Nephrology in America was the first and largest of the new internal medical specialties to emerge after World War II. It was a novel fusion of traditional basic sciences and new clinical tools such as renal biopsy, new imaging, molecular target drugs, dialysis, hemoperfusion and transplantation. The immediate roots were provided by great scientists/clinicians like John Peters, Homer Smith and Tom Addis. The caldron was formed by the tensions arising from newly formed organizations such as the AHA (including NYHA and WHA), NIH, ISN, ASN, ASAIO and NKF. Without these tensions, nephrology might have become a much smaller and narrower specialty of clinical physiology, salt and water and acid-base metabolism. The evolution was rapid from attendance 100+ at the first ISN in Evian, France in 1960 to the 1998 ASN meeting in Philadelphia which drew more than 10,000 nephrologists. This is a personalized history of those tensions and their interactions written by the only nephrologist who has been President of the WHA, ASN, ISN, ASAIO and the NKF.