Physician profile: Brent Miller, MD

Brent Miller, MD is an associate professor of medicine in the division of renal diseases. He is medical director of home dialysis. His areas of clinical interest include kidney transplantation, home dialysis, nocturnal hemodialysis and peritoneal dialysis.

Why did you choose nephrology?

During my internal medicine residency I wasn’t sure what specialty to pursue because I liked being involved in the many different areas we were exposed to on a daily basis. I was attracted to nephrology during my third year of residency because of the diversity of patients and problems. Every day and literally every patient was something unique. I found it interesting, challenging and stimulating.

Another reason I became interested in nephrology was both my grandfathers had kidney failure. My mom’s father lived in rural Indiana in the late 1960s and there wasn’t a dialysis machine anywhere close to his home. He essentially died of renal failure. My dad’s father was actually one of the early patients on peritoneal dialysis in rural Indiana in the late 1970s and early 1980s. I got to see what dialysis was like 30 years ago, compared to what it is now — it is so much different. Watching what both my grandfathers went through was the start of my interest in renal failure.

What brought you to Washington University?

I guess I’m what is known as a “lifer” ““ I came to Washington University as a medical student in 1986 and have been here ever since. I’ve developed long-lasting personal and professional bonds here.

Which aspect of your practice is most interesting?

I deal with a patient population that has a fairly serious illness, and yet we’re able to offer some hope for improvement in their condition. I enjoy being able to help people who might have been told by other physicians that a complete and active life was not possible for them.

In addition, it has taken a lot of work and time, but by changing the way we do dialysis, we’ve been able to have an impact on evolving therapy on a national and international basis. We’ve also been involved in moving kidney transplant forward from where it was 15 years ago.

The part that I enjoy the most is having an idea and seeing an opportunity to improve the way something is done — then watch it develop years later. More than ten years ago, we recognized that if dialysis was moved into patient’s home, it could be done more frequently than three times a week, and the patient would do better. Washington University was one of the first programs in the United States to offer home dialysis. Now it is part of routine care. It has been immensely enjoyable to see an idea go from something on paper to where it is now — a practice that almost every medical center offers.

I’ve also enjoyed changing the process of how patients are treated after transplant. It was a team approach working with Dan Brennan, MD, the surgeons and Barnes-Jewish Hospital transplant program. We were some of the pioneers in figuring out how to prevent patients from getting a viral infection, such as CMV, after transplant. We were also able to reduce rejection rates. When I started as a fellow, rejection rates were 30-40%, and now they are less than 10%. That is quite an impact.

How does the home dialysis work?

We have a smaller machine that’s much easier to use and we teach patients how to do it themselves — typically 5-7 days a week. We have some patients who choose to do it while they sleep at night so they get their days free. They have the flexibility to have dialysis any time of day, in any room in their home. We’re trying to make it less and less cumbersome. Dialysis is never going to be fun, and there is always going to be a certain amount of inconvenience. But we’re trying to make it just one of life’s annoyances rather than a devastating, life-changing event.

What are some of the new developments in your field?

Since integrated circuits were introduced, dialysis machines haven’t changed very much in the last 25-30 years ““ we’re still at the “mainframe” computer stage. The major advance in the field is going to be technological. If I can use an analogy — our goal is to take dialysis from early mainframe that’s the size of a refrigerator, to today’s laptops with WiFi. We hope to make machines lighter, about 40 pounds, with smart technology so that they can be controlled by the patient with a touch pad. The graphic interface and remote connections will allow the machine’s data to feed directly to the doctor’s office, giving him or her the ability to review what’s going on in almost real time.

We’re also trying to go from using two needles to just one. A lot of people might not think that’s a big deal. But ask a patient, “Would you rather be stuck with one or two needles?” Considering the number of times a dialysis patient gets stuck, it makes a difference.

How recent is the invention of dialysis?

Dialysis was first proposed in the 1940s. Willem Kolff, MD, built the first successful dialysis machine in the Netherlands during WWII. Because there was a shortage of supplies, he used a wrecked airplane carriage for the dialysis bath. But there were a lot of problems — of his first 14 patients, only one survived. No one realized that when blood is taken out of the body and run through artificial tubing, it almost instantly clots. Anti-coagulants, such as heparin, had yet to be developed. Plus, there were other advancements that needed to happen in order for dialysis to be effective — such as semi-permeable membranes to filter the blood; and IVs, fistulas and grafts to access the blood. It wasn’t until the late 1960s and early 1970s that dialysis was available on a wide scale.

Dr. Kolff’s initial view was that he thought dialysis might be able to help people in the hospital with acute renal failure until the kidneys could recover. He had no hope that dialysis would ever be able to keep people alive with chronic kidney failure. Dr. Kolff lived until 2009, so over the past 60 years he was able to see that his invention actually could prevent people from dying.

Where are you from?

I’m from a large family in northern Indiana. After high school, I moved across the country to attend Stanford University. It was a very good experience ““ it made me grow up and become independent. The cultural differences between living in a small town in Indiana and the Bay area were very interesting for an 18-year-old.

Which particular award or achievement is most gratifying?

It’s gratifying when professionals from other universities and medical centers visit us to observe and duplicate some of the processes we’ve done. There is no award or plaque on my wall, but I would hold that up as my biggest achievement ““ we’ve had an impact and are recognized as respected leaders in developing this type of patient care.

Something else that is very satisfying is being able to successfully offer home hemodialysis. When we started thinking about this in 1999, people laughed at us and said it would never work ““ but it does work. And those who doubted us are now doing it. That is very rewarding.

What is the best advice you’ve ever received?

The best advice I’ve received is a baseball analogy. When times are tough, take two pitches to see what’s going on, and then hit it to right field. In other words, if things aren’t going well, take a step back — you don’t have to act immediately. Don’t try to hit it out of the park, just hit it to the opposite field and get a single.

Another way to say this is to not get caught in the day-to-day ups and downs. Sometimes you can’t see how it’s going to work out, but if you consistently do the right thing, it will work out.

If you weren’t a doctor, what would you like to be doing?

I would be involved in engineering or architecture. I like working with tools, doing minor carpentry and repair work around the house. I enjoy creating and building.

It’s interesting working in transplant and dialysis because you get to see solutions invented for your patients. It’s amazing when you talk to the engineers and tell them what you need ““ a precise blood flow, a specific composition of calcium, or better venous alarm. They come back a few months later with diagrams on how it could be done and then they figure out how to manufacture it. It’s just incredible people can be that creative without knowing the medical side of it. I would love to be able to do that.