In Memoriam - Prof. Carmelo Giordano (1930-2016)

(Born in Naples (Italy) on August 22, 1930, died in Naples (Italy), on May, 12, 2016).

Prof. Carmelo Giordano (Figure 1) was born in Naples on august 23, in 1930. He completed his medical studies cum laude in Naples,
C.Giordano in 1954, at the faculty of Medicine of the University Federico II. After achieving the MD he moved to Boston  (MA, USA) where   he was  trained  in nephrology  by Prof. John Putnam Merrill “The father of Nephrology  as a discipline” (Prof. Murray Epstein), at the Peter Bent Brigham Hospital of the Harvard  Medical School (“no Institution has done more for propagation of dialysis in  the United States”). Upon his return to Naples he developed a laboratory for nutrition in renal disease, which was supported for the subsequent 21 years (1959-1980) by grants coming from the National Institutes of Health of the United States. He also started dialysis therapy for AKI using a Kolff-Brigham kidney, a personal gift given to him by Mr. Edward Olson, who was the manufacturer.  Dialysis for ESRD was started in 1966. His dietary management of CKD patients (an example of self experimentation) was based on low protein diets of high biological value and rich in energy. Proteins were given as natural foods as well as under the form of L-essential amino acids. The safety and the efficacy of the diets was assessed by measuring the daily nitrogen balance (1-3). Subsequently he organized the first postgraduate school in nephrology (1971) at the University of Naples and the Ph.D. program in Nephrological Science (1980).Prof. Giordano’s group grew in numbers, quality and productivity and was ready to organize in the years 1971-1980 the Capri conferences and Award on Uremia.  In 1975 Prof. Giordano received the tenure (as full professor of nephrology, which in 1990 was extended to   internal medicine). The tenure in medicine lasted until 2005 (his last year at the University) and was associated with the direction of a division of medicine which was fully dedicated to renal transplantation from living and deceased donors.

Prof. Giordano was instrumental for the start of academical pediatric nephrology at the University Federico II in Naples (1980) and he pushed very hard in the Council the Italian Society of Nephrology to develop its own journal (Giornale Italiano di Nefrologia) which in 1983 was separated from the Gruppo Editoriale Minerva (Minerva Nefrologica). He also promoted the birth in Milan―with Wichtig Editore―of the International Journal of Artificial Organs (1975) and of The International Journal of Pediatric Nephrology (1980). In addition he was also elected dean for curricula for one term, and president of the Italian Society of Nephrology (for which he had been one of the 10 founders) and the first president of the college of university professors of nephrology. He received the Golden Kidney from the European Society of Pediatric Nephrology and a Special recognition from the International Society for Renal Nutrition and Metabolism. He also served for one term in the EDTA Council as an ordinary council member.

Particularly impressive is the list of novelties on renal nutrition discussed at ISN meetings: Prague (1963), Washington (1966), Florence (1975), and Athens (1981). In Prague his free communication on nutrition was unique for the topic. In Washington he showed that 75% of CKD patients on a diet providing 25 g of proteins were in positive nitrogen balance.  In a plenary Lecture in Athens he acknowledged the impossibility for nutrition to compete with dialysis and transplantation and proposed to use it very early in the course of CKD (Early diet to slow the course of chronic renal failure). In that occasion he also definitely accepted the use of ketoacids as a nutritional therapeuthical possibility of in tervention, thus he was finally able to compound old dicords and acknowledged the role of Dr. Mackensie Walser.

However to fully appreciate Prof. Giordano’s contribution to renal nutrition one should refer to the Proceedings of the Congress  on Nutritional Aspects of Uremia which took place in Scottsdale, Arizona on October 2-3, 1967 and published in the American Journal of Clinical Nutrition No. 21 (May and June 1968), which also reports on  the debate between scientists. In recent years Prof. Giordano’s work has also been given a historical perspective (4, 5).

Prof. Giordano was very pleased by the paper of Prof. Denis Fouque and Prof. William E Mitch (NDT 2015; 30: 6-8):”In the history of medical sciences a few topics have been the focus of so many clinical trials, reviews, speculation, and discussions than the question of what constitutes an optimal protein intake for patients with kidney disease.... But probably we are reaching a consensus”. He felt that this tenet was  strongly supported  by: (i) studies of Prof. Massimo Cirillo et al. in the middle age population of the Gubbio Study showing that higher protein intake is associated cross-sectionally with higher GFR but longitudinally with greater GFR decline over time (NDT204; 29(9):1733-1740. (ii) data of Prof. Bruno Cianciaruso et al (AJKD 2009; 54(6): 1052-1061), (iii) those of Prof. Vincenzo Bellizzi et al.  (NDT 2015;30:71-77), and by (iiii) a report  on the costs of CKD therapy in the Campania  Region  authored by Prof. Giorgio Liguori et al (Igiene and Sanità Pubblica 2012;68:781-792), and by(iiiii) data of Biagio Di Iorio in Kidney Int (2007;7145-252.

Various creative clinical scientists worked during sabbaticals at the nephrological unit directed by Prof. Carmelo Giordano. The fist— Prof. Kazimierz Backzyk―who was later professor of Nephrology at the Medical  University of Poznan (Poland) —arrived in Naples just in the days in which Eastern Europe was separated from the West with the construction of the wall in Berlin (Germany). Prof. Malcolm E. Phillips came to Naples from London as a Wellcome Trust Research Fellow for 2 years. His fellowship was arranged between Professors Hugh de Wardener and Carmelo Giordano. He studied amino acid losses and the effects of essential amino acid supplements in hemodialysis patients and the utilisation of D-amino acids and keto-acids in healthy and uremic patients (Lancet 1972). Later, when back in London, (Dr). Phillips   was for varying periods General Manager of the Charing Cross Hospital and Medical Director of the Charing Cross and Hammersmith Hospitals. Prof. Otto Busato came from the department of nephrology at the University of Porto Alegre (Brazil) to work on nutrition and peritoneal dialysis. Also Prof. Alejandro Trevino Becerra came with the same goal and subsequently remained―as it is evident― anchored to the topic life-long.  Prof. Francisco Gonzalez, Chair of Medicine and chief of nephrology at Louisiana State university during his stay attracted many young investigators to acid base balance in HD and PD and focused his research on pharmacological means to augment peritoneal dialysis clearances. The list of visiting scientists includes Professors Karl Julius Ullrich, Shaul Massry, Klaus Hierholzer,   Gerhard Malnic, and Willem Kolff who was attracted by the use of sorbents for wearable kidney. In fact Prof. Giordano with Professors Yatzidis, Chang and Friedman introduced the use sorbents in medicine. The monograph on Sorbents and their clinical applications (Academic Press, New York 1980) is the outcome of such interest. The Group of Sorbents for Portable-Wearable kidneys was coordinated by Professor Renato Esposito (professor of nutrition and included Professors Giovanni Demma, Piero   Bello (both Doctors in Chemistry),   Prof. Ernst Quarto (bioengineer) and Prof. Giacomino Randazzo (Professor of Biochemistry), and finally also Doctor Norina Lanzetti (a nephrologist). They synthesized oxystarch and oxycellulose to be used orally (alone or in combination with charcoal) or for regeneration of dialysis fluid in wearable-portable kidneys. Both substances were potent binders for urea, and other nitrogenous waste products. Professors Esposito, Bello and Quarto also hypothesized the advent of inert material used for hydroponic cultivations to reabsorb water in human gastrointestinal tract. A field now in progress in many international laboratories.

This without forgetting the creative collaborations with Professors Jonas Bergstrom, Peter Furst (St. Erik Hospital, Stockholm), Garnar Ryhage, (Institute for Mass spectrometry at the Karolinska Institute), the group of Prof. Peter Richards at St. Mary Hospital Medical School (London) which gave birth to the use of ketoacids in health and uremia (Lancet 1971 and 1972), Prof. Ely A. Friedman (Suny, New York) for the use of charcoal and oxystarch in uremia.
Prof. Carmelo Giordano is survived by his wife Liliana and by  their  four children (all MDs):   Drs. Dario Ranieri (university investigator in  urology), Diego (university investigator in radiology), Mauro (Associate Professor of medicine and director of the specialty school in emergency medicine at the University of Campania Luigi Vanvitelli in Marcianise Caserta),  Laura (Nephrologist),  and by 13  grandchildren.

Prof. Giordano was pleased to participate in nephrological events in the Neapolitan area and he was a charming discussant. He used to participate to SURVIVAL is NOT ENOUGH held at the occasion of   the World Kidney Day in Naples. Also this year he was at the Italian Institute for Philosophical studies (on March 10) where there were many of his previous fellows. He used all his charisma to stimulate  the audience to act as  testimonial for kidney donation  since “renal  transplantation is the best therapy for uremic patients due its low cost, the quality of life granted and the length of survival.” This was the last occasion I saw him alive and brilliant. In that occasion he received an award from The Philosophical institute: a diploma for his life-long achievements in nephrology. Indeed his name and his contribution will  be continually furthered by the many  nephrologists he imprinted over the years, from 1959 onward, the year he started          nephrology  in Naples, in a 40 square meter laboratory on the third floor  of the second pavillon of the Policlinico  in Miraglia Square  (that was then destroyed by the earthquake of Nov 23, 1980).


figure1

Prof. Giordano had also many hobbies. First of all he had great interest in the origins of Italian words (not necessarily related to medicine) and identifying stars at night by focusing from the terrace of his apartment   with the telescope in the starry sky. In addition he had interest in Porsche cars and— much more— in sailing. With Black Swan (I-8155) he won various national and international races.  Prof. Giordano’s Boat (I-8155) is nicely illustrated (Figure 2) in the Italian Lexicon Treccani (Vol XXIV, p.129) because of its peculiar capacity to advance transversally.

(Figure 2 – Black Swan)

 

Ciao Prof. Sit tibi terra levis/May the earth rest lightly on you.

Natale G. De Santo MD, Emeritus Professor of Nephrology, University of Campania ―Luigi Vanvitelli. Email: nataleg.desanto@unina2.it, phone +393484117376

References

GIordano C. Treatment of uremia using essential amino acids and low protein diets. J Lab Clin Med 1963; 62: 231-246.
2. Giordano C. Treatment using essential amino acid and low protein  diet. Proc. 2nd Int Congr Nephrol Prague, Excerpta Medica IntCongr series No.78, Basel Karger 1964:752-755
3. Giordano C, Esposito R, De Pascale C, De Santo NG. Dietary treatment in renal failure. Proc 3rd Int Congr Nephrol, Washington Vol 2, Basel Karger1966, 214-229.
4. De Santo NG, Cirillo M. Low protein diets are mainstay for management of chronic     renal disease.Frontiers in Bioscience 2011; 3. 1432-42.
5.  Di iorio B, DE Santo NG, Anastasio P, Perna A., Pollastro M.R., Di Micco L, Cirillo M. The Giordano-giovannetti  diet. J Nephrol 2013; 26(Suppl.22)