Nephrology (fromAncient Greek νεφρός (nephrós), meaning "kidney", and λόγος (lógos), meaning "study") is aspecialty for both adultinternal medicine andpediatric medicine that concerns the study of thekidneys, specifically normalkidney function (renal physiology) andkidney disease (renal pathophysiology), the preservation of kidney health, and the treatment of kidney disease, from diet and medication torenal replacement therapy (dialysis andkidney 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 ofrenal and nephro- as appropriate including in "nephrology" and "renal replacement therapy", respectively.[1]
Nephrology also studiessystemic conditions that affect the kidneys, such asdiabetes andautoimmune disease; and systemic diseases that occur as a result of kidney disease, such asrenal osteodystrophy andhypertension. A physician who has undertaken additional training and become certified in nephrology is called anephrologist.
The term "nephrology" was first used in about 1960, according to the Frenchnéphrologie proposed byJean Hamburger in 1953, fromAncient Greek νεφρός (nephrós), meaning "kidney", and λόγος (lógos), meaning "study". Before then, the specialty was usually referred to as "kidney medicine".[2]
The worddialysis is from the mid-19th century: via Latin from the Greek worddialusis; fromdialuein (split, separate), fromdia (apart) andluein (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.[5]
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) andautoimmune diseases (e.g.lupus), as well ascongenital or genetic conditions such aspolycystic kidney disease.[6]
Nephrologists may further sub-specialise indialysis,kidney transplantation, home therapies (home dialysis), cancer-related kidney diseases (onco-nephrology), structural kidney diseases (uro-nephrology), procedural nephrology or other non-nephrology areas as described above.
Procedures a nephrologist may perform include native kidney and transplantkidney biopsy,dialysis access insertion (temporary vascular access lines, tunnelled vascular access lines, peritoneal dialysis access lines),fistula management (angiographic or surgical fistulogram and plasty), and bone biopsy.[9] Bone biopsies are now unusual.
To become a nephrologist in India, one has to complete anMBBS (5 and 1/2 years) degree, followed by anMD/DNB (3 years) either in medicine or paediatrics, followed by aDM/DNB (3 years) course in either nephrology or paediatric nephrology.
Nephrology training in Australia and New Zealand typically includes completion of a medical degree (Bachelor of Medicine, Bachelor of Surgery: 4–6 years),internship (1 year), Basic Physician Training (3 years minimum), successful completion of theRoyal Australasian College of Physicians written and clinical examinations, and Advanced Physician Training in Nephrology (3 years). The training pathway is overseen and accredited by the Royal Australasian College of Physicians, though the application process varies across states. Completion of a post-graduate degree (usually aPhD) in a nephrology research interest (3–4 years) is optional but increasingly common. Finally, many Australian and New Zealand nephrologists participate in career-long professional and personal development through bodies such as the Australian and New Zealand Society of Nephrology and the Transplant Society of Australia and New Zealand.
In the United Kingdom, nephrology (often called renal medicine) is a subspecialty of general medicine. A nephrologist has completed medical school, foundation year posts (FY1 and FY2) andcore medical training (CMT), specialist training (ST) and passed theMembership of the Royal College of Physicians (MRCP) exam before competing for a National Training Number (NTN) in renal medicine. The typical Specialty Training (when they are called a registrar, or an ST) is five years and leads to aCertificate of Completion of Training (CCT) in both renal medicine and general (internal) medicine. In those five years, they usually rotate yearly between hospitals in a region (known as a deanery). They are then accepted on to the Specialist Register of the General Medical Council (GMC). Specialty trainees often interrupt their clinical training to obtain research degrees (MD/PhD). After achieving CCT, the registrar (ST) may apply for a permanent post as Consultant in Renal Medicine. Subsequently, some Consultants practice nephrology alone. Others work in this area, and in Intensive Care (ICU), or General (Internal) or Acute Medicine.
Nephrology training can be accomplished through one of two routes. The first path way is through an internal medicine pathway leading to an Internal Medicine/Nephrology specialty, and sometimes known as "adult nephrology". The second pathway is throughPediatrics leading to a speciality in Pediatric Nephrology. In theUnited States, aftermedical school adult nephrologists complete a three-yearresidency in internal medicine followed by a two-year (or longer)fellowship in nephrology. Complementary to an adult nephrologist, a pediatric nephrologist will complete a three-year pediatric residency after medical school or a four-year Combined Internal Medicine and Pediatrics residency. This is followed by a three-year fellowship in Pediatric Nephrology. Once training is satisfactorily completed, the physician is eligible to take theAmerican Board of Internal Medicine (ABIM) orAmerican Osteopathic Board of Internal Medicine (AOBIM) nephrology examination. Nephrologists must be approved by one of these boards. 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 anACGME orAOA accredited fellowship in nephrology. Nearly all programs train nephrologists incontinuous renal replacement therapy; fewer than half in the United States train in the provision ofplasmapheresis.[10] Only pediatric trained physicians are able to train in pediatric nephrology, and internal medicine (adult) trained physicians may enter general (adult) nephrology fellowships.
History andphysical examination are central to the diagnostic workup in nephrology. The history typically includes the present illness, family history, general medical history, diet, medication use, drug use and occupation. The physical examination typically includes an assessment of volume state, blood pressure, heart, lungs, peripheral arteries, joints, abdomen andflank. A rash may be relevant too, especially as an indicator of autoimmune disease.
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 (seeproteinuria), urine output,creatinine clearance or electrolyte handling by therenal 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 ofhemoglobin, white count,platelets, sodium, potassium, chloride, bicarbonate,urea,creatinine, albumin, calcium, magnesium, phosphate, alkaline phosphatase andparathyroid 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 thecreatinine clearance or estimatedglomerular 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.
In certain circumstances, less invasive testing may not provide a certain diagnosis. Where definitive diagnosis is required, abiopsy of the kidney (renal biopsy) may be performed. This typically involves the insertion, underlocal anaesthetic and ultrasound or CT guidance, of acore 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 alsostage a problem affecting the kidney, allowing some degree ofprognostication. In some circumstances, kidney biopsy will also be used to monitor response to treatment and identify earlyrelapse. A transplant kidney biopsy may also be performed to look for rejection of the kidney.
When the kidneys are no longer able to sustain the demands of the body, end-stage kidney failure is said to have occurred. Withoutrenal replacement therapy, death fromkidney failure will eventually result.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 anorgan donor and inducingimmunologic tolerance of that organ withimmunosuppression. 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 arechronic 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 world's first society of nephrology was the French 'Societe de Pathologie Renale'. Its first president was Jean Hamburger, and its first meeting was in Paris in February 1949. In 1959, Hamburger also founded the 'Société de Néphrologie', as a continuation of the older society. It is now called Francophone Society of Nephrology, Dialysis and Transplantation (SFNDT). The second society of nephrologists, theUK Kidney Association (UKKA) was founded in 1950, originally named the Renal Association. Its first president was Arthur Osman and met for the first time, inLondon, on 30 March 1950. The Società di Nefrologia Italiana was founded in 1957 and was the first national society to incorporate the phrase nephrologia (or nephrology) into its name.
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[11] in 2005 and the later history by Barsoum[12] in 2011. The ISN is the largest global society representing medical professionals engaged in advancing kidney care worldwide.[citation needed] It has an international office in Brussels, Belgium.[13]
In the US, founded in 1964, theNational Kidney Foundation is a national organization representing patients and professionals who treat kidney diseases. Founded in 1966, theAmerican Society of Nephrology (ASN) is the world's largest professional society devoted to the study of kidney disease. TheAmerican 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. TheAmerican Association of Kidney Patients (AAKP) is a non-profit, patient-centric group focused on improving the health and well-being of CKD anddialysis patients. TheNational Renal Administrators Association (NRAA), founded in 1977, is a national organization that represents and supports the independent and community-based dialysis providers. TheAmerican 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. TheRenal 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)[14] represent patients, and the UK Kidney Association used to represent renal physicians and worked closely with a previous NHS policy directive called aNational Service Framework for kidney disease.
