition, the creative atmosphere that existed during the years of collaboration yielded innovative approaches to the delivery of dialysis treatment and experimental design that are still applicable today.

These efforts also resulted in the quantification of a wide range of physiological systems, the management of which is the fundamental goal of the treatment of ESRD by dialysis.

The development of Kt/V

Frank was always sought after to lead efforts to evaluate dialyzers and to investigate the adequacy of dialytic treatment. Specifically, he was a key participant in the design and conduct of the National Cooperative Dialysis Study (NCDS) in the 1970s as well as the subsequent Hemodialysis (HEMO) study, both of which were guided by the urea model that we had developed.

Analysis of the NCDS data resulted in describing the importance of a quantitative baseline of dialysis – Kt/V. The application of this parameter has aided in addressing the amount of desired treatment and in measuring whether the intended goal has been achieved.

Some of Frank’s other modeling efforts addressed anemia management; heparin anti-coagulation; the possible toxicity and control of larger solutes; and importantly, acid base management.

A colleague has observed that Frank “wrote the book on the quantification of dialysis therapy – he just thought so quantitatively about everything clinical, from antibiotic levels to electrolyte disturbances.”

Frank staunchly defended this quantitative approach to medical and treatment issues, engaging in discussions with wit and charm, but always insisting on a solid scientific basis in such exchanges.

One hopes that Frank’s legacy will endure in the treatment of ESRD. Even as treatment becomes more routine, fundamental issues persist. The current state of challenges in renal failure and its treatment can continue to benefit from his scientific approach to dialysis therapy and analytical thinking and curiosity.

The lasting legacy of Dr. Frank Gotch will be the establishment of a fundamental quantitative approach to the treatment of ESRD that forms the basis for future advances. -by John Sargent, PhD