[The Early Years of Nephrology at Molinette Hospital in Turin Told by Those Who Lived and Built Them].

This article, written by several authors, describes the birth and early development of the nephrology at Molinette Hospital in Torino, Italy. In particular, it supplies important information on Antonio Vercellone, very motivated and innovative clinician and one of the fathers of Italian nephrology, and on Giuseppe Piccoli, his right-hand man and then his successor. This article also shows the strong professional and human engagement that was requested to the young doctors who, in the early Sixties and Seventies of the past century, had chosen to devote their professional lives to the patients with kidney diseases: from endless workdays without schedules to the anguish caused by the shortage of artificial kidneys to the cure of very fragile and unfortunate patients, and much more.

[Interview with Vito Cagli: his life as a nephrologist and more].

This interview describes the numerous and important contributions that Vito Cagli, who was born in Ancona in 1926, has given to the Italian Nephrology and to other fields of Medicine. These contributions, that are very poorly known today, were produced especially in the years in which Cagli worked as deputy director of the Centre for the Investigation and Treatment of Hypertension and Renal Diseases at Policlinico Hospital Umberto I in Rome. This interview also describes the early phase of Italian Nephrology before the introduction in our country of renal biopsy and of hemodialysis.

Misidentification of epithelial renal tubular cells as decoy cells in the urinary sediment of a kidney transplant recipient: the importance of adequate clinical information.

The examination of the urinary sediment of a kidney transplant recipient, carried out in blind conditions, showed the presence of a moderate number of cells which were identified as decoy cells. Most frequently these cells are a marker of BK polyomavirus reactivation, which can lead to BK virus nephropathy and graft loss. However, the patient's clinical history, the absence of BK viremia, and the renal biopsy findings excluded this condition. The careful examination of the renal biopsy demonstrated a severe tubular damage with cells resembling those identified in the urine as decoy cells. This paper is the first which demonstrates that damaged renal tubular epithelial cells can be misidentified as decoy cells. In addition, it highlights the importance of supplying adequate clinical information for a correct urinary sediment examination.

[The origins of the Renal Immunopathology Group of the Italian Society of Nephrology].

This article describes the birth and development of the Renal Immunopathology Group of the Italian Society of Nephrology. It collects the stories of nephrologists and pathologists who, since the early Seventies up to the first decade of this century, devoted their professional lives to the study of renal pathology with a strong personal involvement, characterized by enthusiasm, commitment, ability, strong spirit of cooperation, and friendship. All this enabled the Group to: propose the criteria for a standardized histological and immuno-histological examination of renal biopsies and reporting; produce several multicenter studies, whose results were also published in important international journals; to set up a national registry of renal biopsies; to organize a number of courses, some of which were associated with the publication of monographs, on various renal diseases. This article also traces the history of renal pathology in Italy from the second half of the Sixties - when young Italian nephrologists and pathologists from different institutions moved to French laboratories to learn new techniques to apply to renal biopsies - up to the present days. It also shows us how Italian renal pathology has been an essential tool for the development of the nephrological clinical practice and the advancement of scientific research.

A morphological classification of the fat particles found in the urinary sediment of patients with Fabry disease.

OBJECTIVES: The search in the urinary sediment (U-sed) of fat particles with peculiar morphology is a simple and inexpensive tool for the diagnosis of Fabry disease (FD) nephropathy. In this study we investigated the morphology of a high number of such fat particles with the aim to obtain a morphological classification to be used for their identification. METHODS: Study of the morphology of fat particles in the U-sed of a cohort of FD patients using: bright field plus phase contrast microscopy (BF + PC), polarized light microscopy (POL), and transmission electron microscopy (TEM). Comparison of these results with those obtained for the fat particles seen in the U-sed of a control group (CG) of patients with non-FD glomerulopathies. RESULTS: FD: 18 U-sed from six patients (three samples/patient) were prospectively investigated and 506 fat particles identified. With BF + PC, these were classified in eight morphological categories (seven of which were confirmed by TEM), and with POL in 10 others. CG: eight U-sed from eight patients were investigated and 281 fat particles identified. These fell into four BF + PC morphological categories and into eight POL categories. While some categories were significantly more frequent in FD others were more frequent in the CG. CONCLUSIONS: Our study demonstrates that 1. The morphology of fat particles found in the U-sed of FD patients is much wider and complex than that described so far 2. Several significant differences exist in the morphology of such fat particles between FD and CG patients.

[Interview to Attilio Losito: my half-century life as a nephrologist in Perugia].

In this interview Attilio Losito tells us about his first nephrological experiences gained in the late sixties of the past century in the Institute of Patologia Medica in Perugia directed by Giovanni Gigli, and his subsequent experiences, which also included a period at Guy's Hospital in London. The interview also describes the important contributions that the school of Perugia produced in the field of nephrology and its main protagonists. This nephrological life story highlights: the role that internal medicine, with its multidisciplinary approach, had in the development of nephrology in its beginnings; the importance of cooperation with foreign institutions; the contributions that specialised research laboratories attached to renal units have given to the improvement of the diagnosis and to the understanding of the pathogenesis of nephropathies.

The Italian External Quality Assessment (EQA) program on urinary sediment by microscopy examination: a 20 years journey.

OBJECTIVES: In spite of the introduction of automated systems for urinary sediment analysis, microscopy examination remains the gold standard, and it is more than ever important to perform it with a good and reliable quality. External Quality Assessment (EQA) programs on urinary sediment are rare. The present paper provides an analysis of results from 2001 to date of the EQA Italian program which involves today 230 laboratories. METHODS: The program includes four surveys per year. Participants are asked the identification and clinical associations of urinary sediment particles, shown as phase contrast microscopy images in the website of the Center of Biomedical Research (CRB) (2 surveys), and the diagnosis of clinical cases presented by both images and a short clinical history (2 surveys). The results of each survey are then scored and commented. In 20 years, 298 images were presented: 90 cells (9 types), 23 lipids (5 types), 87 casts (21 types), 53 crystals (14 types), 22 microorganisms (5 types), and 23 contaminants (9 types). Moreover, 27 clinical cases, covering a wide spectrum of conditions with different degrees of complexity, were presented to participants. RESULTS: Identification: among urinary particle categories, the correct identification rate (obtained for each particle from the sum of correct + partially correct answers) was very high for micro-organisms (mean ± SD: 96.2 ± 3.5%), high for lipids (88.0 ± 11.8%) and crystals (87.0 ± 16.5%) followed, in decreasing order, by cells (82.1 ± 15.9%), casts (81.8 ± 14.8%), and contaminants (76.7 ± 22.1%). Clinical associations (n=67): the rate of correct answers was 93.5 ± 5.7% ranging from 75.0 to 100% for all but one clinical association (i.e., acute glomerulonephritis: 55.4%). Clinical cases: throughout surveys, due to the overall rate of particle misidentification, only 59.8 ± 17.1%, (range 32.5-88.7%) of participants achieved access to clinical diagnosis. Of these, 88.7 ± 10.6% (range 59.9-99.3%) were able to indicate the correct diagnosis. CONCLUSIONS: Our program can be used as a tool to improve the identification of urine particles and the knowledge of their clinical meaning and to encourage specialists of laboratory medicine to correlate urinary findings with other laboratory data and the clinical history, an aspect that improves the value of the day by day work.

[My life as a nephrologist with a passion for renal pathology].

This article retraces the nephrological life of Giovanni Barbiano di Belgiojoso, which started in the late 1960s. Since the beginning renal pathology was his main interest and he was among the pioneers who introduced in Italy the use of immunofluorescence technique in the examination of renal biopsies. Over the years Barbiano di Belgiojoso has carried out, often in cooperation with other nephrological groups, many clinico-pathological studies on a wide spectrum of glomerular diseases. He also played a key role in the foundation and in the activities of the "Group of Renal Immunopathology" of the Italian Society of Nephrology.

Advances in the identification of calcium carbonate urinary crystals.

The examination of the urinary sediment of a 64-year-old woman showed the presence of three different types of crystals, all with unusual morphology, which could not be identified with bright field microscopy, polarized light, and the knowledge of urine pH (7.5). The use of microscopic infrared spectroscopy, Raman spectroscopy and energy dispersive X-ray spectroscopy led to the identification of the three types of crystals as calcite, vaterite and aragonite, which are all variants of calcium carbonate crystals. This paper confirms the complex morphology and nature that urinary crystals may at times have and the utility of advanced infrared spectroscopy techniques for their identification.

[The CROFF pavilion at the Policlinico Hospital in Milan: the beginnings].

This article collects the personal stories of the young doctors who in the early sixties contributed to the birth and development of the Croff pavilion at the Policlinico Hospital in Milan. Inaugurated on October 19, 1964, this has been the first institute in Italy entirely devoted to patients with kidney diseases. Since its inception, it has significantly contributed to the progress of nephrology thanks to important and pioneering investigations in the main fields of our specialty, which still continue nowadays. The different stories reported here follow the chronological order in which the young doctors arrived at Croff, each story representing a personal narrative that interweaves and integrates that of others. This gives rise to a vivid many-voiced account, from which emerge not only the figures of these young doctors, but also those of patients, nurses, and laboratory technicians.

The First Ever External Quality Assessment Program on Urinary Sediment in a Country of Sub-Saharan Africa Based on New Smartphone Technologies.

BACKGROUND: External Quality Assessment (EQA) programs on urinary sediment (U-sed) examination are recommended by international guidelines to improve the quality of this diagnostic tool. However, no such programs have been carried out so far in developing countries of sub-Saharan Africa. This paper describes an EQA program on U-sed which was realized in 2017 and 2018 by means of innovative communication technologies in Benin Republic, a small country of West Africa. METHODS: On Monday morning, weekly in 2017 and fortnightly in 2018, the image of one U-sed element was sent from Italy with a smartphone, via WhatsApp application, to a group of 13 professionals (11 bachelors of science, 2 medical doctors) working in different institutions of Benin Republic. The image showed one U-sed element, for which the participants were asked the identification and, in 2018, also a clinical association. RESULTS: The images of 33 elements were submitted over the two-year period. Particle identification. Altogether 283 answers were received (8.5 ± 2.3/single image), 200 of which were correct (70.7%), 53 incorrect (18.7%), 17 partially correct (6.0%), and 13 "I don't know" (4.6%). Correct identification of elements presented twice (2nd answer vs. 1st). No change: 9/18 (50.0%); improvement: 5/18 (27.8%); worsening: 4/18 (22.2%). Clinical association. Correct answers: 8/17 (47%); incorrect: 8/17 (47.0%); no answer: 1/17 (5.6%). CONCLUSIONS: This paper demonstrates: 1. The need and utility of an EQA program on U-sed in developing countries of sub-Saharan Africa; 2. The feasibility of such programs by means of easily available and inexpensive smartphone applications.

[A life devoted to nephrology].

This paper by Mauro Sasdelli describes the dawn and the development of nephrology first in Bologna, where Sasdelli studied in the nineteen-sixties, and later in Arezzo; the author tells us of the dedication, the enthusiasm, the hard work of all involved, but also of their conflicts and banter. The paper describes the important contributions to nephrology made by prominent personalities such as Domenico Campanacci, Vittorio Bonomini and Pietro Zucchelli, not only at a local level but also more broadly. Finally, text and images of this "personal history" can also be read as the integration of an article published on this same journal in 2016, "The dawn of Nephrology and Dialysis in Bologna with Vittorio Bonomini and Pietro Zucchelli" (Giornale Italiano di Nefrologia, vol. 33, n. 4).

[The dawn of Parma's nefrological school as told by one of its students].

This paper, written by Professor Rosario Maiorca, describes the everyday professional life in the institutes of Clinica Medica and subsequently of Patologia Medica at Parma University in the second half of the fifties and in the first years of the sixties of the past century. Those institutes and that period, which have been very important for the birth of Nephrology in Italy, have already been described, from the historical standpoint, in an Italian monograph on the history of our specialty for the period 1957-2007. The present paper adds to that chapter an insight of "real life", with a lively description of the wide and passionate clinical and scientific activities of the young doctors in training and of the personality, greatly stimulating and altruistic, of their "Masters".

[Interviewing Professor Enrico Malizia, one of the fathers of Italian nephrology].

This article contains an interview to Professor Enrico Malizia (born in 1926), who played an important role in the birth of nephrology in Italy. On April 27th, 1957 Professor Malizia was in fact among the founders of the Italian Society of Nephrology, which he also served as secretary for some years, together with Professor Luigi Migone (1912-2002). In addition, he participated in the organization of the First International Congress of Nephrology, which took place in Geneva and Evian from September 1st to 4th, 1960. Professor Malizia devoted himself to nephrology for many years, both as clinician and as researcher, by publishing many original papers and monographs on different nephrological topics, a few of which are described in detail in the present article. In addition, his interest in renal diseases led him to frequent the institutions of eminent renal scientists of the period such as the physiologist Homer Smith (1895-1962) and the pathologist Jean Oliver (1889-1976) in the United States, and the clinician Jean Hamburger (1909-1992) in Paris.

Glomerular isolated microscopic hematuria: urinary features and long term follow-up of a selected cohort of patients.

BACKGROUND: Isolated microscopic hematuria is a condition characterized by the presence in the urine of an "abnormal" number of erythrocytes in the absence of proteinuria. Several studies have been published on this condition, but with heterogeneous inclusion criteria and variable outcomes at follow-up. In this retrospective study, we describe a selected and homogenous cohort of patients who presented with isolated microscopic hematuria of glomerular origin. METHODS: We included in the study patients with isolated microscopic hematuria of glomerular origin (> 1 erythrocyte/high power field at 400× and ≥ 40% dysmorphic erythrocytes and/or ≥ 5% acanthocytes and proteinuria ≤ 150 mg/24 h) with a follow-up of > 60 months from the first documentation of microscopic hematuria. RESULTS: Forty-two patients (M 12, F 30, age at presentation 14-68 years, eGFR < 60 ml/min/1.73 m2: 1 patient) were included. During a medium term follow-up, microscopic hematuria was persistent in 25 patients (59.5%), transiently absent in 17 (40.5%), always glomerular in 16 patients (38.1%), and occasionally non-glomerular in 26 (61.9%); proteinuria, observed in 16 patients (38.1%), was always transient and < 500 mg/24 h. At the end of a follow-up of 181.8 ± 97.9 (median 168) months, only 2 patients (4.8%) had eGFR < 60 ml/min/1.73 m2, one of whom had reduced eGFR already at presentation. CONCLUSIONS: This study on a small but selected and homogeneous cohort of patients with isolated microscopic hematuria of glomerular origin demonstrates that urinary features can transiently change over time and that the renal outcome is good.

The Friday evening case of acute kidney injury: a crystal dilemma.

We report a case of acute kidney injury (AKI) induced by amoxycillin crystalluria suggested by massive amounts of urinary crystals of unusual morphology. This hypothesis was further reinforced by a particular solubility pattern when the urine sample was exposed to various temperatures, alkali, acids and alcohol. We therefore suspended amoxycillin, which produced a rapid and complete recovery of kidney function. Infrared spectroscopy later confirmed the amoxycillin composition of the crystals. Since infrared spectroscopy is not easily available, we propose that these solubility tests of urinary crystals be used as a first-step investigation when amoxycillin crystalluria is suspected.