Interventional nephrology in Italy: Past achievements, present challenges, and future directions

Interventional nephrology has progressively emerged as a discipline aimed at integrating clinical management with procedural expertise in the care of patients with kidney disease. Historically, Italy has represented one of the leading international models in the management of dialysis access and ultrasound-guided procedures, largely due to the direct procedural involvement of nephrologists. This narrative review examines the historical evolution, status, and future perspectives of interventional nephrology in Italy. Early national surveys and data from the Dialysis Outcomes and Practice Patterns Study documented exceptionally high rates of native arteriovenous fistula use and minimal reliance on central venous catheters, outcomes closely associated with the active procedural role of nephrologists. However, more recent national surveys and international registry data indicate a gradual decline in nephrologists' direct procedural involvement, paralleled by increasing catheter use and greater reliance on other specialties for dialysis access creation and related procedures. Several factors appear to contribute to this transition, including healthcare system reorganization, workforce reductions affecting training and mentorship, epidemiological changes in the dialysis population, increasing use of pre-emptive kidney transplantation, and evolving medico-legal considerations. Despite these challenges, Italian nephrology retains significant technical expertise and organizational potential. Strengthening structured training pathways, establishing coordinated educational initiatives, such as a proposed Academy of Interventional Nephrology and implementing collaborative hub-and-spoke networks could support the revitalization of procedural competencies within the specialty. Reintegrating procedural skills into nephrology practice may not only improve the quality and timeliness of dialysis access care and ultrasound-guided procedures but also help redefine the professional identity and future attractiveness of the discipline.