Prof Zoccali: You are fascinated by creative and iconoclastic scientists. In a way modern clinical research is a sort of concerted, multiparty enterprise. What element would you strongly recommend be preserved in the modern organization of scientific research, be it basics or clinical.

Prof Maggiore: The explosive growth of basic research on the molecular and genetic basis of disease has shifted resources away from the bedside towards the laboratory. On the other hand, the ever growing popularity of the canons of clinical epidemiology has diverted the target of clinical research from small patients' groups to large patients' populations. This trend makes it more difficult for the nephrologists, than for other specialists (for instance, the cardiologist), to assemble patients' groups that are large enough to meet the statistical requirements of the randomized clinical trial. Finally, most clinical trials today are promoted and financed by pharmaceutical industries to test new drugs or, even more often, the 'me too' drugs. There is very little satisfaction for the young doctor to be involved in such trials where his or her function resembles more that of a carpentry boy than that of a clinical scientist. In such a situation I think that it is essential not only for our subspecialty, but also for Clinical Medicine in general, to restore a space providing a favourable habitat for the individual enterprise in clinical research. It is important not to forget that clinical scientists have generated much of the medical progress we enjoy today, nonetheless they are becoming an endangered species risking extinction unless vigorous initiatives are taken for their safeguard.

 

Prof Zoccali: Who is the colleague that you consider the most creative?

Prof Maggiore: In my opinion, Barry Brenner. His studies on the mechanism of chronic renal disease have been most influential in inspiring a great deal of experimental and clinical research world-wide. One might argue, however, that by addressing most efforts toward the common pathway of disease progression, the enthusiasm for Brenner's hypothesis may have hindered the search for new specific remedies for kidney diseases.

 

Prof Zoccali: Which is the scientific paper that influenced you most?

Prof Maggiore: Since I have been a kind of “libertine” in my intellectual “love-fallings” , there have been several papers. I prefer not to quote them because these paper s were of doubtful scientific quality, and have almost been completely forgotten. Yet they contained some new information interpreted in a way which I did not agree with, which stimulated my undertaking of a new approach to find a more convincing explanation.

 

Prof Zoccali: Presently clinical research receives less attention than basic research and we perhaps need to redesign a role model for the clinical investigator. Which initiatives could be taken in this direction? Which is the ideal environment in the near future for bringing up creative and productive clinical scientists?

Prof Maggiore: The problem you mention came to the public attention more than 20 years ago, yet only recently did it call for specific remedies. The working group of the Academy of Medical Sciences (in UK) has suggested a series of proposals (BMJ 327:1041; 2003) for resuscitating clinical research which I think should be adopted by every country in the European Union.

 

Prof Zoccali: You invented cold dialysis and opened a new and stimulating research field. Which are the main questions that you would like be studied in this particular area of research?

Prof Maggiore: To me the dialysis-induced hypotensive crisis appears as a manifestation of heat intolerance. Physical training has been proved to be effective in enhancing heat tolerance in normal individuals. If I were an active researcher, I would like to assess whether improving exercise capacity of the patients enhances their heat tolerance and attenuates their propensity to hypotension.

 

Prof Zoccali: You are an active user of the Internet. Do you believe that Internet communications will eventually eliminate or radically change the way scientific congresses are organized?

Prof Maggiore: I do not think that Internet will substitute scientific congresses for the same reason that television has not eliminated theatre performances. Congresses fulfill the need for a direct contact with fellow scientists, the gratification of the applause, the challenge of a lively discussion, the wish of traveling and visiting foreign countries, and the like. It is instead possible that thanks to Internet the oral presentations delivered during the congress will survive much longer than with the present format.

 

Prof Zoccali: One of your major scientific interests has been dietary treatment of chronic renal failure. Given the miniscule effects of diet in slowing renal disease progression and the lack of information on the effect of low protein diet on all-cause and cardiovascular mortality in patients with advanced renal diseases could you tell us which is the main challenge now for clinical scientists interested in this topic?

Prof Maggiore: The randomized clinical trials published so far have shown that besides the questionable capacity on slowing the progress of the disease, none of them achieved a satisfactory patients' compliance with the prescribed low protein diet. Moreover, the very scope of low protein diet needs reappraisal. Besides the limitation in the total amount (0.6-0.7 g/kg/ideal body weight), the low protein diet requires the selection of protein intake according to their biological value (at least 75% of animal origin) which implies a rather severe restriction in the intake of vegetable proteins and polyunsaturated fats, namely those found in cereals, legumes and nuts. These foods together with fish, vegetables and fruit constitute the core of the Mediterranean diet, recommended by the American Heart Association (Circulation 102:2284;2000) as a means for preventing cardiovascular complications in the general population. Cardiovascular complications, either fatal or nonfatal, occur in renal patients much more frequently than in the general population; therefore, the Mediterranean diet should be strongly recommended for them. Ignoring the possible harmful effect of the low protein diet on the cardiovascular system to pursue a questionable renoprotective effect sounds to me like 'mistaking the finger pointing to moon for the moon'. Obviously, the cardioprotective potential of the Mediterranean diet in renal patients needs to be tested by appropriate clinical trials.

 

Prof Zoccali: Which non-medical book are you reading at the moment?

Prof Maggiore: In these days I am reading 'The Black Box' by Amos Oz. This book follows a series of novels written by other Jewish writers, such as Philip Roth and Abraham Yehoshua, which I have been recently reading with great pleasure.

 

Prof Zoccali: Which red Italian wine would you recommend to our European colleagues?

Prof Maggiore: I live on the border of the Chianti region where the Chianti “Gallo Nero” is produced. As far as my scarce competence can judge, I recommend this wine because it offers a good compromise between quality and cost.