Linguistic and Cultural Adaptation and Italian Validation of the Renal iNUT, a Nutrition Screening Tool for Hospitalized Patients with Chronic Kidney Disease

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Giovanni Cangelosi

DOI: 10.69097/43-02-2026-04

Sara Morales Palomares1,2*, Silvia Cappelletti2*, Gaetano Ferrara2,3, Stefano Mancin2, Giovanni Cangelosi2,4, Giada Vrenna2, Mauro Parozzi2,5, Domenica Gazineo2,6, Marco Sguanci2, Mattia Bozzetti7*, Elena Sandri8*
*These authors contributed equally

AI tools were used to support language editing and translation, but not for content generation. No AI-generated content was included without human review and revision.

1 Department of Pharmacy, Health and Nutritional Sciences (DFSSN), University of Calabria, 87036 Rende (CS), Italy
2 Italian Society of Nephrology Nurse (SIAN), Via Capotesta 1/30, 07026 Olbia, Italy
3 Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Montpellier 1, 00128 Rome, Italy
4 School of Pharmacy, Experimental Medicine and “Stefani Scuri” Public Health Department, University of Camerino, Via Madonna delle Carceri 9, 62032 Camerino (MC), Italy
5 Medicine and Surgery Department, University of Parma, Via Gramsci 14, 43126 Parma, Italy
6 Governo Clinico e Qualità, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
7 Direction of Health Professions, ASST Cremona, Viale Concordia 1, 26100 Cremona, Italy
8 Faculty of Medicine and Health Sciences, Catholic University of Valencia San Vicente Martir, 46001 Valencia, Spain

Corresponding author:
Dr. Giovanni Cangelosi
School of Pharmacy, Polo Medicina Sperimentale e Sanità Pubblica,
62032 Camerino, Italy
E-mail: giovanni01.cangelosi@unicam.it

 

Abstract

Background/aim. Malnutrition is a frequent and serious issue among patients with chronic kidney disease (CKD), often leading to worse clinical outcomes. The Renal Inpatient Nutrition Screening Tool (Renal iNUT), originally developed in the United Kingdom, provides a quick and renal-specific method for screening hospitalized CKD patients. While a Spanish version has been adapted, no validated Italian translation is currently available. This study set out to translate and culturally adapt the Renal iNUT for application in Italian clinical contexts, as well as to evaluate its psychometric properties.
Methods. The adaptation followed the methodological approach described by Sousa and Rojjanasrirat, proceeding through seven structured phases to secure conceptual, linguistic, and cultural equivalence. After a pilot phase with healthcare professionals, the tool was administered to hospitalized patients with CKD to assess both inter- and intra-rater reliability.
Results. Feedback from the pilot testing indicated that the Italian Renal iNUT was clear, intuitive, and easy for clinicians to use in daily practice. Psychometric testing confirmed good intra-rater reliability [Intraclass Correlation Coefficients (ICC) = 0.83; 95% Confidence Interval (CI) 0.69 – 0.91] and excellent inter-rater reliability (ICC = 0.90; 95% CI 0.82–0.95). Total scores remained stable across repeated measurements [median = 2.0; Interquartile Range (IQR) 1.0 – 3.0/2.5].
Conclusions. Overall, the Italian version of the Renal iNUT demonstrated strong reliability and practical usability, supporting its use for nutritional screening in patients with CKD. Its implementation may help promote standardized nutritional screening and early nutritional interventions in Italian hospital settings, ultimately improving the quality of care and patient outcomes for individuals with CKD.

Keywords: Chronic kidney disease, nutritional screening of malnutrition, Renal Inpatient Nutrition Screening Tool (Renal iNUT), cross-cultural adaptation, validity and reliability, Italy

Introduction

Chronic kidney disease (CKD) is becoming increasingly common and now affects around 10–11% of adults worldwide [1]. Among its many complications, malnutrition is one of the most relevant, as it strongly influences both disease progression and the patient’s overall well-being [2, 3]. According to recent systematic reviews, the global prevalence of malnutrition in CKD varies widely depending on clinical setting, disease stage, and the criteria or tools used to assess it [4]. Malnutrition in CKD has a multifactorial origin, resulting from several overlapping biological and clinical mechanisms [5]. A reduced dietary intake, often related to anorexia, nausea, or gastrointestinal symptoms, is one of the most common contributors. Metabolic and hormonal disturbances linked to chronic inflammation and the accumulation of uremic toxins further aggravate protein-energy wasting and muscle catabolism [6]. Changes in taste and smell perception can also lessen appetite and dietary variety, while dietary restrictions prescribed to control electrolyte or mineral imbalance, multiple medications, and the effects of repeated hospitalizations all play a role [7, 8]. Taken together, these factors not only raise the likelihood of malnutrition but also have a negative impact on patients’ overall clinical course. Individuals who are malnourished often respond less effectively to treatment, experience longer hospital stays, and are more likely to be readmitted, leading to greater healthcare costs [9]. As a result, their quality of life tends to decline, and long-term outcomes are poorer [10]. This issue becomes even more evident with advancing age and progressive kidney impairment, which highlights how essential regular nutritional screening and timely interventions are in this population [11]. To provide a clearer framework for describing nutrition-related disorders in CKD, the International Society of Renal Nutrition and Metabolism (ISRNM) proposed the concept of protein–energy wasting (PEW), a condition characterized by the loss of body protein and energy stores caused by metabolic and inflammatory disturbances [12]. Recent meta-analyses have shown that PEW occurs across all stages of CKD, with particularly high prevalence among dialysis patients [13]. In those undergoing hemodialysis, identifying nutritional risk and applying targeted interventions have been associated with improved outcomes [14], whereas persistent loss of appetite remains a powerful predictor of both hospitalization and mortality [15]. Common anthropometric indicators such as body mass index (BMI), triceps skinfold thickness (TSF), and mid-arm muscle circumference (MAMC) are often used to estimate nutritional status [16–18]. However, validated screening tools are still rarely applied in everyday practice [19]. The 2020 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines stress the need for more research to define optimal combinations of nutritional indicators for early detection and to standardize screening approaches for non-dialysis CKD populations [20]. In response to these needs, Jackson et al. developed the Renal Inpatient Nutrition Screening Tool (Renal iNUT), a concise screening instrument that showed high sensitivity and specificity when compared with the Subjective Global Assessment (SGA) [21]. Although the SGA remains the recognized gold standard for evaluating nutrition-related morbidity and mortality [22], the Renal iNUT offers clear advantages in terms of speed and usability, particularly for CKD inpatients [5, 9]. Its concise structure allows quick identification of at-risk patients and facilitates timely nutritional support [19]. The Renal iNUT has already been translated and validated in Spanish-speaking settings, confirming its reliability and ease of use [23]. Yet, no validated Italian version is currently available. Developing one could help healthcare professionals perform more consistent and standardized nutritional screening in Italian hospitals. Ultimately, an Italian adaptation might promote earlier dietary interventions, strengthen the integration of clinical nutrition within CKD care, and contribute to better long-term patient outcomes. Addressing this gap is crucial, since malnutrition continues to be a frequent but often underestimated complication that significantly impacts prognosis, complication rates, and quality of life in people with CKD.

Aim

This study aimed to translate, culturally adapt, and psychometrically validate the Renal iNUT tool for application in Italian hospital settings.

 

Methods

Study Design and Setting

This single-centre study focused on the translation, cultural adaptation, and psychometric validation of the Renal iNUT tool into Italian, following formal authorization from the original developers [21]. Briefly, the Renal INUT is a kidney-specific screening instrument developed to identify hospitalized patients with CKD who are at risk of malnutrition. It consists of a small set of items exploring key domains that are particularly relevant in this population: current BMI or clinical appearance of malnutrition, recent unintentional weight loss, changes in usual appetite and food intake, and the use of oral nutritional supplements. For each domain, predefined response options associated with nutritional risk are scored as positive, and the total number of “at-risk” responses generates an overall risk score (range 0–4), with higher scores reflecting a higher risk of malnutrition. This score is used to classify patients as low risk (0), at risk (1) or in need of dietetic referral (≥ 2). The tool also includes a brief follow-up section for weekly re-screening during hospitalization, in which weight, BMI and changes in appetite and food intake since admission are reassessed. The Renal iNUT is designed to be completed by ward nurses at the bedside in a few minutes using routinely available clinical information and a brief patient interview. The study followed a seven-phase cross-cultural adaptation protocol adapted from Sousa and Rojjanasrirat [24], ensuring rigorous methodology to preserve the conceptual, semantic, and cultural integrity of the tool. Phases 1–3 were conducted between March and April 2025, Phases 4–5 in May 2025, and Phases 6–7 from June to August 2025. Each phase is described below, to ensure the tool’s cultural and linguistic relevance and its applicability in clinical practice.

Ethical Considerations

The study was approved by the Bioethics Committee of Bologna (protocol no. 0390138). All participants provided written informed consent in accordance with the principles outlined in the Declaration of Helsinki. They were clearly informed about the voluntary nature of their participation and their right to withdraw at any stage without any negative consequences.

Translation and Cultural Adaptation Process

The Italian adaptation of the Renal iNUT followed a structured seven-phase process designed to ensure both linguistic accuracy and cultural relevance.

Translation of the Original Tool into Italian

During the first phase, two independent bilingual translators, both fluent in English and Italian, produced separate translations of the original tool. One translator specialized in healthcare terminology and was familiar with the conceptual basis of the questionnaire, while the other focused more on everyday language to maintain clarity and accessibility. This phase resulted in two Italian versions (IT1 and IT2), each reflecting a slightly different linguistic register.

Reconciliation of Translated Versions

In the next phase, an independent translator compared IT1 and IT2 to reconcile differences and produce a single harmonized version. Any inconsistencies were discussed and resolved to achieve the best possible balance between conceptual precision and linguistic naturalness. The resulting version was labeled Preliminary Italian Version 1 (PI-V1).

Blind Back-Translation

The reconciled Italian text was then translated back into English by two translators whose native language was English and who had no prior knowledge of the original instrument. This “blind” back-translation aimed to highlight any discrepancies or shifts in meaning that might have occurred during the translation process.

Multidisciplinary Committee Review

After the back-translation, a multidisciplinary panel composed of a methodologist, nephrology specialists, and all translators involved reviewed the materials side by side. The committee examined both semantic and conceptual equivalence, resolving any discrepancies and refining the Italian version to ensure it was consistent with the original content. This stage led to the creation of a pre-final Italian version of the Renal iNUT.

Content Validity Assessment

The pre-final version was then reviewed by the expert panel to evaluate item clarity, cultural appropriateness, and clinical relevance. The experts verified that all items maintained the intended meaning of the original version and that the instructions and response options were suitable for use in the Italian healthcare context.

Pre-Test of the Pre-Final Version

The pre-final version was pilot-tested with a group of 15 healthcare professionals, including nephrology nurses, dietitians, and physicians, working at Azienda Socio Sanitaria Territoriale (ASST) Lariana – Fermo della Battaglia, Como (Italy). Participants gave written informed consent and were asked to comment on the clarity of the instructions, the relevance of the items, and the ease of completing the questionnaire. Their feedback was incorporated to make minor adjustments and finalize the tool for clinical application.

Psychometric Testing

The final phase focused on evaluating the psychometric properties of the Renal iNUT tool in a representative sample of hospitalized patients with CKD. Healthcare professionals, including physicians and nurses from nephrology and internal medicine wards, were tasked with using the tool to assess the nutritional risk of patients. This phase was critical in determining the tool’s reliability and validity in clinical practice by assessing its consistency and accuracy across various patient scenarios.

Sample size for phase 7

The expected reliability for this study was based on the previously published validation of the Renal iNUT tool, which reported a Cohen’s kappa of 0.74 (95% CI [0.58, 0.90]), indicating substantial agreement. Assuming a similar level of agreement, an expected Intraclass Correlation Coefficients (ICC) of approximately 0.74 was considered. A simulation-based a priori power analysis indicated that for expected (ICC) values around 0.7–0.8, a sample of 30–40 patients with two raters is sufficient to obtain reliable and precise estimates, with a 95% confidence interval width of approximately 0.3 [25]. Accordingly, the inclusion of n = 35 patients in the present study can be regarded as adequate to assess inter- and intra-rater reliability. 

Data collection for phase 7

Data were collected between June and August 2025 in the tertiary nephrology department of ASST Lariana, Fermo della Battaglia (Como, Italy). Before data collection began, the participating healthcare professionals received specific training on how to administer and score the Renal iNUT, ensuring a uniform application of the tool across assessors. Patients diagnosed with CKD were recruited consecutively at the time of hospital admission, after signing written informed consent. The Renal iNUT was then administered by two independent raters following a structured schedule designed to test both intra- and inter-rater reliability:

Rater 1 (T0): Initial nutritional assessment performed at the time of patient admission.

Rater 1 (T6h): Repeat evaluation 6 hours later by the same professional to assess consistency within the same operator.

Rater 2 (T24h): Independent evaluation conducted within 24 hours of admission by another professional to assess inter-rater consistency.

All scores were assigned strictly according to the standardized Renal iNUT criteria to ensure objective and comparable evaluations of nutritional risk.

An overview of the entire process of translation, cultural adaptation, and validation is presented in Figure 1.

Flow diagram of the seven-phase cross-cultural adaptation and validation process
Figure 1. Flow diagram of the seven-phase cross-cultural adaptation and validation process of the Renal iNUT tool into Italian. Legend. CKD: Chronic Kidney Disease; ICC: Intraclass Correlation Coefficients; ASST: Azienda Socio Sanitaria Territoriale; PI-V1: Preliminary Italian Version 1; PF-IV: pre-final Italian version; BT1: Back Translation 1; BT2: Back Translation 2; I-CVI: Item-Content Validity Index; S-CVI: Scale-Content Validity Index.

Statistical Analysis

Descriptive statistics were produced for both demographic and clinical variables. Because continuous data were not normally distributed, they are presented as medians with interquartile ranges (IQR). Categorical variables, such as item-level responses, are expressed as absolute frequencies and percentages. Test–retest reliability (agreement between T0 and T6 h) was examined using the intraclass correlation coefficient [ICC (3, 1)] calculated through a two-way mixed-effects model (absolute agreement, single measures). Inter-rater reliability (agreement between T6 h and T24 h assessments) was analyzed with ICC (2,1) using a two-way random-effects model under the same agreement assumptions. Ninety-five-percent confidence intervals (CIs) were reported for all ICCs and interpreted according to conventional cut-offs: < 0.50 = poor, 0.50–0.75 = moderate, 0.75–0.90 = good, and > 0.90 = excellent reliability [26]. All analyses were conducted using R, version 4.5.0.

 

Results

The results of this study are presented according to the seven phases outlined in the Methods section, each representing a critical step in the linguistic and cultural adaptation and validation of the Renal iNUT tool for use in Italian clinical settings.

Translation and expert review (phases 1–5)

Phases 1–5 resulted in an Italian version of the Renal iNUT that was conceptually consistent with the original tool and suitable for use in Italian clinical settings. In phases 1–3, two independent forward translations were produced and reconciled into a single Italian draft, which was then blindly back-translated into English. Comparison of the back-translations with the original version showed good conceptual overlap, with no major discrepancies in meaning. During the multidisciplinary committee review (phase 4), nephrology experts, dietitians, a methodologist and the translators introduced only minor linguistic refinements to improve clarity and idiomatic flow, while preserving the original content and structure of the tool. In phase 5, content validity indices met a priori benchmarks I-CVI: Item-Content Validity Index (I-CVI) ≥ 0.78 and Scale-Content Validity Index (S-CVI) ≥ 0.80, indicating that the items were judged as clear, relevant and culturally appropriate by the expert panel and could be retained in the Italian version without substantial modification.

Pre-test with healthcare professionals (phase 6)

In phase 6, the pre-final Italian version (PF-IV) of the Renal iNUT was pre-tested with 15 healthcare professionals (nephrology nurses, dietitians and physicians) working in nephrology and internal medicine wards. Overall, participants considered the tool easy to understand, clinically relevant, and straightforward to administer. They also reported that it could be completed quickly and integrated into routine clinical assessments without affecting workflow, although the exact administration time was not formally measured in this study. Their feedback led to a few minor wording and layout adjustments, but no substantial changes to item content, resulting in the final Italian version used for psychometric testing (Supplementary File 1).

Phase 7: Psychometric Testing

Sample characteristics

A total of 35 hospitalized patients with CKD participated in psychometric testing. The median age of the sample was 71.4 years (IQR 56.7–80.9), and the median BMI was 23.6 kg/m² (IQR 21.2–25.6).

Renal-iNUT Scores

Across repeated assessments, total Renal iNUT scores remained stable, with median values of 2.0 at T0 (IQR 1.0–3.0), 2.0 at T6 h (IQR 1.0–2.0), and 2.0 at T24 h (IQR 1.0–2.5). The observed range was 0–4 at all time points (Table 1).

Item-level responses were consistent over time (Table 2). The domains most frequently endorsed were Food Intake (60.0% at T0; 48.6% at T6 h; 45.7% at T24 h) and Appetite (54.3%; 48.6%; 51.4%), followed by Weight Loss (37.1%; 40.0%; 38.2%). The items Malnutrition/BMI ≤ 20 (≈ 17%) and Nutritional Supplements (≈ 11–17%) appeared less frequently. Overall, these findings indicate a consistent response pattern across all assessment points. 

Timepoint n Median (IQR) Min Max
T0 35 2.0 (1.0–3.0) 0 4
T6h 35 2.0 (1.0–2.0) 0 4
T24h 35 2.0 (1.0–2.5) 0 4
Table 1. Total scores. Legend: n = number of participants; IQR = Interquartile Range; Min = Minimum; Max = Maximum; T0 = first evaluation; T6h = 6h evaluation; T24h = 24h evaluation. Note: Median (IQR) and range values for total Renal iNUT scores across the three assessment time points (T0, T6h, and T24h) in 35 hospitalized patients with chronic kidney disease (CKD).
Item T0

n (%)

 T6h

n (%)

 T24h

n (%)
Weight loss (involuntary) 13 (37.1%) 14 (40.0%) 13 (38.2%)
Malnutrition or BMI ≤ 20 6 (17.6%) 6 (17.1%) 6 (17.1%)
Nutritional supplements 4 (11.4%) 6 (17.1%) 5 (14.3%)
Food intake 21 (60.0%) 17 (48.6%) 16 (45.7%)
Appetite 19 (54.3%) 17 (48.6%) 18 (51.4%)
Table 2. Item response frequencies at T0, T6h, and T24h (only observed categories). Legend: BMI: body mass index; n = number of participants; T0 = first evaluation; T6h = 6h evaluation; T24h = 24h evaluation. Note: Frequencies and percentages of positive responses for each Renal iNUT item across the three assessment time points (T0, T6h, and T24h) in 35 hospitalized patients with CKD.

Reliability

Intra-rater Reliability (T0 vs T6h)

Intraclass correlation coefficients (ICC [3, 1]) for item-level agreement ranged from 0.78 to 1.00. The ICC for the total score was 0.83 (95% CI 0.69–0.91), indicating good reproducibility within the same rater (Table 3).

Item ICC 95% CI

(Lower)

 95% CI

(Upper)

 n
Item 1 0.82 0.67 0.91 35
Item 2 1.00 1.00 1.00 34
Item 3 0.78 0.60 0.88 35
Item 4 0.79 0.63 0.89 35
Item 5 0.78 0.60 0.88 35
Total 0.83 0.69 0.91 35
Table 3. Intraclass Correlation Coefficients [ICC (3, 1)] for Items and Total Score Between T0 and T6h. Legend: ICC = Intraclass correlation coefficients; n = number of participants; CI = Confidence Interval. Note: Intraclass correlation coefficients (ICC [3, 1]) and 95% confidence intervals (CI) for item-level and total scores obtained by the same rater at two time points (T0 and T6h).

Inter-rater reliability (T6h vs T24h)

Item-level ICC (2,1) values ranged from 0.83 to 1.00. The ICC for the total score was 0.90 (95% CI 0.82–0.95), indicating excellent agreement between different raters (Table 4).

Item ICC (2,1) 95% CI

(Lower)

 95% CI

(Upper)

 n
Item 1 0.94 0.88 0.97 34
Item 2 1.00 1.00 1.00 35
Item 3 0.90 0.80 0.95 35
Item 4 0.83 0.69 0.91 35
Item 5 0.83 0.69 0.91 35
Total 0.90 0.82 0.95 35
Table 4. ICC (2,1) (two-way random, absolute agreement) between T6h and T24h. Legend: ICC = Intraclass correlation coefficients; n = number of participants; CI = Confidence Interval. Note: Intraclass correlation coefficients (ICC [2, 1]) and 95% confidence intervals (CI) for item-level and total scores obtained by two different raters at T6h and T24h.

 

Discussion

This study set out to translate, culturally adapt, and psychometrically validate the Renal iNUT for use in Italian hospital settings, filling an important gap in renal-specific nutritional screening.

Malnutrition remains a common and complex complication in chronic kidney disease (CKD) [1, 2]. It contributes to higher morbidity, longer hospital stays, frequent readmissions, and rising healthcare costs [9]. Because of this, identifying nutritional risk early is essential to initiate prompt and effective interventions [27, 28]. The Renal iNUT was created to offer a concise, kidney-specific screening tool that combines anthropometric and dietary dimensions such as appetite, food intake, and oral nutritional supplement (ONS) use. These elements are highly relevant in CKD, where nutritional deterioration is often worsened by polypharmacy, uremic toxin buildup, gastrointestinal disturbances, and taste changes like dysgeusia, all of which reduce dietary intake [7, 8, 29]. By integrating these features, the tool allows for a more focused and clinically meaningful evaluation of nutritional risk. The process of translation, cultural adaptation, and validation followed a rigorous seven-phase protocol that has already been successfully applied in international studies [30]. This approach ensured that the Italian version maintained semantic alignment with the original tool while remaining appropriate for clinical use within the Italian healthcare system. The procedure included bilingual forward and back translations, review by a multidisciplinary committee, and an expert evaluation of each item’s clarity and cultural fit. Both the I-CVI and the S-CVI were above the recommended cutoffs, confirming the strength and reliability of the adapted version. Feedback gathered from 15 healthcare professionals, including nephrologists, dietitians, and nurses, confirmed that the Italian Renal iNUT was clear, practical, and easy to apply, with only minor wording adjustments required. Psychometric testing in a sample of 35 hospitalized CKD patients further supported its reliability, showing excellent reproducibility: intra-rater reliability (T0 vs T6 h) reached an ICC of 0.83 (95% CI 0.69–0.91), and inter-rater reliability (T6 h vs T24 h) achieved 0.90 (95% CI 0.82–0.95) [26]. These results are particularly noteworthy considering the difficulties inherent in assessing nutrition among CKD patients, where factors such as hydration status, inflammation, and metabolic alterations often interfere with anthropometric and biochemical measurements [31, 32]. From a clinical standpoint, the stable score distributions across repeated assessments, median 2.0 with consistent domain responses, underline the tool’s reliability for longitudinal monitoring. This is important because malnutrition in CKD is not static; it fluctuates with disease progression, dialysis regimens, comorbid conditions, and hospitalization episodes [33].

When compared with more general screening instruments such as the MUST [34] or the SGA [22], the Renal iNUT demonstrates several advantages [24, 35]. Traditional screening tools often rely heavily on body weight or BMI, yet these indicators can mask nutritional risk when patients present with fluid overload, sarcopenia, or protein–energy wasting [36]. The Renal iNUT offers a broader view: by including dietary intake, appetite, and the use of ONS, it captures CKD-specific conditions such as fluid imbalance and appetite loss, providing a more realistic picture of a patient’s nutritional status [24, 30]. Another advantage of the tool is the structured training offered to the professionals who use it. When staff receive standardized instruction, differences between observers tend to decrease, making the tool more consistent across units and professional roles [37, 38]. Incorporating this training into routine clinical practice could support wider and more reliable adoption of the Renal iNUT in nephrology settings [39]. The tool’s usefulness extends beyond nutritional screening alone. In older adults with CKD, malnutrition frequently overlaps with frailty, falls, longer hospital stays, and higher mortality rates [40]. Detecting nutritional risk early, through a CKD-specific tool like the Renal iNUT, can complement frailty assessments and help promote a more integrated and patient-centered model of care [24, 35]. Because nutritional decline and inflammation are closely linked, using the Renal iNUT alongside inflammatory or metabolic biomarkers may also enhance risk stratification and prognostic assessment [24, 41]. On a broader level, applying validated nutritional screening tools in a systematic way can contribute to shorter hospitalizations, fewer readmissions, and lower healthcare costs [42]. Embedding the Renal iNUT into standard care pathways could therefore benefit both patients and health systems [24]. Finally, as clinical nutrition becomes increasingly digitalized, there are growing opportunities to connect validated instruments like the Renal iNUT with electronic health records, mobile apps, and telemedicine systems. These integrations allow for real-time data entry, automatic scoring, and faster communication among multidisciplinary teams, ultimately supporting more efficient and coordinated nutritional care [43, 44]. In this context, artificial intelligence (AI) also holds promise: predictive algorithms trained on large clinical datasets could enhance risk prediction, personalize dietary strategies, and monitor trends over time. For CKD patients, whose nutritional trajectories often change rapidly, the combination of standardized screening instruments such as the Renal iNUT with AI-based technologies could represent a meaningful step toward precision nutrition and improved quality of care [45].

Future studies should also investigate how Renal iNUT scores relate to objective markers of nutritional status, such as serum albumin, inflammatory biomarkers, muscle strength, and body composition parameters, as well as to clinically meaningful outcomes including length of stay, readmissions, and mortality. Such evidence would provide a more comprehensive understanding of the clinical value of the tool and further support its use in routine nephrology practice.

Limitations

This study presents several limitations that should be acknowledged. First, it was carried out in a single Italian hospital, and therefore the findings may partly reflect local dietary habits, healthcare practices, and organizational models. While this setting enhances the cultural fit of the adaptation, it may restrict the broader applicability of the results to other regions or healthcare systems. The study sample was relatively small (n = 35). Although this number met the predefined requirements for estimating ICCs with adequate precision, it may not fully represent the diversity of the CKD population. Moreover, the short retest intervals (6–24 hours) helped to minimize clinical changes between assessments but could have introduced some degree of memory or learning bias among raters. Furthermore, we did not formally record the time required to complete each Renal iNUT assessment, and we were therefore unable to quantify its impact on workflow. In addition, we did not systematically collect biochemical and functional indicators of nutritional status (e.g., serum albumin, muscle strength, or muscle mass), which prevented us from evaluating the concurrent validity of the Renal iNUT against objective clinical markers. Finally, this investigation focused primarily on content validity and reliability. Other psychometric properties, such as construct, concurrent, and predictive validity, were not examined here and should be evaluated in future, larger-scale studies.

Relevance to clinical practice

The Italian adaptation of the Renal iNUT provides a fast, kidney-specific tool for detecting malnutrition in CKD patients and addresses a clear gap in daily clinical practice. By including key parameters such as appetite, food intake, and ONS use, the instrument captures nutritional risk more accurately than generic screening tools, which may fail in the presence of fluid overload or altered body composition. The Renal iNUT uses a standardized scoring system that helps nephrologists, dietitians, and nurses communicate more effectively and work toward a shared nutritional plan. The tool is easy to use, requires only a short period of training, and can be repeated several times during a patient’s hospital stay. This practicality makes it particularly useful for detecting early signs of nutritional decline and for triggering timely interventions aimed at preventing protein–energy wasting, reducing complications, and shortening recovery times. Thanks to its solid reproducibility, the Renal iNUT can be applied consistently from admission to discharge, ensuring continuity in the monitoring of nutritional status. Integrating the tool into electronic health records (EHRs) would make its use even smoother, automatic data capture and follow-up could be handled directly within the system. Beyond simplifying daily practice, this would enable real-time clinical decisions and generate valuable information for tracking hospital malnutrition at a national level. These datasets could in turn help health authorities refine care pathways and design more effective nutrition-related policies. In the near future, combining Renal iNUT data with artificial intelligence-based analytical platforms may further improve risk prediction and support more personalized nutritional care for patients with CKD. In summary, the Italian adaptation of the Renal iNUT stands out as a practical and reliable tool, one that promotes consistent screening, strengthens collaboration across disciplines, and contributes to better outcomes in nephrology care.

 

Conclusion

The Italian adaptation of the Renal iNUT resulted in a tool that remains true to the original version while being fully attuned to the linguistic and cultural characteristics of the Italian healthcare environment. Every domain, wording choice, and response option was carefully reviewed to reflect local dietary habits and clinical practice, making the instrument directly relevant to Italian patients and professionals. Clinically, having a renal-specific screening tool is a real step up from generic instruments. By focusing on appetite, actual food intake, and use of ONS, the Renal iNUT offers a more nuanced and sensitive picture of nutritional risk in CKD. Crucially, it can flag malnutrition even when usual markers, weight or BMI, are misleading because of fluid overload or altered body composition. Beyond accuracy, the tool helps standardize assessment across wards and roles, and it makes communication between nephrologists, dietitians, and nurses more consistent, bringing nutritional monitoring firmly into multidisciplinary CKD care. Because it is concise and easy to administer, it can be used routinely during a hospital stay to catch early decline and trigger timely action. Introducing a validated, kidney-specific screener into the Italian system addresses a clear gap: with malnutrition common in CKD and tightly linked to poor outcomes, the Renal iNUT could support earlier detection, better quality of care, and reductions in complications, length of stay, and costs. In summary, the Italian Renal iNUT is both a practical clinical tool and a step forward in nephrology care, promoting more proactive, standardized, and patient-centered nutritional management.

 

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Competencies of Nephrology Nurses in Italy: A Nationwide Cross-Sectional Study

Posted on Scarica PDF

Sara Morales Palomares

DOI: 10.69097/42-03-2025-09

Domenica Gazineo1, Desirèe Andreoli2, Sara Morales Palomares3, Addolorata Palmisano4, Mauro Parozzi5 Stefano Mancin6, Serenella Salvini7, Lea Godino8

AI tools were used to support language editing and translation, but not for content generation. No AI-generated content was included without human review and revision.

1 Governo clinico e qualità, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
2 Azienda Ospedaliera Santa Maria della Misericordia, Perugia, Italia
3 Dipartimento di Farmacia, Scienze della Salute e della Nutrizione (DFSSN), Università della Calabria, Rende, Italia; U.O.C di Nefrologia, Dialisi e Trapianto. Azienda Ospedaliera di Cosenza, Italia
4 Ospedali Riuniti Padova Sud “Madre Teresa di Calcutta”, Monselice, Italia
5 Università degli Studi di Milano, Scuola di Infermieristica, Campus "San Paolo", Asst Santi Paolo e Carlo, Milano, Italia
6 IRCCS Humanitas Research Hospital, Rozzano, Milano, Italia
7 Dipartimento delle Professioni Sanitarie e Sociali, Asl Roma 4, Civitavecchia, Roma, Italia
8 Unità di Genetica Medica, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia

Corresponding author:
Sara Morales Palomares RN, MSc, PhD,
Dipartimento di Farmacia, Scienze della Salute e della Nutrizione (DFSSN), Università della Calabria, Rende, Italia;
U.O.C di Nefrologia, Dialisi e Trapianto. Azienda Ospedaliera di Cosenza, Italia
Phone: +39 3404249439
Mail: sara.morales@unical.it

 

Abstract

Background. Nurses working in nephrology play a critical role in managing patients with kidney diseases, providing highly personalized care that integrates advanced technical and specialized competencies. However, the absence of a formal professional profile in Italy limits both professional development and the standardization of competencies. This study aims to explore the basic and advanced competencies of nephrology nurses to propose unified educational and professional standards.
Design. A cross-sectional study based on an ad hoc questionnaire was conducted between March and May 2024 among nurses working in nephrology within the National Health Service, with dissemination support from the Society of Nephrology Nurses. The questionnaire was structured into three sections: theoretical knowledge, practical competencies, and professional development, and was validated through a pilot phase. Data were analyzed using SPSS 27 software.
Results. The study involved 296 nurses, 77% of whom were employed in hemodialysis. Only 14% reported having completed specific post-basic training courses, while 71% expressed interest in further educational opportunities. Technical-specialist competencies in hemodialysis were widely applied, but significant gaps were identified in pharmacological management (37% with moderate or low competency levels) and nutrition (35% with moderate or low competency levels). Decision-making and communication skills scored higher, with 65% of participants perceiving themselves at a high or excellent level in these areas.
Conclusion. This study represents an important step towards defining a comprehensive professional profile for nephrology nurses in Italy. The findings underscore the need of standardized educational and professional frameworks to promote formal recognition of this specialization while enhancing the quality of care through advanced competencies, humanized approaches, and personalized patient support.

Keywords: nephrology, nursing competencies, professional profile, post-basic training, Italy, nationwide cross-sectional study

Sorry, this entry is only available in Italiano.

Introduzione

L’infermiere specializzato nel campo della nefrologia svolge un ruolo fondamentale nella gestione e nel trattamento dei pazienti affetti da malattia renale [1]. Questo ambito, altamente complesso, comprende non solo le terapie sostitutive della funzione renale, come la dialisi e il trapianto di rene, ma anche interventi conservativi basati su regimi dietetici personalizzati, supporti nutrizionali specifici e cure palliative mirate [2, 3].

Grazie a una formazione specifica, questo professionista è in grado di gestire e di monitorare le condizioni cliniche, offrendo un’assistenza personalizzata che integra competenze tecniche avanzate e supporto umano [4]. Tuttavia, nonostante l’importanza di questa figura all’interno del team sanitario, in Italia la specializzazione infermieristica in nefrologia non dispone ancora di un riconoscimento formale, contrariamente a quanto avviene in altri contesti sanitari internazionali [5]. Questa carenza di riconoscimento istituzionale si traduce in un’assenza di una chiara e formale descrizione del profilo professionale, che delinei in modo dettagliato le attività e le responsabilità specifiche degli infermieri in nefrologia. Di conseguenza, la mancanza di un quadro normativo ben definito può limitare la valorizzazione delle competenze acquisite attraverso la formazione e l’esperienza sul campo, influenzando la percezione del ruolo dell’infermiere nefrologico sia tra i professionisti stessi che all’interno delle strutture sanitarie. Tale ambiguità comporta implicazioni significative non solo per lo sviluppo professionale, ma anche per la qualità dell’assistenza erogata e per la sicurezza dei pazienti [6].

La letteratura evidenzia come le competenze specialistiche siano essenziali per garantire un’assistenza efficace, soprattutto nei contesti di emodialisi, dove l’esecuzione di procedure come la incannulazione e la gestione delle apparecchiature richiedono un alto livello di competenza. Studi come quelli condotti da Saeed e colleghi [7] dimostrano che una corretta esecuzione delle tecniche di incannulazione è fondamentale per prevenire complicazioni, quali la perdita ematica e altre problematiche che possono compromettere il benessere del paziente.

Oltre alle competenze tecniche, è fondamentale che gli infermieri specializzati dispongano di abilità comunicative e di capacità di advocacy. La comunicazione efficace non solo migliora la soddisfazione e la fiducia del paziente, come evidenziato da Salmani e colleghi [8], ma gioca anche un ruolo cruciale nella gestione delle ansie e delle incertezze che spesso accompagnano le terapie di lunga durata, come l’emodialisi. Questi infermieri, attraverso il loro supporto costante, fungono da intermediari tra il paziente e il resto del team sanitario, aiutando a interpretare e gestire il piano terapeutico e a promuovere l’aderenza al trattamento [9].

Tuttavia, uno dei principali ostacoli al pieno sviluppo di queste competenze è rappresentato dalla carenza di programmi di formazione continua e di risorse adeguate. Nobahar & Tamadon [10] hanno evidenziato che una conoscenza approfondita delle tecnologie e delle apparecchiature è essenziale per rispondere efficacemente alle esigenze dei pazienti, mentre Fanta e colleghi [11] hanno dimostrato che gli infermieri che ricevono formazione specifica sono più propensi a dimostrare pratiche di alta qualità. Inoltre, distinguere tra infermieri di assistenza di base e quelli con competenze avanzate o specialistiche è essenziale per migliorare la qualità dell’assistenza e contenere i costi sanitari [12]. Questi dati risultati evidenziano la necessità di investire nella formazione e nell’aggiornamento continuo degli infermieri specializzati, al fine di mantenere standard di cura elevati e affrontare con successo le sfide cliniche.

In conclusione, la mancanza di una descrizione formale del profilo professionale per gli infermieri che lavorano in ambito nefrologico in Italia rappresenta una lacuna significativa che limita sia la definizione delle loro competenze sia le opportunità di sviluppo professionale. Questo studio nasce con l’obiettivo di indagare le reali attività e competenze degli infermieri italiani che operano in ambito nefrologico, per evidenziare le sfide e le opportunità legate a questa specializzazione e per proporre un modello che valorizzi e riconosca formalmente le loro capacità e competenze all’interno del Sistema Sanitario Nazionale.

 

Obiettivo

Lo scopo di questo studio è analizzare la percezione e l’applicazione delle competenze infermieristiche, di base e avanzate, tra i professionisti che operano in ambito nefrologico in Italia, al fine di identificare aree di forza, bisogni formativi e opportunità per la definizione di uno standard professionale condiviso.

 

Materiali e metodi

Studio osservazionale trasversale condotto attraverso la compilazione di un questionario online. La popolazione target comprende tutti gli infermieri di area nefrologica che lavorano in Italia. La partecipazione allo studio è subordinata al rispetto di specifici criteri di eleggibilità e all’ottenimento del consenso informato. I criteri di inclusione sono:

  • essere infermieri;
  • avere un’età compresa tra i 21 e i 65 anni;
  • essere inscritti all’OPI;
  • lavorare da oltre sei mesi in ambito nefrologico.

I criteri di esclusione sono:

  • studenti di infermieristica;
  • infermieri pensionati;
  • lavorare all’estero.

Procedura e strumenti di studio

I partecipanti sono stati arruolati su base volontaria. Il questionario è stato proposto a tutti gli infermieri che lavorano nei contesti di cura di area nefrologica nel Servizio Sanitario Nazionale iscritti alla Società Infermieri Area Nefrologica (SIAN), con la richiesta di divulgarlo anche ad altri colleghi della stessa area specialistica. L’arruolamento è avvenuto tra marzo e maggio 2024.

Lo studio ha previsto la compilazione di un questionario online anonimo, caricato su Microsoft Forms. Il questionario è stato redatto e adattato sulla base della revisione della letteratura esistente [6, 12–15].

Il questionario è strutturato in 18 aree tematiche suddivise in tre sezioni: conoscenze teoriche specializzate, competenze nella pratica clinica e capacità di sviluppo professionale (Figura 1). Per ogni area tematica viene indagata la percezione dei partecipanti sulle competenze possedute e il livello di impiego delle stesse nella pratica clinica. La percezione e l’applicazione delle proprie skills nell’ambito dell’infermieristica nefrologica sono considerate come indicative della competenza dei partecipanti in tale ambito. Oggetto di indagine sono inoltre le caratteristiche socio-demografiche dei partecipanti.

Figura 1 Schema del questionario sulle competenze infermieristiche in nefrologia
Figura 1. Schema del questionario sulle competenze infermieristiche in nefrologia: tre sezioni di indagine:  (1) conoscenze teoriche specializzate, (2) competenze nella pratica clinica, e (3) capacità di sviluppo professionale.

Fase pilota

Prima della somministrazione su larga scala, è stata condotta una fase pilota per valutarne la fattibilità, la chiarezza e la comprensibilità. Un campione di 20 infermieri ha partecipato a questa fase preliminare, durante la quale sono state condotte interviste cognitive finalizzate a esplorare in profondità la comprensione degli item, l’interpretazione dei termini utilizzati e l’adeguatezza del linguaggio rispetto al contesto professionale degli infermieri [16–18]. Questo approccio qualitativo, particolarmente utile per individuare eventuali ambiguità o fraintendimenti, ha confermato la chiarezza e la coerenza del questionario, senza evidenziare la necessità di modifiche sostanziali. Poiché l’obiettivo principale di questa fase era il miglioramento qualitativo dello strumento piuttosto che la sua validazione psicometrica, non sono stati calcolati indicatori statistici come l’alpha di Cronbach. I risultati di questa fase hanno quindi confermato l’adeguatezza del questionario, consentendo l’avvio dell’arruolamento su scala nazionale.

Analisi statistica

I dati raccolti sono stati organizzati in variabili nominali, rendendo più agevole la loro elaborazione statistica tramite il programma Statistical Package for Social Science 27.0 per Windows (IBM SPSS v. 27.0).

Considerazioni etiche

Lo studio ha seguito i principi etici della Dichiarazione di Helsinki e ha ottenuto l’approvazione dal Comitato di Ricerca della SIAN in data 20 gennaio 2024.

 

Risultati

Caratteristiche del campione

Durante la fase di somministrazione del questionario online, 322 infermieri/e hanno avuto accesso al link per la compilazione. Di questi, 302 (93,8%) hanno espresso il consenso informato alla partecipazione allo studio. Tuttavia, 6 partecipanti sono stati esclusi in quanto non conformi ai criteri di inclusione: 5 operavano in contesti infermieristici non nefrologici e 1 dichiarava di esercitare la propria attività professionale all’estero. Pertanto, il numero finale dei partecipanti considerati idonei per l’analisi è stato di 296, corrispondente al 98,0% di coloro che avevano dato il consenso alla partecipazione.

Per quanto riguarda la distribuzione dei partecipanti in base al genere, 217 erano di sesso femminile (73%), 75 di sesso maschile (25%) e quattro hanno preferito non dichiarare il proprio genere (1%). In relazione al livello di formazione più alto ottenuto in ambito infermieristico, 101 partecipanti (34%) hanno dichiarato di possedere un Master di I livello, 94 (32%) una laurea triennale, e 80 (27%) un diploma. Un numero inferiore, 14 partecipanti (5%) hanno indicato una laurea magistrale, 6 (2%) un Master di II livello, mentre un partecipante (<1%) ha riportato di aver conseguito un dottorato di ricerca.

Analizzando la distribuzione geografica, 56 partecipanti (19%) lavoravano in Lombardia, 49 (17%) in Campania, 38 (13%) in Emilia-Romagna e 21 (7%) in Veneto. Le altre regioni hanno avuto una distribuzione complessiva di 136 partecipanti (44%). Questo dato evidenzia una partecipazione eterogenea dei partecipanti distribuiti su gran parte del territorio nazionale, con una maggiore concentrazione nelle regioni sopra menzionate.

In merito all’attività principale svolta, la maggior parte degli infermieri, pari a 266 (90%), ha indicato che svolge attività clinico-assistenziale centrata sulla cura del paziente. Un numero inferiore, 28 partecipanti (9%), ha dichiarato di essere impegnato in attività di coordinamento o management, mentre due partecipanti (1%) hanno riportato di svolgere attività legate alla formazione. Nessuno dei partecipanti ha indicato la ricerca come attività principale.

In relazione al servizio in cui attualmente lavorano, 229 partecipanti (77%) erano impiegati in servizi di emodialisi, 33 (11%) lavoravano in reparti di nefrologia, 31 (10%) in dialisi peritoneale e 3 (1%) erano attivi in setting territoriali di area nefrologica.

Per quanto concerne la frequenza di corsi post-base universitari specifici in area nefrologica, 237 partecipanti (80%) hanno dichiarato di non aver seguito corsi di formazione in tale ambito. Al contrario, 41 partecipanti (14%) hanno riferito di aver frequentato corsi post-base specifici, mentre 18 (6%) hanno indicato di non ricordare se ne avessero seguito qualcuno.

Infine, alla domanda sull’interesse per ricevere maggiore formazione in ambito nefrologico per supportare il lavoro quotidiano, 210 partecipanti (71%) hanno risposto in modo affermativo, dichiarando di voler ricevere più formazione. Un totale di 64 partecipanti (22%) ha indicato che sarebbe interessato, ma che non rappresenta una priorità, mentre 17 (6%) non erano sicuri. Un numero inferiore, 5 partecipanti (2%) hanno dichiarato di non essere per nulla interessati a ricevere ulteriore formazione.

Conoscenze teoriche specializzate

L’analisi delle competenze infermieristiche specifiche in ambito nefrologico ha evidenziato che il 29% dei partecipanti applica frequentemente le proprie conoscenze (“spesso”), seguito dal 20% che le utilizza “sempre” e un altro 20% che le applica “a volte”. Una quota rilevante, pari al 16%, ha riferito di impiegarle “raramente”, mentre il 15% ha dichiarato di non utilizzarle “mai”. In termini di percezione del proprio livello di competenza, il 37% si considera a un livello “medio”, un ulteriore 37% si percepisce con un livello “alto”, e l’8% riporta un livello “eccellente”. Tuttavia, il 12% dei partecipanti percepisce un livello “basso” e il 5% afferma di non avere competenze in quest’area (Figura 2.a).

Per quanto riguarda le conoscenze sui farmaci specialistici per la malattia renale cronica, il 30% dei partecipanti applica tali competenze “a volte”, il 25% “spesso” e solo il 7% “sempre”. Una parte considerevole utilizza queste competenze “raramente” (24%) o “mai” (14%). La percezione delle competenze evidenzia che il 44% dei partecipanti si considera a un livello “medio”, il 26% a un livello “basso”, il 20% a un livello “alto” e solo il 3% si percepisce con un livello “eccellente”, mentre il 7% riferisce di non avere alcuna competenza (Figura 2.b).

L’analisi delle competenze relative alla gestione nutrizionale della malattia renale cronica ha mostrato che il 29% dei partecipanti applica tali competenze “spesso”, il 23% “a volte” e il 20% “sempre”. Il 14% le utilizza “raramente” e un ulteriore 14% “mai”. Per quanto concerne la percezione del proprio livello di competenza, il 39% si considera a un livello “medio”, il 30% “alto”, il 17% “basso” e il 9% “eccellente”, con il 5% che riferisce di non possedere competenze in quest’area (Figura 2.c).

L’analisi delle competenze riabilitative per la malattia renale cronica mostra che il 26% dei partecipanti utilizza tali competenze “a volte”, il 24% “spesso” e solo l’8% “sempre”. Il 22% le applica “raramente” e il 20% “mai”. Per la percezione del livello di competenza, il 37% si considera a un livello “medio”, il 23% “basso”, il 20% “alto” e il 5% “eccellente”, mentre il 15% riporta di non possedere competenze in quest’area (Figura 2.d).

Infine, l’analisi sull’applicazione delle competenze legate ai metodi e strumenti di valutazione per la malattia renale cronica indica che il 28% le utilizza “a volte”, il 24% “spesso” e il 7% “sempre”. Una parte significativa dei partecipanti ha dichiarato di impiegarle “raramente” (20%) o di non utilizzarle mai (21%). La percezione del livello di competenza mostra che il 41% si considera a un livello “medio”, il 23% “alto”, il 18% “basso” e solo il 5% “eccellente”, mentre il 13% non possiede alcuna competenza in quest’area (Figura 2.e).

Il dettaglio delle analisi delle singole domande del questionario è riportato nel Materiale Supplementare in Tabella S1.

 

 

Conoscenze teoriche specializzate. (a) Conoscenze teoriche delle specialità nefrologiche
Figura 2. Conoscenze teoriche specializzate. (a) Conoscenze teoriche delle specialità nefrologiche (b) Conoscenze dei farmaci specialistici per la malattia renale cronica (c) Conoscenze sulla gestione nutrizionale della malattia renale cronica (d) Esercizi per la malattia renale cronica e conoscenze riabilitative (e) Applicazioni di metodi e strumenti di valutazione relativi alla malattia renale cronica.

Competenze nella pratica clinica

L’analisi delle competenze infermieristiche in ambito nefrologico ha delineato un quadro dettagliato e specifico delle capacità pratiche e della percezione delle competenze nei diversi settori specialistici. Per quanto concerne le competenze tecnico-specialistiche legate all’emodialisi, il 70% dei partecipanti ha dichiarato di utilizzarle “sempre”, seguito dal 12% che le applica “spesso” e dal 6% che le utilizza “a volte”. Una minoranza riferisce un impiego “raro” (1%) o “mai” (10%). La percezione del proprio livello di competenza in questa area vede il 43% dei partecipanti considerarsi a un livello “eccellente”, il 36% a un livello “alto”, il 9% a un livello “medio”, il 4% a un livello “basso” e il 7% dichiara di non possedere alcuna competenza (Figura 3.a).

Relativamente alle competenze nella dialisi peritoneale, i risultati hanno evidenziato una distribuzione più eterogenea: il 54% dei partecipanti ha riferito di non applicare mai queste competenze, il 13% le utilizza “sempre” o “raramente”, l’11% le impiega “a volte” e il 9% le applica “spesso”. La percezione del livello di competenza mostra il 43% senza alcuna competenza, il 17% a un livello “basso”, il 16% a un livello “medio”, il 15% a un livello “alto” e il 9% a un livello “eccellente” (Figura 3.b).

Per le competenze tecnico-specialistiche inerenti al trapianto di rene, il 72% dei partecipanti ha indicato di non applicarle mai, il 12% di farlo “a volte”, il 9% “raramente”, il 5% “spesso” e solo il 2% “sempre”. La percezione delle competenze evidenzia che il 44% dei partecipanti non possiede alcuna competenza, il 22% si percepisce a un livello “basso” o “medio”, il 10% si considera a un livello “alto” e solo il 2% riporta un livello “eccellente” (Figura 3.c).

Le abilità comunicative si distinguono per un impiego frequente: il 54% dei partecipanti ha riferito di utilizzarle “sempre”, il 35% “spesso” e l’8% “a volte”. Solo il 2% le usa “raramente” e l’1% non le impiega “mai”. La percezione del livello di competenza in quest’area è “alta” per il 48%, “eccellente” per il 26%, “media” per il 23% e “bassa” per il 2%, con nessun partecipante che ha riportato una mancanza di competenze (Figura 3.d).

La capacità collaborativa è applicata “spesso” dal 25% e “sempre” dal 23%, mentre il 19% dei partecipanti le impiega “a volte”. Il 16% riferisce di usarle “raramente” e un ulteriore 16% “mai”. La percezione del livello di competenza in quest’ambito varia: il 32% si considera a un livello “medio”, il 24% “alto”, il 16% “eccellente”, il 17% “basso” e il 10% dichiara di non possedere competenze (Figura 3.e).

Per quanto riguarda le competenze gestionali, il 33% dei partecipanti le utilizza “sempre”, il 32% “spesso” e il 21% “a volte”. Il 10% riferisce un impiego “raro” e il 5% non le applica mai. La percezione delle competenze mostra che il 38% si considera a un livello “alto”, il 29% “medio”, il 21% “eccellente”, l’11% “basso” e il 2% dichiara di non avere alcuna competenza in quest’area (Figura 3.f).

Le capacità pedagogiche risultano meno frequentemente utilizzate: il 37% non le applica mai, il 22% le utilizza “a volte”, il 16% “raramente”, il 15% “spesso” e il 10% “sempre”. Per la percezione delle competenze, il 34% si percepisce a un livello “medio”, il 23% “alto”, l’8% “eccellente”, il 18% “basso” e il 17% riporta una totale assenza di competenze (Figura 3.g).

Per le capacità di educazione sanitaria, il 24% dei partecipanti le utilizza “a volte”, il 23% “spesso” e il 12% “sempre”, mentre il 21% non le impiega mai e il 20% le usa “raramente”. La percezione delle competenze indica che il 36% dei partecipanti si considera a un livello “medio”, il 25% “alto” e il 7% “eccellente”, mentre il 20% si percepisce a un livello “basso” e il 12% dichiara di non avere competenze in quest’area (Figura 3.h).

La cura umanistica evidenzia un utilizzo frequente: il 44% la impiega “sempre”, il 41% “spesso” e il 12% “a volte”, con solo il 3% che la utilizza “raramente” e l’1% che non la applica mai. La percezione della competenza è “alta” per il 45%, “eccellente” per il 28% e “media” per il 24%, con il 3% a livello “basso” e nessuno senza competenze (Figura 3.i).

Infine, la capacità decisionale è applicata “spesso” dal 41% e “sempre” dal 26% dei partecipanti. Il 42% si percepisce a un livello “alto”, il 33% a un livello “medio” e il 19% a un livello “eccellente”, mentre il 6% riporta un livello “basso” e nessuno dichiara l’assenza di competenze (Figura 3.l).

Il dettaglio delle analisi delle singole domande del questionario è riportato nel Materiale Supplementare in Tabella S1.

Figura 3. Competenze nella pratica clinica. (a) Emodialisi: Capacità tecnico-specialistiche.
Figura 3. Competenze nella pratica clinica. (a) Emodialisi: Capacità tecnico-specialistiche. (b) Dialisi peritoneale: Capacità tecnico-specialistiche. (c) Trapianto di rene: Capacità tecnico-specialistiche. (d) Abilità comunicative. (e) Capacità collaborativa. (f) Capacità gestionale (g) Capacità pedagogiche (h) Capacità di educazione sanitaria del paziente (i) Competenze nella cura umanistica (l) Capacità decisionale.

Capacità di sviluppo professionale

L’analisi delle competenze infermieristiche in ambito di ricerca ha evidenziato che il 22% dei partecipanti dichiara di non applicare mai queste competenze, mentre il 25% le utilizza “raramente”. Il 30% dei rispondenti ha riferito di impiegarle “a volte”, il 18% “spesso” e solo il 6% “sempre”. Per quanto riguarda la percezione del proprio livello di competenza, il 38% si considera a un livello “medio”, il 29% a un livello “basso”, il 16% a un livello “alto” e il 6% si percepisce come “eccellente”. Una quota pari all’11% dichiara di non possedere competenze in quest’area (Figura 4.a).

Per quanto concerne la capacità di sviluppo personale, l’analisi ha evidenziato una distribuzione eterogenea nella frequenza di utilizzo. Il 23% dei partecipanti ha affermato di non applicare mai tali competenze, mentre il 27% le utilizza “raramente” e il 29% “a volte”. Una minoranza impiega queste competenze “spesso” (15%), e solo il 6% le utilizza “sempre”. Relativamente alla percezione delle proprie competenze, il 39% si ritiene a un livello “medio”, il 26% a un livello “basso”, il 16% a un livello “alto” e il 5% a un livello “eccellente”. Il 14% dei partecipanti dichiara di non avere competenze in quest’ambito (Figura 4.b).

Infine, l’analisi della capacità di autoapprendimento ha rivelato che il 31% dei partecipanti utilizza questa competenza “a volte”, il 24% “spesso” e il 14% “sempre”. Il 16% riporta di impiegarla “raramente” e il 15% “mai”. Per quanto riguarda la percezione del livello di competenza, il 42% si considera a un livello “medio”, il 26% a un livello “alto” e il 10% a un livello “eccellente”. Una quota del 14% si percepisce a un livello “basso” e l’8% ha dichiarato di non possedere alcuna competenza in questo ambito (Figura 4.c).

Il dettaglio delle analisi delle singole domande del questionario è riportato nel Materiale Supplementare in Tabella S1.

Figura 4. Capacità di sviluppo professionale. (a) Capacità di ricerca (b) Capacità di sviluppo personale (c) Capacità di autoapprendimento.
Figura 4. Capacità di sviluppo professionale. (a) Capacità di ricerca (b) Capacità di sviluppo personale (c) Capacità di autoapprendimento.

 

Discussione

Linee Guida internazionali descrivono specifici interventi per la gestione della malattia renale cronica e per il trattamento olistico del paziente al fine di ridurre il rischio di progressione della malattia [19]. Le Linee guida della National Kidney Foundation (NKF), negli Stati Uniti, sottolineano l’importanza di programmi di formazione continua e di competenze specialistiche in aree come la dialisi e il trapianto renale, in linea con i temi emersi nel nostro studio [20]. Analogamente, le Linee guida dell’ European Renal Association (ERA) evidenziano la necessità di una formazione avanzata specifica per gli infermieri, in particolare nell’ambito della dialisi peritoneale e dell’assistenza ai pazienti con insufficienza renale cronica [21].

In Italia, il Ministero della Salute sottolinea l’importanza della definizione e del consolidamento delle competenze come azione indispensabile per garantire cure sicure ed efficaci [22]. Tuttavia, la letteratura nazionale, ad oggi, al meglio delle nostre conoscenze, non ha ancora delineato in modo dettagliato le competenze di base e avanzate degli infermieri di area nefrologica, né è stata formulata una descrizione formale del profilo professionale. I dati emersi dalla presente indagine offrono una panoramica delle competenze percepite dagli infermieri, della loro frequenza di applicazione e del grado di preparazione autovalutato dagli stessi professionisti.

I risultati di questo studio suggeriscono che, sebbene una parte significativa degli infermieri ritenga di possedere conoscenze e competenze adeguate, esiste una porzione non trascurabile che percepisce la necessità di migliorare la propria formazione in ambiti specifici, come la gestione farmacologica, la nutrizione e la riabilitazione. In particolare, l’80% dei partecipanti ha dichiarato di non aver seguito corsi di formazione post-base specifici, ma il 71% ha espresso interesse per percorsi formativi aggiuntivi. Questo dato riflette un gap significativo tra l’offerta formativa disponibile e le esigenze percepite dagli operatori. La formazione mirata, pertanto, rappresenta uno strumento cruciale per garantire un’assistenza di qualità e rispondere alle crescenti esigenze dei pazienti nefropatici, in linea con quanto riportato dallo studio di Andreoli [23].

Le competenze tecnico-specialistiche nell’emodialisi risultano ampiamente applicate, con una parte significativa dei partecipanti che si considera a un livello alto o eccellente in quest’ambito. Tuttavia, le competenze legate alla dialisi peritoneale e al trapianto renale mostrano un utilizzo e una percezione delle capacità decisamente inferiori. Le Linee guida internazionali [20, 21] supportano la nostra osservazione che, sebbene in Italia siano emerse carenze nella formazione avanzata degli infermieri nefrologici, tali esigenze di formazione mirata sono condivise a livello globale, in particolare per quelle tecniche meno frequentemente applicate, come la dialisi peritoneale. Come descritto nella revisione sistematica e meta-analisi di Nopsopon T. et al. (2022), gli infermieri impegnati in attività specialistiche, come ad esempio nella dialisi peritoneale, grazie al loro apporto educativo, assistenziale e alla formazione specialistica, migliorano la qualità di vita dei pazienti e riducono il rischio di peritoniti [24]. Le lacune evidenziate nelle competenze sulla dialisi peritoneale potrebbero essere attribuite sia a una minore esposizione clinica, come suggerito dalla bassa percentuale di partecipanti operanti in tale ambito, sia a una carenza di formazione specifica. La distinzione tra questi due fattori è cruciale, poiché implica strategie d’intervento differenti: da un lato, favorire una distribuzione più equa delle esperienze professionali nelle diverse modalità dialitiche; dall’altro, rafforzare l’offerta formativa, sia a livello accademico che tramite programmi di aggiornamento post-base, al fine di garantire un’adeguata preparazione anche in contesti meno frequentemente affrontati nella pratica clinica. Tale scenario sottolinea l’urgenza di promuovere percorsi formativi più uniformi e trasversali, capaci di fornire una preparazione completa e omogenea per affrontare efficacemente la complessità dell’assistenza nefrologica.

Un aspetto positivo emerso dallo studio riguarda le competenze trasversali, come le abilità comunicative e la capacità decisionale, che sono percepite come elevate dalla maggior parte dei partecipanti. Queste competenze rappresentano un elemento cruciale per l’assistenza in nefrologia, un ambito in cui la cronicità delle malattie richiede un approccio centrato sulla persona e sulla relazione terapeutica [23–25].

La necessità di definire chiaramente le competenze degli infermieri di area nefrologica non rappresenta soltanto un’esigenza operativa, ma una priorità per il progresso della professione. Misure raccomandate a livello internazionale indicano come la standardizzazione dei percorsi formativi e la definizione di profili professionali chiari siano essenziali per garantire un’assistenza di qualità nel settore nefrologico. Come evidenziato da Melnyk e colleghi [26], lo sviluppo di competenze avanzate orientate alla pratica basata sulle evidenze risulta indispensabile per garantire un miglioramento della qualità dell’assistenza sanitaria e degli esiti clinici dei pazienti. In Italia, il contesto dell’assistenza infermieristica specialistica evidenzia un crescente riconoscimento della necessità di competenze altamente qualificate in molteplici ambiti. Esempi significativi includono l’area critica [27–30], la cardiologia [29, 30], le cure palliative [31], la genetica clinica [32, 33], le neuroscienze [34, 35], la neonatologia [36] e l’oncologia [37, 38]. Questi settori rappresentano aree chiave che richiedono un costante aggiornamento e una formazione specialistica mirata per rispondere efficacemente alle sfide poste da quadri clinici sempre più complessi.

L’evoluzione della pratica infermieristica richiede un impegno continuo nel definire e rafforzare le competenze specialistiche, in linea con i progressi scientifici e le necessità dei pazienti. La formazione degli infermieri, in particolare in aree complesse come la nefrologia, non può essere considerata un elemento statico, ma deve adattarsi dinamicamente ai cambiamenti del contesto sanitario e alle sfide emergenti. Un approccio integrato, che combini formazione accademica, aggiornamento continuo e politiche sanitarie mirate, rappresenta la chiave per affrontare in modo efficace tali esigenze. L’infermiere di area nefrologica deve essere adeguatamente preparato a rispondere alle sfide del futuro, garantendo un’assistenza che sia allo stesso tempo sicura.

Alla luce di queste evidenze, risulta fondamentale avviare un confronto istituzionale con attori chiave del sistema sanitario, come il Ministero della Salute e la Federazione Nazionale degli Ordini delle Professioni Infermieristiche (FNOPI), per tradurre i risultati dello studio in azioni concrete. In particolare, i dati raccolti possono costituire una base solida per definire un profilo professionale ufficiale dell’infermiere nefrologico e promuovere l’elaborazione di standard formativi nazionali per la formazione post-base. Tali interventi favorirebbero non solo il riconoscimento formale della specializzazione, ma anche l’equità nell’accesso alla formazione e la qualità dell’assistenza su tutto il territorio nazionale.

 

Limiti

I limiti di questo studio risiedono principalmente nella natura auto-compilata del questionario, che potrebbe aver introdotto un potenziale bias di risposta legato alla soggettività delle percezioni e all’autovalutazione delle proprie competenze, in particolare in ambiti come la comunicazione o la gestione multidisciplinare. Per mitigare questo rischio, le domande sono state formulate in modo chiaro, specifico e riferite a situazioni professionali concrete, e la comprensibilità del questionario è stata confermata attraverso una fase pilota con interviste cognitive. Tuttavia, la soggettività delle risposte rimane un elemento intrinseco alla metodologia adottata, e va tenuta in considerazione nell’interpretazione dei risultati.

Sebbene il questionario fosse rivolto a infermieri operanti su tutto il territorio italiano, il campione si è rivelato maggiormente rappresentativo del contesto del Nord Italia, da cui proviene circa il 44% dei partecipanti. Tale concentrazione geografica potrebbe aver influenzato i risultati, in particolare per quanto riguarda l’accesso alle opportunità formative, le risorse disponibili e l’organizzazione dei servizi. Questo potenziale bias territoriale rappresenta un aspetto rilevante, poiché le differenze regionali possono riflettersi sulla percezione delle competenze e sui bisogni professionali espressi. In aggiunta, l’ambito lavorativo prevalente è risultato essere quello dell’emodialisi, con una partecipazione limitata di professionisti attivi in altri ambiti assistenziali della nefrologia. Questa distribuzione non omogenea ha rappresentato un limite significativo, poiché non ha permesso di condurre analisi inferenziali approfondite per confrontare le competenze percepite nei diversi contesti lavorativi o nelle diverse aree geografiche. Tali aspetti sottolineano la necessità di un campionamento più rappresentativo e stratificato nei futuri studi per ottenere una visione più completa delle competenze infermieristiche a livello nazionale.

Questi limiti, pur non compromettendo la validità generale dei risultati, evidenziano la necessità di condurre studi futuri con un campionamento più rappresentativo e metodologie di raccolta dati che permettano una valutazione più precisa e articolata delle competenze infermieristiche in ambito nefrologico.

 

Conclusione

Questo studio rappresenta un primo passo verso la definizione di un profilo professionale chiaro e condiviso per gli infermieri di area nefrologica in Italia. I risultati evidenziano una buona padronanza delle competenze tecnico-specialistiche nell’emodialisi, ma anche lacune significative in ambiti quali la dialisi peritoneale, il trapianto renale e la gestione farmacologica e nutrizionale. Tali evidenze sottolineano l’urgenza di sviluppare standard formativi e professionali univoci, promuovendo il riconoscimento formale di questa specializzazione e garantendo una formazione più uniforme su tutto il territorio nazionale.

Le evidenze raccolte offrono una base solida per avviare un dialogo costruttivo con tutti gli stakeholder del settore sanitario, finalizzato a colmare le lacune emerse e a valorizzare il ruolo degli infermieri nefrologici. Un investimento mirato nel miglioramento delle competenze non solo contribuirebbe a rendere i percorsi diagnostici e terapeutici più efficaci, ma anche a favorire un approccio assistenziale centrato sul paziente, in grado di promuovere una relazione di cura profonda e un’educazione alla salute più mirata.

In futuro, sarà fondamentale continuare a monitorare e sviluppare le competenze infermieristiche in ambito nefrologico, tenendo conto delle esigenze di un sistema sanitario in continua evoluzione, delle sfide poste dalle nuove tecnologie e dalla medicina personalizzata. Tali interventi contribuiranno non solo a migliorare gli esiti clinici, ma anche a consolidare il ruolo degli infermieri nefrologici come figure centrali nel team sanitario e nella gestione complessa dei pazienti con malattia renale cronica.

 

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Nephrology and nephrologists in Italy between the two World Wars

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Attilio Losito

Attilio Losito

Già direttore della Struttura complessa di Nefrologia Dialisi e Trapianto dell'Ospedale Santa Maria della Misericordia di Perugia.

Corrispondenza a:
Attilio Losito
Via Pellini 4, 06123 Perugia Italia
email: alosito3@gmail.com

 

Abstract

The First World War was a turning point for medicine worldwide and the following 20 years brought many important innovations. Kidney studies in Italy were part of this general trend. In this contribution, all the papers relating to kidney physiology, pathology and therapeutics produced by Italian scientists in the years between the two World Wars are retrieved and examined. The authors who produced strictly nephrological articles are also singled out and their activity described. This research retrieved 638 articles dealing with kidneys and published by Italian scientists over the period described. The topics covered were up-to-date, and the level was consistent with that of foreign contemporaries. Among the authors, a group of young scientists particularly dedicated to the study of the kidney emerges. Most of them would subsequently be among the founders of the Italian Society of Nephrology and leaders of Italian nephrology.

Keywords: history, nephrology, Italy, scientists, World Wars

Introduction

World War I was a turning point for medicine. Giorgio Cosmacini, doctor and historian of medicine, in his book “War and Medicine” defines war as a “paradoxical” source of progress from a medical point of view [1]. The need to treat a huge number of soldiers wounded and/or suffering from serious and new pathologies forced doctors to seek new, previously unknown, answers to deal with new emergency situations. The results of this research had a tremendous impact on world medicine in the years following the conflict.

The Italian doctors, especially the younger ones, who found themselves serving in war zones also benefited from those experiences and from contacts with colleagues in the allied armies. The clinical and research approach changed, both in terms of timing and methods. Kidney diseases occupied a prominent position among war-related morbidities. For example, since the first months of the conflict, there had been reports of an apparently new type of “nephritis”: the “trench nephritis” or war nephritis.
This new form of nephropathy attracted the attention of the greatest clinicians of the time including William Osler (1849-1919) [2]. Italian doctors promptly turned their attention to this new form and such was the interest that the first post-war congress of the Italian Society of Internal Medicine dedicated a session to it. Significantly, this meeting was held in Trieste that, at the time, had just become Italian (Fig. 1) [3]. Due to the techniques used and the progress achieved, we may consider this as the start of a new cycle of nephrology studies compared to the previous two decades [4].

Figure 1: Session of the 1919 Internal Medicine Congress held in Trieste, dedicated to war nephritis
Figure 1: Session of the 1919 Internal Medicine Congress held in Trieste, dedicated to war nephritis

We, too, chose to start from this date for an excursus on Italian nephrology between the two wars.

 

Materials and methods

We have searched all the scientific articles concerning kidney studies (anatomy, physiology, clinic) published by Italian authors between the two World Wars. The specific nephrological items searched in the literature between 1918 and 1939 are listed in Table I.

Subject N. of Papers %
Nephropaty (general) 118 18.4
Glomerulonephritis 82 12.8
Renal function 73 11.4
Hematuria 63 9.8
Kidney stones 45 7.0
Polycystic kidney 38 5.9
Diuretics 38 5.9
Albuminuria 36 5.6
Azotemia 37 5.7
Renal diabetes 26 4.0
Hypertension & Kidney 21 3.2
Creatinine 17 2.6
Nephrosis 15 2.3
Nephrosclerosis 12 1.8
Uremia 10 1.5
Pielonephritis 7 1.0
Total 638 100
Table I: Kidney studies published by Italian authors between World War One and World War Two

Within these subject areas, we have also singled out specific issues, emerged during the observed period, that were not dealt with in previous years and that that are still of scientific interest today. We also examined the respective chapters of two major Italian medical treatises, published in 1931 and 1939.

Of each author we have encountered, we have reported the age and the subsequent professional development, searching for those who, in the second post-war period, would have a role in modern Italian nephrology and in the foundation of the Italian Society of Nephrology (SIN) in 1957 [5].

 

Results

We retrieved 638 published papers dealing with kidney studies published by 343 Italian authors (Table I). The mean number of papers per author was 1.6.

Subject of the papers

The largest group has been labeled “general nephropathies” and includes different types of conditions, investigations, and therapies.

The second group concerns glomerulonephritis. This includes 10 papers on “trench nephritis”. These are of particular interest since they show that their authors were up to date on research carried out in other countries and that their pathogenetic hypotheses were sufficiently well founded [6]. It was believed that the conditions of the soldiers in the war environment had created a general and/or renal vulnerability and that this favored infectious processes, causing glomerulonephritis. Histologically it was identified as a diffuse proliferative form. The long-term prognosis was considered poor. Most concepts, especially those concerning the infective etiology, were in good keeping with the conclusions drawn on the matter by the top medical figures of the time [7].

The investigation of renal function is the subject of 11.8% of the papers. The analysis shows that in Italy in the mid ’30 this was a much-debated topic. In a 1931 medical treatise, the concentration-dilution test was deemed the most reliable assessment of renal function [8]. No clearance tests were taken into account. In the following years new concepts and new tests came into play. The urea clearance as a measure of the efficiency with which the kidneys remove urea from the blood stream was introduced after the WW1 and spread rapidly [9]. Its precision in assessing glomerular filtration was however invalidated by the rate of urea reabsorption by the tubules.

Rehberg had tried to overcome this drawback by devising a clearance method aimed at measuring the glomerular filtration based on an administration of a substance only filtered by the glomeruli [10]. Unfortunately, the load of creatinine administered was so large that the high blood concentration attained caused a tubular excretion of the substance together with glomerular filtration, altering the results [11]. Therefore, in Italy, the assessment of glomerular filtration through the recently proposed formula caused enthusiasm and controversy at the same time. Some studies did not fully support the results obtained by applying Rehberg’s method to the measurement of glomerular filtration in renal diseases [12]. On the other hand, other scientists found that this method could be improved to provide reliable results. In this way, by introducing the concentration of naturally occurring plasma creatinine in the formula of Rehberg, the Italian doctor Ferro-Luzzi was the first in the world to describe the clearance of endogenous creatinine and to obtain reliable results (Fig. 2) [13,14,15]. These studies were among the few to be published on foreign journals. The same applies to a basic science study on glomerular filtration published on an American journal and that deserves particular attention as it was written by a young Italian scientist destined for a very brilliant academic career Fig. 3 [16].

Figure 2: One of the papers on the use of the creatinine clearance by Ferro-Luzzi published in a German journal
Figure 2: One of the papers on the use of the creatinine clearance by Ferro-Luzzi published in a German journal
Figure 3: The first nephrological paper published by an Italian scientist in an American Journal
Figure 3: The first nephrological paper published by an Italian scientist in an American Journal

Azotemia (BUN) and creatinine are the subject of 8.3% of published research and are closely related to the studies of semeiology and renal physiology.

Among the other studies, those dealing with the relationship between kidney and hypertension should be highlighted. These 21 papers represent 12.5% of all hypertension articles and provide interesting insights into the research trends of the time. Renal denervation was attempted as a treatment for arterial hypertension [17]. The possibility of irradiating the carotid sinus to reduce blood pressure was also explored [18]. Finally, attempts at surgical therapy for arterial hypertension proposed by important clinicians of the time also deserve to be reported [19].

Other subject listed in table I are of lesser relevance or are tainted by concepts that have completely disappeared in the evolution of nephrology. An example is represented by the “nephrosis” group: this word, at the time, indicated conditions completely different from what we mean today.

The progress made in Italy, with the aforementioned studies, and abroad during the decade 1930-40 is well evidenced and discussed in the ponderous section (397 pages) on the kidney of the “Ceconi and Micheli” internal medicine treatise of 1940 [20]. From those pages, and the relative bibliographic references, we could also identify the Italian authors considered as “opinion leaders” in kidney studies at the time.

Authors

In order to single out the authors with a greater nephrological interest, we have arbitrarily selected those with a number of publications on the topic equal to or greater than five. In Table II these authors are listed along with their age and research location. All of them came from the most prestigious Italian universities, where studies on the kidney had already developed in previous years [4].

Author N°papers Birth and death City of work
Ferro-Luzzi Giovanni 28 1903-2000 Roma-Messina
Marcolongo Fernando 23 1905-1969 Torino
Condorelli Luigi 17 1899-1985 Napoli-Catania
Cesa-Bianchi Domenico 6 1879-1956 Milano
Gavazzeni Mauro 6 1904-1935 Pavia
Bufano Michele 5 1901-1993 Parma
Fieschi Aminta 5 1904-1991 Pavia
Table II: Authors with 5 or more nephrological papers

Interestingly, all but one were quite young at the time of the nephrological research we have retrieved. Three of them stand out for the number of published articles and their quality: Ferro-Luzzi, Marcolongo and Condorelli.

Ferro-Luzzi produced a series of studies on the kidney published in important international German-language journals between 1931 and 1939. The most interesting were those on plasma creatinine and its pioneering use in the calculation of clearance [13, 22]. Ferro-Luzzi is also the most cited Italian author in the chapter on renal function of the aforementioned treatise by Ceconi and Micheli [20]. For historical purposes, it should be noted that Filippo Romeo (1908-1981), who was a little younger than Ferro-Luzzi, conducted some nephrological research in association with him and, many years later, was one of the founders of the SIN [22]. This collaboration was interrupted when Ferro-Luzzi went to direct the Italian hospital in Asmara in 1939, where he founded the local medical school and remained until 1955.

Marcolongo belonged to the Turin academic school of Ferdinando Micheli (1872-1937). Since his degree in medicine in 1927, he devoted much of his research activity to the study of the kidney under all its physio-pathological, clinical and therapeutic aspects. In recognition of his experience in the nephrology field, he was entrusted with writing the chapter on kidney diseases of various medical treatises, first of all the Ceconi-Micheli of 1939 [20]. He obtained the academic position of professor of medicine in Siena and, years later, he appears among the members of the first board of the newly formed SIN.

Condorelli appears in this list not only for the number of kidney studies published, but also because he is the first Italian to publish a nephrological article in an American journal (Fig. 3, above) [16]. After this early interest in nephrology, Condorelli extended his research to other organs, especially the heart, where he obtained even more brilliant results. At the height of his career, he became a renowned professor of medicine at the University of Rome.

The presence of Bufano and Fieschi in our list of authors is of particular interest, since both of these researchers played an important role in post-war nephrology. Bufano created one of the most important Italian nephrological schools in Parma and was one of the founders of SIN. From an academic point of view, he achieved the position of professor of medicine in Rome. Fieschi, later a member of the first board of the SIN, was a pioneer of renal dialysis. In fact, in 1947, before becoming professor of medicine in Genoa, he conceived and built his original model of artificial kidney [23].

A sad fate awaited the last of these authors. Gavazzeni, who had carried out some brilliant research in the department of Adolfo Ferrata (1880-1946) in Pavia, died as a hero in the war of 1935 [24]. The city of Bergamo named a street after him.

Finally, after having considered some of the most prolific authors in the nephrological field, we cannot forget those who were taking their first steps back then. Among them, especially noteworthy are Domenico Campanacci (1898-1986) and Cataldo Cassano (1902-1998) who, in the early ’30s, had proposed their theories on the nature of lipoid nephrosis [25]. Years later, both authors founded important nephrological schools.

 

Conclusions

From the results of this investigation on kidney studies in Italy between the two World Wars we can draw a few conclusions. Italian scholars were very active in this area of medicine and their knowledge was up to date and on the same level of their colleagues abroad. The most productive researchers were young, which may indicate that the complex issues inherent to kidney function required a fresh and prepared mind. Therefore, only few selected researchers chose to approach this field. All of them carried out their research in the context of the most advanced medical schools in Italy. Here, a fruitful synthesis took place between these researchers’ new ideas and the structures most suitable for supporting their work. The quality of these young researchers is also confirmed by their success in their subsequent academic career. It is astonishing that all of them obtained positions of great importance in Italian medicine and inspired internal clinical schools or, more specifically, nephrological institutions. Finally, the names of many of these scholars appear in the formal act of foundation of the SIN, which ratified the existence of a substantial number of clinicians and researchers dedicated to the study of the kidney in Italy. This confirms the very close connection existing between “modern” Italian nephrology and what was achieved in this field between the two World Wars.

 

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