UniSR's nephrology residency programme trains specialists in one of the least familiar disciplines among medical students, and one of the least visible in the public imagination. Perhaps because the kidney is seen as a “silent” organ, and because, during medical school, the subject can feel dense and hard to visualise.
Nephrology is a broad, cross-cutting discipline: it draws on physiology, internal medicine, emergency care, immunology, cardiology, technology, invasive procedures, transplantation and research. It suits anyone who enjoys connecting different clues, reading complex clinical pictures and building a diagnosis step by step: an almost “Dr House” style of clinical reasoning (House, after all, is also a specialist in nephrology and infectious disease), but one grounded in teamwork and in a long, close relationship with the patient.
Chiara Livia Lanzani, Associate Professor of Nephrology at Vita-Salute San Raffaele University and Director of the Nephrology Residency Programme, puts it this way: «Specialising in nephrology, and then working as a nephrologist, ranges from the technological side of dialysis to managing a chronic patient you follow in outpatient clinic for ten years, right through to the patient in intensive care you save at three in the morning. Few other branches of medicine have this breadth or demand the same closeness to the patient».
In the same working week, a nephrologist might perform a kidney biopsy, manage a dialysis session for a patient in cardiac intensive care, and discuss a high-risk pregnancy with a gynaecologist because of kidney complications. This range is what makes the field so distinctive.
Those who join the programme work at the crossroads of internal medicine and practical procedures. They treat kidney-specific conditions, such as glomerulonephritis, often autoimmune or genetic in origin, and step into wards of every kind whenever the kidney is affected by infection, medication, heart failure, major surgery or systemic disease.
«Contemporary nephrology is changing. In England, many hospitals are no longer organised by department but by intensity of care, and the nephrologist follows patients wherever they are, not only within their own ward. It's a model that is arriving in Italy too, and one we're already adopting, in part, here at San Raffaele Hospital», Lanzani explains.
In the UK, medicine wards are typically split into low, medium and intensive care tiers based on the severity of a patient's condition and the need for invasive support, rather than on the disease that led to admission.
At UniSR, the kidney is also at the centre of a practical application of AI in medicine, through a model being built to help predict the recurrence of kidney cancer.
Aspiring nephrologists at UniSR train directly at IRCCS San Raffaele Hospital, one of Italy's leading clinical and research hospitals and also a reference centre for kidney transplantation in Lombardy. Here, they follow patients with kidney disease across the full course of care: from diagnosis to dialysis, and from transplantation to post-transplant follow-up.
«Every day, around lunchtime, senior physicians and residents meet for handover, a moment to discuss every ongoing case in the hospital, which keeps treatment decisions shared and consistent over time. This dialogue between different generations of doctors pushes each of us to reflect on how we work: what's effective, what isn't, and where we can improve», Lanzani observes.
Daily handover doubles as a training ground for clinical reasoning: cases are reviewed together, hypotheses tested, decisions shared. For a resident, this means learning not just “what to do”, but why and how to do it. Around 100 patients are currently followed on haemodialysis at the hospital. Nationally, the Italian Dialysis and Transplant Registry of the Italian Society of Nephrology counts around 42,000 patients on extracorporeal dialysis and more than 27,000 with an active kidney transplant, figures that show just how much nephrology, in Italy, is a discipline built around chronic care on a national scale.
In this treatment, the blood-filtering function normally carried out by the kidneys is taken over by an external machine that acts as a fully functioning artificial kidney. For the patient, this means going to hospital at least three times a week, for three to four hours at a time: a commitment that deeply affects daily life and demands clinical and technical skill, organisational ability, listening, and real continuity in the care relationship.
«To address exactly these aspects, at San Raffaele we're taking part in a project that invests in peritoneal dialysis. Instead of the external machine, this procedure uses the peritoneum, the membrane lining the abdominal organs, as a natural blood filter. The goal is to make dialysis more accessible across the region. It does require a caregiver's support, but unlike standard haemodialysis, it can be carried out at home», Lanzani notes.
Peritoneal dialysis shows with particular clarity how nephrology is both a technological and a highly personalised discipline. Because the treatment can be carried out at home, choosing it means weighing the patient's level of independence, family support, home environment, daily habits and the ability to fit therapy around work and social life. This is exactly why peritoneal dialysis, beyond technical skill, requires the nephrologist to build a care pathway that is genuinely tailored to the individual.
Beyond chronic dialysis, residents learn to manage continuous renal replacement therapies used in intensive care spanning general medicine, cardiac surgery, neurosurgery and bone marrow transplantation. This is where nephrology meets emergency medicine: acid-base balance, electrolytes, fluids and organ function all have to be assessed quickly, alongside other specialists.
Before working with patients, residents can practise at the University's SimLab. On the mannequin, they learn to place central venous catheters and, going forward, will also be able to train on peritoneal dialysis and kidney biopsy. Simulation allows them to repeat procedures, correct mistakes, and move on to direct patient care with greater confidence.
The first year of the programme is split between ward, outpatient clinics and dialysis. It builds the foundations, but it also helps residents work out which part of nephrology interests them most: the diagnosis of primary kidney disease, dialysis, transplantation, intensive care, interventional procedures or research.
Theory classes are organised into two cycles: renal physiology, primary kidney disease and acute and chronic kidney failure in the first two years; dialysis and transplantation in the years that follow. The clinical training alternates between ward, dialysis and transplantation, and includes a placement within the network at the hospital in Cernusco sul Naviglio and a placement outside the network, of up to 18 months, in Italy or abroad.
«The hospital in Cernusco sul Naviglio is a smaller facility, where residents learn to work with fewer resources, which makes it more demanding», Lanzani adds. The variety of settings has real training value: a large centre teaches complexity and multidisciplinary work, while a smaller facility builds independence, the ability to set priorities, and decision-making responsibility.
Nephrology is also a fast-moving research field. New drugs have changed the prognosis for many kidney diseases, while genetics, biomarkers, immunology and precision medicine are making diagnosis and treatment increasingly specific.
Its connection with IRCCS San Raffaele Hospital gives residents access to international multicentre clinical trials and to independent projects funded through ministerial and regional grants and the PNRR, Italy's national recovery and resilience plan, covering the entire research process from the initial idea to study design, funding and completion.
The group has its own laboratory dedicated to the genetics and biomarkers of kidney disease, alongside a mouse clinic with murine models of hypertension and kidney disease. Research lines include glomerulonephritis and biologics, the progression of chronic kidney disease, acute kidney injury, kidney aging, and genetically determined kidney diseases, with a particular focus on polycystic kidney disease.
Residents who want to can also spend a period doing research abroad: in recent years, residents have worked in the United States (New York, and Rochester, Minnesota, at the Mayo Clinic), in Barcelona, in Tokyo, and at other universities across Europe and beyond, depending on the group's collaborations and personal interests. The final year of specialisation can also overlap with the first year of a PhD.
«I care a great deal that future nephrologists learn to run a research project across the four years of specialisation, even if they never do research again later in their career, because understanding what research really involves pushes you towards a deeper view of disease. It also means being able to read a scientific paper critically, and to understand where the guidelines that shape everyday clinical decisions actually come from», Lanzani stresses.
By the end of the programme, a specialist must have an in-depth knowledge of kidney physiology, be able to correctly assess a patient with kidney disease, and manage dialysis treatments independently. From these foundations, each specialist can build a personal profile that follows their own interests.
Nephrologists often follow the same patient for many years and work hand in hand with numerous specialists and healthcare professionals, well beyond the “simple” management of creatinine and electrolytes.
«One of my mentors, the person who introduced me to this discipline, made me understand that the kidney is the centre of the body, and that a person's physical and mental wellbeing depends closely on it», Lanzani recalls.
Following the same patient over years of chronic therapy calls for a different mindset from many other disciplines. Success, in nephrology, includes both results with an immediate impact and outcomes such as recovery, slowing a disease, avoiding a complication, preserving years of kidney function, or making a complex therapy sustainable.
Asked, in short, why she would recommend nephrology to a new graduate, Lanzani replies: «because it's a complete speciality, one that calls for clinical intuition, reasoning, technology, manual skill and humanity. You're never bored: the kidney may seem silent, but it's often this very organ that tells a patient's whole story in detail».