Interview to Prof. E. Ritz

Ritz No, I think quite to the contrary, contact with an inspiring mentor is even more important than it was 20 or 30 years ago. Young trainees tend to be drowned in the flood of information and to learn the art to distinguish between what is important and what is not important is a major task and this can be greatly helped by the assistance of an experienced old hand. Furthermore expertise (and hopefully wisdom) of a mentor is necessary to direct the young trainee to work on topics which are either scientifically interesting or clinically highly relevant - and which at the same time can be solved with an available methodology. Advice on how to evaluate literature, how to perform studies (design, statistics) and many other points may be of invaluable help to a trainee. It must be admitted that there has been abuse by mentors, i.e. undue dependency of junior investigators and even exploitation which led to some resentment against mentors in general. Therefore the young trainee is well advised to be very careful in the selection of his mentor which is second most difficult task, rivalling selection of a good spouse.

Drüeke In your own professional career, which were the most important factors that influenced your orientation towards nephrology ?

Ritz Scarcity of positions unfortunately does not allow the young trainee to select the discipline he likes best. Actually I did not select nephrology and was forced to be involved in building up a renal unit because someone was needed to take care of uraemic patients who had to be kept alive on the waiting list for renal transplantation - I had to comply against my will after much kicking and screaming. It is testimony to how interesting nephrology is that I never regretted to work in this speciality: nephrology is certainly one of the most exciting areas in internal medicine.

Zoccali Which is the recommendation you would make to academic departments to strengthen postgraduate training in nephrology?

Ritz There are several items which I think markedly improve the level of postgraduate training in nephrology although obviously one has to take into consideration that department structures differ from country to country.
First I think there should be a formal programme so that everyone admitted into nephrology goes through a series of training steps and is exposed to all clinical aspects of nephrology.
Second, a tutorial system so that someone of the senior nephrologists is in charge of a given trainee is useful indeed.
Third provision of a structure series of in-house nephrological conferences, including pathology conferences is of great importance. Clear understanding of renal pathology is the entry ticket into good academic nephrology.
Fourth, it is also important for the nephrologists to receive adequate training in imaging procedures; particularly nephrologists should do ultrasonographic examinations on their own.
Fifth, ideally the young nephrologist in academic departments should first undergo through training in scientific methodology. It does not terribly matter which topic he is working on in order to become acquainted with methods, sine the standard molecular, immunological or histological technics are the same whether one works on gut, brain or kidney.
What is important, though, is that young trainee is competent in these methodologies so that he will be able to supervise a laboratory despite his clinical commitments - which is not an easy task indeed.
Sixth, I feel that it is of value to work abroad for one year or two. This need not necessarily be the United States. There are fantastic scientific facilities in Europe, In Japan, in Australia and I dare say that one can easily distinguish colleague who has always been sitting around "at home" from one who has been abroad an exposed to a foreign clinical and academic culture.

Zoccali Do you think that the value of Scientific Congresses in scientific communication has lost momentum? Should scientific meetings be downsized or restructured?

Ritz There is no question that scientific congresses have become mammoth enterprises in which even senior, let alone junior, nephrologists get easily lost. Nevertheless one should nor throw out the baby with the bathing tub. It goes without saying that small, topic-orientated meetings, run by active investigators in the field are the most productive type of meeting, particularly for colleagues working in the respective area of science.
Nevertheless big congresses e.g. the ERA Meeting, the ASN Meeting, and the Congresses organized by ISN provide the unique opportunity to receive an update even in areas which are somewhat remote from one's own field of expertise. I have also found it most useful to listen to speakers and particularly to their reaction in discussions - one obtains a much better impression of the solidity and relevance of scientific (or clinical)findings or hypotheses if one has had the opportunity to watch investigator "in persona".
All major societies have recognized, however, that in addition to the standard congress format specific educational courses should be added to the programme. It will be very useful if young trainees get involved in this effort by proposing topics, by participating in interactive sessions and by attending these events in the first place.
In retrospect I must say that our Society, "The European Renal Association", previously EDTA, has gone a long way from the "European Dining and Travel Association" to become a serious scientific society.

Drüeke Concerning the participation at medical/scientific meetings would you advise young training nephrologists to prefer postgraduate educational
courses, topic-orientated symposia, or meetings of national and international nephrology societies ?

Ritz Whilst promiscuity is generally not well accepted by society, promiscuity in selecting the kind of meeting is the best way to proceed. Talented cooks know that the ideal approach to prepare an exquisite meal is to combine ingredients. The young trainee is therefore well advised to follow the same policy and the participate in different type of meetings.

Zoccali Which is the scientific paper that struck you most and inspired you new projects and research plans?

Ritz My earliest interest was in calcium-phosphate metabolism. The scientific paper that struck me most was a paper in Nature by Kodicek from Cambridge who provided the first evidence for synthesis of an active vitamin D metabolite by the kidney. This paper provided a paradigm which, at one stroke, clarified a number of most puzzling and contradictory clinical observations and allowed to propose a great number of fascinating working hypotheses. After his paper of disturbed calcium metabolism in uremia I was advised by my chief to stop working on calcium metabolism because in his opinion all potential problems had been resolved by the observation of Kodicek. It is an illustration of the unpredictability of scientific progress that - as we know today - nothing is farther from the truth.
The second paper was the observation of Converse in the New England Journal of medicine showing by micronneurography that sympathetic nerve traffic is increased in renal failure. This pointed to an entirely new way of looking to the pathogenesis of hypertension and cardiovascular complications in renal failure and promoted me to carry out a number of studies on sympathetic overactivity and progressions of renal disease together with my collaborator Prof. Amann.

Drüeke Ultrasonography of the urinary tract is done in most countries by radiologists; in contrast, in most other places in Europe particularly in Germany and in Italy nephrologists perform ultrasonographic examinations routinely. Why do you think it is important to keep this type of diagnostic tool in the hands of nephrologists ?

Ritz As I had mentioned above nephrologists should do their own ultrasonographyc examination of renal disease. This is the first important in emergency situations, e.g. in the differential diagnosis of acute renal failure. This is also important follow-up, for instance follow-up of renal transplants (these studies are highly investigator dependent and should therefore be done by the same investigator). Third the nephrologists should do his own renal biopsies and this by necessity requires ultrasonography. It should also be mentioned that imaging and Duplex examination an important for recognition of renal artery stenosis, monitoring of fistula flow, examination of the parathyroid glands etc. I am of the opinion that good training in ultrasonography is an indispensable part of the training of a nephrologists.

Zoccali Do you think cloned or transgenic kidneys in 10 years will solve the problem of organ shortage ? Do you think that we will be able to downsize and then to start closing dialysis units?

Ritz Everyone is aware of the danger of making predictions and we all know the statement: "Don't make predictions, particularly not about the future". I think the issue of transgenic kidneys should be pursued scientifically but I am very sceptical indeed whether it will have become clinical routine in ten years time. In order to alleviate the potential anxieties of colleagues who go into nephrology about the long term prospects of a nephrologists: even if this xenogenic transplantation will turn out to function within ten years time, (contrary to the predictions of a simple nephrologist in Heidelberg), nephrologists will still be necessary for problems such as control of progression, follow-up of transplanted patients, etc. In brief, they would certainly not go out of business.

Drüeke What are for you the most important issues to be solved for the prevention and early treatment of renal disease in patients with type 2 diabetes ?

Ritz Renal disease in type 2 diabetes patients has become the single most important cause of end-stage renal failure in many countries of Europe. The issue of prevention goes far beyond the realm of clinical nephrology. First, it involves modification of lifestyle which includes information and education of the general public to prevent type 2 diabetes in the first place. Second it involves adequate management of the type 2 diabetic patient by physicians (in general non-nephrologists and non-diabetologists); several investigations including our own have documented that a large majority of these patients are not managed according to current standards of medical care with respect to hyperglycemia control, hypertension control, control of hyperlipidemia..etc.