Interview with Prof Mezzano

Prof S. Mezzano Department of Nephrology School of Medicine Universidad Austral Bueras Valdivia, Chile

Prof Zoccali: Your country has a widespread dialysis program with about 600 patients on RDT per million of the population, and a growing scientific output in clinical nephrology. Could you tell us how nephrology and dialysis were developed in your country?

Prof Mezzano: In actual fact, in my country, as in the rest of the world, the number of patients with chronic renal disease is on the increase, and right now there are around 700 patients on RDT per million. Dialysis and renal transplantation began in the 60s in just a few academic nephrology centers, but thanks to the economic growth in Chile, dialysis has become affordable for most patients and so has transplantation , limited only by the number of donors (8.3 per million population). The Chilean Government guarantees the opportunity and quality of treatment for all patients who do not have private health insurance. More than 90 % of the patients are supported by the state, and treated in public or private dialysis centers. Unfortunately, the number of nephrologists has not increased in the same proportion, and in Chile we are less than 200 nephrologists for a population of 15 million. Young physicians are not greatly interested in nephrology fellowships, and the four accredited centers usually cannot cope with the programs offered for training. I think that, in a broad sense, the clinical care of renal patients is good and that it is improving, but the same can not be said for clinical and basic research. Although over recent years, Chile has shot up to fourth place in scientific productivity in Latin-American, after Brazil, Mexico and Venezuela, academic nephrology is only covered by three centers and is still far from the optimum.

Prof Zoccali: Are you collecting information on the epidemiology of CKD in your country?

Prof Mezzano: Yes, we have a national register of all the patients in dialysis and transplantation. Moreover, our data are also collected for the Latin-American Society of Nephrology and Hypertension (SLANH). The Ministry of Health recently performed a survey on a representative population over a 17-year period, and it was found that 33 % of the population is hypertensive, 14 % have proteinuria, 5.7 % have a CKD phase 3, and 0.2% phase 4 with a GFR estimate. There is broad knowledge of the risk factors of CKD, and this year, jointly with COMGAN/ISN, SLANH, and the participation of KDIGO, we are organizing a two-day prevention meeting in our region entitled “Chronic Kidney Disease in Latin America: Disease Burden and Prevention Strategies” with a view to collecting information on the epidemiology in all our countries.

Prof Zoccali: Does nephrology have common ground and programs in South America? Do you have joint projects with colleagues in other South American countries?

Prof Mezzano: Six years ago, when Dr Pablo Massari was President of SLANH and with COMGAN/ISN support, we set down the recommendations and guidelines for the training program in nephrology in Latin-America. This program is handled by the SLANH Curriculum and Postgraduate Training Committee, and its main purpose is to type-approve the different programs by creating a list of accredited centers for training in our countries, to define the pre-requisites to apply and the main objectives of the program. Today, we have around 15 accredited centers in several countries, and SLANH is supporting short training programs in specific areas with own funds and this program mainly is devoted to young nephrologists from countries in which accredited training centers do not exist. Traditionally, the ISN has always collaborated in the training of our young nephrologists through the International Fellowship Program. Moreover, during recent years we have extended our cooperation programs with the American Society of Nephrology, which has granted 10 fellowships, lasting 1 month each, in an accredited center of USA, finishing with the ASN Renal Week. Furthermore, with the Spanish Society of Nephrology, we began a new fellowship program to permit 6 young nephrologists to spend six months in a recognized training center in Spain. Moreover, a fellowship in dialysis has been created, in memoriam of Prof Dr Fernando Valderrábano, a great professor and friend of many Latin-American nephrologists. In brief, I really think that there are more opportunities than ever to get a good training program, in our own countries as well as in recognized centers abroad.

Prof Zoccali: What problem related to our specialty to you consider to be the real priority in your country and in South America in general?

Prof Mezzano: The social, economic and medical reality in our countries is very dissimilar. Unfortunately, I do believe that the main unresolved problem in several of our countries is that people are still dying of chronic renal failure. All the efforts we can make in education, detection and primary and secondary prevention of CKD are real priorities. The ISN sister program in some areas, for example the work carried out by Dr Remuzzi in Bolivia, is an extraordinary example of education and collaboration.

Prof Zoccali: What led you to become a nephrologist?

Prof Mezzano: This is not an easy answer. When I finished my Internal Medicine fellowship, I was quickly designated as an attending physician in my School of Medicine. During those years, the substitutive therapy for ESRD was just beginning in this country and my university was interested in developing the specialty of nephrology. I was intrigued by the research and fascinated with the immunopathogenesis of some renal diseases. Then, with the support of my faculty, I became a Nephrology fellow in the Cincinnati University Medical Center, under the sponsorship of Dr Victor Pollak. Very soon, after returning to Valdivia, we started the hemodialysis and renal transplant program, and a research unit with an experimental and clinical laboratory. Since then, we have developed a Tissue Typing Lab, a Nephropathology Diagnostic Center for the southern area of Chile, and a training program in Nephrology. Today, looking back, I think that I was in the right place at the right time, because I have had the opportunity to create a Nephrology Department that has had a fairly strong influence in the Chilean Nephrology community. In the meanwhile, I also had the good fortune to work, as visiting professor, with Prof John Zabriskie in Rockefeller University and with Prof Giovanni Camussi in Torino, Italy.

Prof Zoccali: You have a particular interest in Angiotensin II and experimental models of renal injury. I see that you developed your research work in close contact with the Egido group from Madrid. How was this successful collaboration generated?

Prof Mezzano: Our friendship and collaboration with Dr Jesús Egido can be traced back to 15 years ago, when he visited Chile for the first time. At that time in my country, we were beginning research grants with international cooperation programs, and since then we have maintained a very successful collaboration in different aspects of renal diseases, mainly in relation to intrarenal activation of the RAS system, immunopathogenesis of renal diseases and progression of CKD. The influence and support of the Egido group to our work has been outstanding.

Prof Zoccali: Do you believe that Spain is destined to become a major scientific partner of Chilean Nephrology in the near future?

Prof Mezzano: I believe that science and research are universal, but that language and history can be a great help. The influence and development of Spanish Nephrology has been important during the last decade, but that influence is mainly due to the high level of the Spanish nephrologists, than purely to the influence of the language. Another aspect, not less important, is the financial support for Latin-American candidates, and Spain is actually opening those avenues. In our department, for example, one member of our staff was trained in Cambridge with Dr Martin Lockwood (r.i.p), two others in Bergamo, at the Mario Negri Institute with Dr Giuseppe Remuzzi as sponsor, and our renal pathologist was trained by Dr Charles Jennette in Chapel Hill, USA. All of them were ISN fellows. The next year, and for the first time, a young nephrologist will be trained with a fellowship from Fundación Carolina, to do research in Madrid, with Dr Egido.

Prof Zoccali: Which project/program currently interests you most?

Prof Mezzano: Currently, our main research project is related to the study of the molecular mechanisms of renal disease progression. We are studying the role of Gremlin (BMP-7 antagonist) in epithelial mesenchymal transdifferentiation (EMT) in tubules and glomerular crescents. We attempt to study the role of proteinuria and Ang II in EMT. This research is done in collaboration with Dr Hugh Brady from Dublin, Jesús Egido and Marta Ruiz from Madrid. Additionally, we are following some other research projects on hypertension and salt sensitivity with the collaboration of Bernardo Rodríguez-Iturbe from Maracaibo. Concerning our nephrology program, we have a two-year training program for post-residents in Internal Medicine from Chile or Latin America, some CME courses for nephrologists, and our department is the reference center in the South of Chile for tissue typing, renal transplantation and renal pathology.

Prof Zoccali: What advice would you give to a young colleague starting a career in Nephrology in your country? What difficulties does a young nephrology trainee have to face in Chile?

Prof Mezzano: It is difficult to give advice to young physicians. At least in my country, I strongly recommend starting with a regular two-year nephrology fellowship in an accredited academic center. Thereafter, if the candidate has an academic interest, he should apply to enter a PhD program in Chile or in a foreign country. For those going into clinical practice, which is the case of the majority of our residents, I recommend keeping in close touch with the training center, for the CME courses, patient referral, multi-center studies… Given the length and narrowness of our country (4,200 kms), we need university reference centers that maintain a network of clinic support for the patients, clinic and/or basic research, and postgraduate education.

Prof Zoccali: What your favorite hobby?

Prof Mezzano: My hobbies have continued to change throughout my life. I live in a region full of rivers, lakes and volcanoes. I love nature and, in summer time, I usually spend a lot of time fishing in lakes and rivers. I also go jogging and play tennis, at a basic level, though! Furthermore, my other favorite hobby is travelling, mainly to unknown cities.