Presently, it would be difficult to explain why a kidney biopsy was not performed in light of nephrotic syndrome that do not respond to corticosteroids, a severe acute or chronic deterioration in kidney function, the impact of the kidneys from a systemic disease, or in light of a kidney graft failure.

We should recognise that with the help the nephropathology departments which receive, process and study biopsies, we know, via the Sociedad Española de Nefrología (Spanish Society of Nephrology, SEN) and the Registro Español de Glomerulonefritis (Spanish Registry of Glomerulonephritis), the incidence and prevalence of the different diseases with renal pathology in Spain. Despite this information, we must accept as a negative fact that in around 50% of patients with chronic kidney disease, the cause of this disease is unknown, and that a complete study using an electron microscope is only carried out in very few cases. Without a doubt, both the Sociedad Española de Anatomía Patológica (Spanish Society of Nephropathology, SEAP) and the SEN should analyse the reasons why Spanish centres do not have experienced pathologists and infrastructure equipped with a special processing laboratory which includes immunofluorescence or immunohistochemistry and an electron microscope.

The high costs of kidney biopsy studies and the need for the pathologist to with enough knowledge requires planning of kidney biopsy studies at both autonomous community and state level in Spain. The wide dispersion of nephrology departments, even in regional centres, leading to a low number of kidney biopsies, prevents the funding of expert pathologists in kidney diseases and even means that conducting kidney biopsies is not cost-efficient from the healthcare point of view or the financial point of view, for as long as the reliability of a histopathological diagnosis is not guaranteed.

The complexity of studying kidney disease, the high cost of clinical processes and treatment demands, with increasing urgency, a new horizontal-type organisation in Spanish hospitals, moving away from the classic vertical structure in which the organisation of medical specialties into isolated compartments prevents teamwork. This horizontal organisation as work teams requires the integrated presence of pathologists who are experts in nephrology and who offer with their knowledge and experience. The demand for nephrologists with sufficient training to undertake the challenge of patient care and scientific analysis is a current reality calling for a response from the scientific societies involved, as well as from the healthcare administration.

There are sufficient indicators to compel scientific societies, specifically the SEAP and the SEN, to narrow any gaps. There are destabilising factors, one is the fact that nephropathology as such is not, and has never been, a formally developed sub-specialty, and it is not an area of pathology inspiring new vocations, with only some exceptions.

Contrary to what happens in the USA, United Kingdom and other European countries, in which kidney biopsy studies have been centralised, the “decentralisation” policy has been maintained in Spain. We believe that this is a mistake, as it has prevented the necessary diagnostic method from reaching levels of quality and of required experience, increasing the cost and making the outcome uncertain. In the above-mentioned countries, there are reference nephropathology centres or groups, with a proven track record, which receive all the kidney biopsies performed in a certain healthcare area (state, city, etc.) and which issue a report, for the clinic taking care of the patient, quickly and with fluid and continuous communication. This system, in addition to ensuring a high level of quality of nephropathological information and an analysis of all the kidney biopsies with all the indicated techniques (including electron microscopy), has meant that these groups of nephropathologists, together with clinical nephrologists and other professionals interested in these diseases, have developed leading research groups on kidney diseases.

We believe that it is important to consider the activity of the nephropathologist not as an independent specialty, but as a basic integrating element within a multidisciplinary team for which the fundamental objective will be studying kidney diseases, not only from the histopathological and ultrastructural point of view, but fully addressing nephrological diseases, from optical microscopy to molecular biology. The emergence of quality cost-effective results will never be possible if there is no in-depth knowledge of the specific field of renal pathology.