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NEPHROLOGY
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 systemic disorders not limited to the organ itself,
and may require special treatment. Examples include systemic vasculitides
and autoimmune diseases such as lupus.
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.
Information that a nephrologist learns in training are fluid and
acid base and electrolyte physiology, medical management of acute
and chronic renal failure, glomerular and vasuclar disorders,
tubular/interstitial disorders, mineral metabolism, clinical pharmacology,
hypertension, epidemiology, 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. Subspecialties within nephrology include interventional
nephrology, dialytician, and transplant nephrology.
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.
Patients are referred to nephrology specialists for various reasons,
such as:
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Acute renal failure, a sudden
loss of renal function |
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Chronic kidney disease, declining renal
function, usually with an inexorable rise in creatinine. |
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Hematuria, blood loss in the urine |
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Proteinuria, the loss of protein especially
albumin in the urine |
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Kidney stones, usually only recurrent stone
formers. |
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Chronic or recurrent urinary tract infections |
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Hypertension that has failed to respond
to multiple forms of anti-hypertensive medication or could
have a secondary cause |
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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.
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:
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Renal biopsy, to obtain a tissue
diagnosis of a disorder when the exact nature or stage remains
uncertain.; |
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Ultrasound scanning of the urinary tract
and occasionally examining the renal blood vessels; |
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CT scanning when mass lesions are suspected
or to help diagnosis nephrolithiasis; |
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Angiography or Magnetic resonance imaging
angiography when the blood vessels might be affected; |
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• 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; |
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.
Sub-specialties within nephrology include interventional nephrologists
who focus on access placement and maintenance, a dialytician who
focus upon ordering dialysis for patients, and transplant nephrologists
who focus on the acute or sub-acute monitoring of immunosuppression
in the transplant patient.
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.
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