Nephrology

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A drawing of the human kidney from Gray's Anatomy.

Nephrology (from Greek: nephros, "kidney"; and λόγος, logos, "speech" lit. "to talk about kidney") is a branch of internal medicine and pediatrics dealing with the study of the function and diseases of the kidney.^[1]

[edit] Scope of the specialty

Nephrology concerns itself with the diagnosis and treatment of kidney diseases including electrolyte disturbances and hypertension, and the care of those requiring renal replacement therapy, including dialysis and renal transplant patients. Many diseases affecting the kidney are not limited to the organ itself, but are systemic disorders, and may require not only a whole patient approach, but also special treatment, such as systemic vasculitides or other autoimmune diseases, such as lupus.

[edit] Training

A nephrologist is a physician who has been trained in the diagnosis and management of kidney disease, by regulating blood pressure, regulating electrolytes, balancing fluids in the body, and administering dialysis. Nephrologists treat many different kidney disorders including acid-base disorders, electrolyte disorders, nephrolithiasis (kidney stones), hypertension (high blood pressure), acute kidney disease and end-stage renal disease. Nephrology is a subspecialty of internal medicine. In the United States, after medical school nephrologists complete a three year residency in internal medicine followed by a two year (or longer) fellowship in nephrology.

Knowledge of internal medicine is required to obtain certification. To become a nephrologist requires many years of school and training. Nephrologists also must be approved by the board. To be approved, the physician must fulfill the requirements for education and training in nephrology in order to qualify to take the board's examination. If a physician passes the examination, then he or she can become a nephrology specialist. Typically, nephrologists also need two to three years of training in an ACGME accredited program in nephrology.

Things that a nephrologist learns in training are fluid and acid base and electrolyte physiology, medical management of acute and chronic renal failure, glomerular and casuclar disorders, tubular/interstitial disorders, mineral metabolism, clinical pharmacology, hypertension, epidemiology, thics, and nutrition. Procedures a nephrologist may learn in a training program include native and transplant kidney biopsies, ultrasound guidance, placement of temporary dialysis catheters, placement of tunneled hemodialysis catheters and placement of peritoneal dialysis catheters. Nearly all programs train nephrologists in continuous renal replacement therapy; fewer than half train in the provision of plasmapheresis.^[2] Once training is satisfactorily completed, the physician is eligible to take the ABIM nephrology examination.

Only pediatric trained physicians are able to train in pediatric nephrology, and internal medicine (adult) trained physicians may enter general (adult) nephrology fellowships. Physicians that achieved training in both medicine and pediatrics may subspecialize in both adult and pediatric nephrology.

[edit] Who sees a nephrologist?

Patients are referred to nephrology specialists for various reasons, such as:

• Acute renal failure, a sudden loss of renal function
• Chronic kidney disease, declining renal function, usually with an inexorable rise in creatinine.
• Hematuria, blood loss in the urine
• Proteinuria, the loss of protein especially albumin in the urine
• Kidney stones, usually only recurrent stone formers.
• Chronic or recurrent urinary tract infections
• Hypertension that has failed to respond to multiple forms of anti-hypertensive medication or could have a secondary cause
• Electrolyte disorders or acid/base imbalance

Urologists are surgical specialists of the urinary tract - see Urology. They are involved in renal diseases that might be amenable to surgery:

• Diseases of the Bladder and prostate such as malignancy, stones, or obstruction of the urinary tract.

[edit] Diagnosis

As with the rest of medicine, important clues as to the cause of any symptom are gained in the history and physical examination.

Laboratory tests are almost always aimed at: urea, creatinine, electrolytes, and urinalysis-- which is frequently the key test in suggesting a diagnosis.

More specialized tests can be ordered to discover or link certain systemic diseases to kidney failure such as hepatitis b or hepatitis c, lupus serologies, paraproteinemias such as amyloidosis or multiple myeloma or various other systemic diseases that lead to kidney failure. Collection of a 24-hour sample of urine can give valuable information on the filtering capacity of the kidney and the amount of protein loss in some forms of kidney disease. However, 24-hour urine samples have recently, in the setting of chronic renal disease, been replaced by spot urine ratio of protein and creatinine.

Other tests often performed by nephrologists are:

• Renal biopsy, to obtain a tissue diagnosis of a disorder when the exact nature or stage remains uncertain.;
• Ultrasound scanning of the urinary tract and occasionally examining the renal blood vessels;
• CT scanning when mass lesions are suspected or to help diagnosis nephrolithiasis;
• Scintigraphy (nuclear medicine) for accurate measurement of renal function (rarely done), and MAG3 scans for diagnosis of renal artery disease or 'split function' of each kidney;
• Angiography or Magnetic resonance imaging angiography when the blood vessels might be affected

[edit] Therapy

Many kidney diseases are treated with medication, such as steroids, DMARDs (disease-modifying antirheumatic drugs), antihypertensives (many kidney diseases feature hypertension). Often erythropoietin and vitamin D treatment is required to replace these two hormones, the production of which stagnates in chronic kidney disease.

When chronic kidney disease progresses to stage five, dialysis or transplant is required. Please refer to the main articles dialysis and renal transplant for a comprehensive account of these treatments.

If patients proceed to transplant, nephrologists will continue to follow patients to monitor the immunosuppressive regimen and watch for the infection that can occur post transplant.

[edit] Notable nephrologists

• Morrell Avram, among the first in the United States to use the artificial kidney to treat patients with kidney failure.

• Priscilla Kincaid-Smith

• Hugh R. Brady, President of University College Dublin, Ireland

• William Bright, one of the initial physicians to realize that the microscopic presence of blood and protein in the urine indicated kidney damage, known today as glomerulonephritis.

• Joseph W. Eschbach, nephrologist whose research lead to the treatment of anemia in renal patients.

• Georg Haas, performed the first human hemodialysis treatment.

• Steven C. Hebert, made major contributions to medicine, notably in the cloning of genes that mediate or regulate the transport of sodium, potassium and calcium across cell membranes. His work won him election to the National Academy of Sciences (NAS) in 2005, and his research was the basis for a new class of drugs which are used to treat hyperparathyroidism, a hormonal disorder that affects many of the more than 1 million patients worldwide with end-stage kidney disease.

• Willem Johan Kolff, is a pioneer in the development of the hemodialysis machine as well as in the field of other artificial organs.

• Arthur Arnold Osman, was the first doctor to call himself a nephrologist.

• Belding H. Scribner, one of the pioneers of ongoing kidney dialysis.

[edit] Organizations

In the USA, the National Kidney Foundation is a national organization representing patients and professionals who treat kidney diseases. The American Society of Nephrology (ASN) is a not-for-profit organization of 11,000 physicians and scientists dedicated to the study of nephrology and committed to providing a forum for the promulgation of information regarding the latest research and clinical findings on kidney diseases. In the United Kingdom, the National Kidney Federation represents patients, and the Renal Association represents renal physicians and works closely with the National Service Framework for kidney disease. The Renal Support Network (RSN) is a nonprofit, patient-focused, patient-run organization that provides non-medical services to those affected by chronic kidney disease (CKD). The American Association of Kidney Patients (AAKP) is a non-profit, patient-centric group focused on improving the health and well-being of CKD and dialysis patients.

[edit] References

1. ^ American Society of Nephrology | Facts and Statistics | FAQ
2. ^ http://www.ncbi.nlm.nih.gov/pubmed/18417748 Clin J Am Soc Nephrol. 2008 Apr 16

[edit] External links

• American Society of Nephrology
• British Journal of Renal Medicine
• Nature Clinical Practice Nephrology
• West Virginia University Department of Medicine - Section of Nephrology