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Nephrology is a specialty for both adult internal medicine and pediatric medicine that concerns the study of the , specifically normal renal function (renal physiology) and kidney disease (renal pathophysiology), the preservation of kidney health, and the treatment of kidney disease, from diet and medication to renal replacement therapy (Kidney dialysis and kidney transplantation). The word "renal" is an adjective meaning "relating to the kidneys", and its roots are French or late Latin. Whereas according to some opinions, "renal" and "nephro-" should be replaced with "kidney" in scientific writings such as "kidney medicine" (instead of "nephrology") or "kidney replacement therapy", other experts have advocated preserving the use of renal and nephro- as appropriate including in "nephrology" and "renal replacement therapy", respectively.
Nephrology also studies systemic disease conditions that affect the kidneys, such as diabetes and autoimmune disease; and systemic diseases that occur as a result of kidney disease, such as renal osteodystrophy and hypertension. A physician who has undertaken additional training and become certified in nephrology is called a nephrologist.
The word dialysis is from the mid-19th century: via Latin from the Greek word dialusis; from dialuein (split, separate), from dia (apart) and luein (set free). In other words, dialysis replaces the primary (excretory) function of the kidney, which separates (and removes) excess toxins and water from the blood, placing them in the urine.
Many diseases affecting the kidney are systemic disorders not limited to the organ itself, and may require special treatment. Examples include acquired conditions such as systemic vasculitides (e.g. ANCA vasculitis) and autoimmune diseases (e.g. lupus), as well as congenital or genetic conditions such as polycystic kidney disease.
Patients are referred to nephrology specialists after a urinalysis, for various reasons, such as acute kidney injury, chronic kidney disease, hematuria, proteinuria, , hypertension, and disorders of acid/base or .
Nephrologists may further sub-specialise in Kidney dialysis, Organ transplant, home therapies (home dialysis), cancer-related kidney diseases (Onconephrology), structural kidney diseases (uro-nephrology), procedural nephrology or other non-nephrology areas as described above.
Procedures a nephrologist may perform include native kidney and transplant renal biopsy, Kidney dialysis access insertion (temporary vascular access lines, tunnelled vascular access lines, peritoneal dialysis access lines), fistula management (angiogram or surgical fistulogram and plasty), and bone biopsy. Bone biopsies are now unusual.
To become a nephrologist in India, one has to complete an MBBS (5 and 1/2 years) degree, followed by an MD/DNB (3 years) either in medicine or paediatrics, followed by a DM/DNB (3 years) course in either nephrology or paediatric nephrology.
Examination of the urine (urinalysis) allows a direct assessment for possible kidney problems, which may be suggested by appearance of blood in the urine (hematuria), protein in the urine (proteinuria), pus cells in the urine (pyuria) or cancer cells in the urine. A 24-hour urine collection used to be used to quantify daily protein loss (see proteinuria), urine output, creatinine clearance or electrolyte handling by the renal tubules. It is now more common to measure protein loss from a small random sample of urine.
Basic blood tests can be used to check the concentration of hemoglobin, white count, platelets, sodium, potassium, chloride, bicarbonate, urea, creatinine, albumin, calcium, magnesium, phosphate, alkaline phosphatase and parathyroid hormone (PTH) in the blood. All of these may be affected by kidney problems. The serum creatinine concentration is the most important blood test as it is used to estimate the function of the kidney, called the creatinine clearance or estimated glomerular filtration rate (GFR).
It is a good idea for patients with longterm kidney disease to know an up-to-date list of medications, and their latest blood tests, especially the blood creatinine level. In the United Kingdom, blood tests can monitored online by the patient, through a website called RenalPatientView.
More specialized tests can be ordered to discover or link certain systemic diseases to kidney failure such as infections (hepatitis B, hepatitis C), autoimmune conditions (Lupus nephritis, ANCA vasculitis), paraproteinemias (amyloidosis, multiple myeloma) and metabolic diseases (diabetes, cystinosis).
Structural abnormalities of the kidneys are identified with imaging tests. These may include Medical ultrasonography/ultrasound, computed axial tomography (CT), scintigraphy (nuclear medicine), angiography or magnetic resonance imaging (MRI).
In certain circumstances, less invasive testing may not provide a certain diagnosis. Where definitive diagnosis is required, a biopsy of the kidney (renal biopsy) may be performed. This typically involves the insertion, under local anaesthetic and ultrasound or CT guidance, of a core biopsy needle into the kidney to obtain a small sample of kidney tissue. The kidney tissue is then examined under a microscope, allowing direct visualization of the changes occurring within the kidney. Additionally, the pathology may also stage a problem affecting the kidney, allowing some degree of Prognosis. In some circumstances, kidney biopsy will also be used to monitor response to treatment and identify early relapse. A transplant kidney biopsy may also be performed to look for rejection of the kidney.
Chronic kidney disease is typically managed with treatment of causative conditions (such as diabetes), avoidance of substances toxic to the kidneys (nephrotoxicity like contrast medium and non-steroidal anti-inflammatory drugs), antihypertensives, diet and weight modification and planning for end-stage kidney failure. Impaired kidney function has systemic effects on the body. An erythropoetin (ESA) may be required to ensure adequate production of red blood cells, calcitriol supplements and phosphate binders may be required to counteract the effects of kidney failure on bone metabolism, and blood volume and electrolyte disturbance may need correction. Diuretics (such as furosemide) may be used to correct fluid overload, and alkalis (such as sodium bicarbonate) can be used to treat metabolic acidosis.
Auto-immune and Inflammation kidney disease, such as vasculitis or transplant rejection, may be treated with immunosuppression. Commonly used agents are prednisone, mycophenolate, cyclophosphamide, ciclosporin, tacrolimus, everolimus, thymoglobulin and sirolimus. Newer, so-called "biologic drugs" or monoclonal antibodies, are also used in these conditions and include rituximab, basiliximab and eculizumab. Blood products including intravenous immunoglobulin and a process known as plasma exchange can also be employed.
When the kidneys are no longer able to sustain the demands of the body, end-stage kidney failure is said to have occurred. Without renal replacement therapy, death from kidney failure will eventually result. Kidney dialysis is an artificial method of replacing some kidney function to prolong life. Renal transplantation replaces kidney function by inserting into the body a healthier kidney from an organ donor and inducing immunologic tolerance of that organ with immunosuppression. At present, renal transplantation is the most effective treatment for end-stage kidney failure although its worldwide availability is limited by lack of availability of donor organs. Generally speaking, kidneys from living donors are 'better' than those from deceased donors, as they last longer.
Most kidney conditions are chronic conditions and so long term followup with a nephrologist is usually necessary. In the United Kingdom, care may be shared with the patient's primary care physician, called a General Practitioner (GP).
The word 'nephrology' appeared for the first time in a conference, on 1–4 September 1960 at the "Premier Congrès International de Néphrologie" in Evian and Geneva, the first meeting of the International Society of Nephrology (ISN, International Society of Nephrology). The first day (1.9.60) was in Geneva and the next three (2–4.9.60) were in Evian, France. The early history of the ISN is described by Robinson and Richet in 2005 and the later history by Barsoum[2] in 2011. The ISN is the largest global society representing medical professionals engaged in advancing kidney care worldwide. It has an international office in Brussels, Belgium.
In the US, founded in 1964, the National Kidney Foundation is a national organization representing patients and professionals who treat kidney diseases. Founded in 1966, the American Society of Nephrology (ASN) is the world's largest professional society devoted to the study of kidney disease. The American Nephrology Nurses' Association (ANNA), founded in 1969, promotes excellence in and appreciation of nephrology nursing to make a positive difference for patients with kidney disease. 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 Kidney dialysis patients. The National Renal Administrators Association (NRAA), founded in 1977, is a national organization that represents and supports the independent and community-based dialysis providers. The American Kidney Fund directly provides financial support to patients in need, as well as participating in health education and prevention efforts. ASDIN (American Society of Diagnostic and Interventional Nephrology) is the main organization of interventional nephrologists. Other organizations include CIDA, VASA etc. which deal with dialysis vascular access. 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).
In the United Kingdom, UK National Kidney Federation and Kidney Care UK (previously known as British Kidney Patient Association, BKPA) represent patients, and the UK Kidney Association used to represent renal physicians and worked closely with a previous NHS policy directive called a National Service Framework for kidney disease.
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