Machiavelli and urinalysis


theless, in our fully adjusted model, the 95% CI for the
hazard ratio associated with the administration of
paricalcitol versus calcitriol included the point estimate
reported by Teng et al.3 Paricalcitol appears to confer
no survival advantage over doxercalciferol. The point
estimates for hazard ratios for doxercalciferol versus
paricalcitol ranged from 0.99 to 1.06 and each 95% CI
included 1.0. However, we cannot exclude the possibility
that doxercalciferol may be associated with a small benefit
or disadvantage over paracalciferol.

Our retrospective study reflects clinical practice. Since
different vitamin D preparations became available at
different times, the treatments were not simultaneous, and
switching was the major cause of censoring. The vitamin D
analogs were not dosed according to KDOQI guidelines,
since most of the study occurred before these were published.

1. Sprague SM. Mortality risk among hemodialysis patients receiving
different vitamin D analogs. Kidney Int 2006; in press.

2. Tentori F, Hunt WC, Stidley CA et al. Mortality risk among hemodialysis
patients receiving different vitamin D analogs. Kidney Int 2006; 70:
1858–1865.

3. Teng M, Wolf M, Ofsthun MN et al. Activated injectable vitamin D and
hemodialysis survival: a historical cohort study. J Am Soc Nephrol 2005;
16: 1115–1125.

F Tentori1, WC Hunt1, CA Stidley1, MR Rohrscheib1, EJ Bedrick1,

KB Meyer1, HK Johnson1 and PG Zager1
1Dialysis Clinic Inc. (DCI), Quality Management, Albuquerque, New Mexico,

USA

Correspondence: F Tentori, Dialysis Clinic Inc., Quality Management, 1500

Indian School Rd NE, Suite 200, Albuquerque, New Mexico 87102, USA.

E-mail: francesca.tentori@dciinc.org

Immunofluorescence on
proteinase XXIV-digested paraffin
sections
Kidney International (2007) 72, 896; doi:10.1038/sj.ki.5002495

To the Editor: In their comparison of immunofluorescence
(IF) on frozen sections with pronase-digested paraffin
sections, Nasr et al.1 found that pronase digestion was a
useful technique for IF on paraffin (IF-P) sections. However,
the sensitivity of this technique was low for membranous
glomerulopathy and anti-glomerular basement membrane
disease (50 and 20%, respectively), which was mainly due
to weak staining of IgG (immunoglobulin G).

In our laboratory, we use bacterial proteinase XXIV
(Sigma, St Louis, MO, USA), as described by Bancroft and
Gamble,

2 instead of pronase. We compared IF-P on
proteinase XXIV- and pronase-digested paraffin sections.
We selected five cases of lupus nephritis that showed full-
house fluorescence staining on frozen sections. In all cases,
staining intensity was similar or better on proteinase XXIV-
digested slides, and less background was observed. Impor-
tantly, staining for IgG and C1q was more intense in sections
digested with proteinase XXIV than in those digested with

pronase. In addition, we tested five cases of anti-glomerular
basement membrane disease. One of these was negative after
pronase, as well as after proteinase XXIV digestion, one was
positive with both techniques, whereas the remaining three
were positive only after proteinase XXIV digestion. Finally, in
nine cases of membranous glomerulopathy, diagnostic IF-P
staining for IgG was obtained in six cases after pronase
digestion and in five cases after proteinase XXIV digestion.

In conclusion, we agree with Nasr et al. that IF-P is a
valuable salvage technique for renal biopsies. To this, we
would like to add that IF-P on sections digested with
proteinase XXIV is generally more sensitive than IF-P on
pronase-digested sections.

1. Nasr SH, Galgano SJ, Markowitz GS et al. Immunofluorescence on
pronase-digested paraffin sections: a valuable salvage technique for renal
biopsies. Kidney Int 2006; 70: 2148–2151.

2. Bancroft JD, Gamble M. Theory and Practice of Histological Techniques,
5th edn. Churchill Livingstone, London, 2002, pp 450–451.

K van der Ven1, TQ Nguyen1 and R Goldschmeding1
1Department of Pathology, University Medical Center Utrecht, Utrecht,

The Netherlands

Correspondence: R Goldschmeding, Department of Pathology, University

Medical Center Utrecht, Utrecht, The Netherlands.

E-mail: R.Goldschmeding@umcutrecht.nl

Machiavelli and urinalysis
Kidney International (2007) 72, 896–897; doi:10.1038/sj.ki.5002496

To the Editor: I read with great interest the article on the
history of urinalysis in Western culture by Armstrong.1 It
gives a detailed outline of how uroscopy developed into a
prominent medical diagnostic tool, and later was abandoned
due to the poor scientific basis of such practice. In Dr
Amrstrong’s article, however, it is not mentioned that
uroscopy was so popular to be included in the most famous
play by Niccolò Machiavelli, ‘La Mandragola (The Man-
drake)’,

2,3 making fun of presumptuous physicians and
credulous patients. In another important paper on uroscopy
by Voswinckel,4 the contribution of Machiavelli is not
mentioned as well.

Niccolò di Bernardo dei Machiavelli (May 3, 1469 to June
21, 1527) was an Italian political philosopher. He is a central
figure of the political component of the Italian Renaissance,
most widely known for his treatises on realist political theory
(The Prince). However, he also was a musician, poet, and
romantic comedic playwright.

The Mandragola has been widely performed and very
popular since the sixteenth century. The title comes from
the popular tale that a woman who drinks a potion made
from the mandrake root is certain to conceive a child, the
only drawback being that the man with whom she first has
sex after taking the potion will die within 8 days. The story
evolves around Callimaco, a lovesick Florentine who
came form Paris to conquer the heart (and the graces) of
Lucrezia, the beautiful young wife of Messer Nicia Calfucci, a

896 Kidney International (2007) 72, 895–898

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foolish wealthy merchant whose only thought is having an
heir. The clever Callimaco therefore disguises himself as a
physician, and to gain Nicia’s faith, he performs an hilarious
uroscopic exam (Act II, Scene 6), reported in Table 1.

Machiavelli reports how easy could be for an educated
imposter to play the part of an expert doctor, without seeing
his patient. It is crucial to note the importance of Nicia’s
credulous attitude towards someone who could speak Latin,
educated in a foreign Country, asking for an absolute faith in
his previous experience. It is possible that Machiavelli took
his inspiration from the first printed medical books on
uroscopy, such as the Epiphanie Medicorum

5
or the

Fasciculus Medicinae.6 In any case, he tried to denigrate the
inappropriate use of uroscopy much earlier than Thomas
Brian.7

ACKNOWLEDGMENTS
I thank Dr Roberta Zanoli from the Piccolo Teatro di Milano, for her
help in retrieving bibliographic material on Machiavelli’s works.

1. Armstrong JA. Urinalysis in Western culture: a brief history. Kidney Int
2007; 71: 384–387.

2. Machiavelli N. La Mandragola (written between 1513 and 1520). First
published in Rome, 1524. Here we refer to the edition cured by Gerolamo
Lazzeri, Milano. Corbaccio 1924.

3. Machiavelli N. Mandragola (English translation Mera J. Flaumenhaft)
Waveland Press, Inc.: Prospect Heights, IL, 1981.

4. Voswinckel P. From uroscopy to urinalysis. Clin Chim Acta 2000; 297: 5–16.
5. Pinder, Ulrich (Udalricus Binder). Epiphanie Medicorum. Speculum videndi

urinas hominum. Clavis aperiendi portas pulsuum. Berillus discernendi
causas & differentias febrium. Sodalitas Celtica: Nuremberg, 1506.

6. Ketham, John de (Johannes de Ketham, Hans von Kirchheim). Fasciculus
medicinae. Venice, Giovanni & Gregorio Di Gregorii, Latin Edition: 1491;
Italian Edition: 1493. See also http://archive.nlm.nih.gov/proj/ttp/flash/
ketham/ketham.html.

7. Brian T. The Pisse-Prophet, or certaine pissepot lectures. London, Printed by
E. P. for R. Thrale, 1637. See also http://eee.uci.edu/clients/bjbecker/
PlaguesandPeople/week3h.

M Gallieni1
1A.O. San Paolo, Renal Unit, Milano, Italy

Correspondence: M Gallieni, A.O. San Paolo, Renal Unit, via di Rudinı̀, 8,

Milano 20142, Italy. E-mail: maurizio.gallieni@fastwebnet.it

Classification of pediatric lupus
nephritis
Kidney International (2007) 72, 897–898; doi:10.1038/sj.ki.5002497

To the Editor: We read with great interest the review by
Markowitz and D’Agati1 on the 2003 International Society of
Nephrology (ISN)/Renal Pathology Society (RPS) classifica-
tion of lupus nephritis (LN).2 We agree that the new
classification has provided a standardized approach to renal
biopsy interpretation which was required to compare
outcome data across centers and facilitate intervention trials
in LN.

The authors highlight the controversy regarding the
introduction of a subclassification within diffuse LN (class IV)

Table 1 | Transcript of the play ‘La Mandragola’, relevant to uroscopy, from the original Scene 6, Act II, in Italian and Latin,
followed by English translation

CALLIMACO Avete voi el segno?
NICIA E’ l’ha Siro, sotto.
CALLIMACO Dàllo qua. Oh! questo segno mostra debilità di rene.
NICIA Ei mi par torbiccio; eppur l’ha fatto or ora.
CALLIMACO Non ve ne maravigliate. Nam mulieris urinae sunt semper maioris grossitiei et albedinis, et minoris pulchritudinis, quam virorum. Huius autem,
inter caetera, causa est amplitudo canalium, mixtio eorum quae ex matrice exeunt cum urina.
NICIA Oh! uh! potta di san Puccio! Costui mi raffinisce in tralle mani; guarda come ragiona bene di queste cose!
CALLIMACO Io ho paura che costei non sia, la notte, mal coperta, e per questo fa l’orina cruda.
NICIA Ella tien pure addosso un buon coltrone; ma la sta quattro ore ginocchioni ad infilzar paternostri, innanzi che la se ne venghi al letto, ed è una
bestia a patir freddo.
CALLIMACO Infine, dottore, o voi avete fede in me, o no; o io vi ho ad insegnare un rimedio certo, o no. Io, per me, el rimedio vi darò. Se voi avrete fede
in me, voi lo piglierete; e se, oggi ad uno anno, la vostra donna non ha un suo figliolo in braccio, io voglio avervi a donare duemila ducati.
NICIA Dite pure, ché io son per farvi onore di tutto, e per credervi piú che al mio confessoro.

CALLIMACO Have you got the specimen?
NICIA Siro’s got it, under his mantle.
CALLIMACO Give it to me. Oh! This specimen shows a weakness of the kidneys.
NICIA Indeed, it looks quite cloudy to me; and yet she just did it.
CALLIMACO You should not be surprised. Nam mulieris urinae sunt semper maioris grossitiei et albedinis, et minoris pulchritudinis, quam virorum. Huius
autem, inter caetera, causa est amplitudo canalium, mixtio eorum quae ex matrice exeunt cum urina. (In fact, urine from females is always thicker and whiter,
and less exquisite, than urine from males. Of such things, among others, the cause is the width of the channels, combined with the materials which exit from
the body matrix with the urine).
NICIA Oh! uh! Pussy of Saint Puccio! This man gets better and better while I listen to him; see how well he speaks about these things!
CALLIMACO I fear the patient may not be well covered at night, and perhaps this is the reason why her urine is not well matured.
NICIA She is well covered, with a good blanket, but then she’ll spend four hours on her knees threading paternosters together, before she comes to bed,
and yet she is as strong as an ox when it comes to standing the cold.
CALLIMACO Well now, sir, the question is, have you faith in me, or haven’t you; and do you want me to teach you a certain remedy or don’t you? For my
part, I’m ready to give you the cure. If you have faith in me, you’ll get it, and if your wife doesn’t have a baby in her arms by this time next year, then I’ll
be willing to give you two thousand ducats.
NICIA Go on then, tell me, because I am ready to give you credit and honors for everything, and ready to believe you more than my own confessor.

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