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Nephrology

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Nephrology (from Greek νεφρός – nephros, "kidney", combined with the suffix -logy, "the study of") is a speciality of medicine and pediatrics. It concerns itself with the study of normal kidney function, kidney problems and their treatment.

Scope of the specialty

Nephrology concerns 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 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 for various reasons, such as acute renal failure, chronic kidney disease, hematuria, proteinuria, kidney stones, hypertension, and disorders of acid/base or electrolytes.

Nephrologist

A nephrologist is a medical doctor who has undertaken training to specialise in nephrology. Additionally, due to their unique skills, nephrologists may provide care to people without kidney problems and may work in general/internal medicine, transplant medicine, immunosuppression management, clinical governance, medical education, medicolegal medicine, public health, intensive care medicine, clinical pharmacology, perioperative medicine and research.

Nephrologists may further sub-specialise in dialysis, kidney transplantation, chronic kidney disease, procedural nephrology or other non-nephrology areas as described above.

Procedures a nephrologist may perform include native kidney and transplant kidney 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.

Training

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 vascular disorders, tubular/interstitial disorders, mineral metabolism, clinical pharmacology, hypertension, epidemiology, and nutrition. Nearly all programs train nephrologists in continuous renal replacement therapy; fewer than half in the United States train in the provision of plasmapheresis.[1]

United States

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. Once training is satisfactorily completed, the physician is eligible to take the American Board of Internal Medicine (ABIM) or American 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 an ACGME or AOA accredited fellowship in 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.[citation needed]

Australia and New Zealand

Nephrology training in Australia and New Zealand typically includes:

  • Bachelor of Medicine, Bachelor of Surgery degree (MBBS or equivalent) at university (4-6 years)
  • internship (1 year) at a teaching hospital
  • Basic Physician Training (3 years minimum) at a teaching hospital accredited by the Royal Australasian College of Physicians
  • successful completion of a written and clinical examination through the Royal Australasian College of Physicians
  • Advanced Physician Training in Nephrology (2-3 years) at a teaching hospital accredited by the Royal Australasian College of Physicians
  • increasingly, the completion of a post-graduate degree (usually a PhD) in a Nephrology research interest (3-4 years)
  • ongoing participation in professional development through the Royal Australasian College of Physicians and other bodies such as the Australian and New Zealand Society of Nephrology and the Transplant Society of Australia and New Zealand

Diagnosis

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

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:

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 complications that can occur post-transplant.

Organizations

The International Society of Nephrology is the largest global society representing medical professionals engaged in advancing kidney care worldwide. In the USA, 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. 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. 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.

References

  1. ^ Berns JS, O'Neill WC (2008). "Performance of procedures by nephrologists and nephrology fellows at U.S. nephrology training programs". Clin J Am Soc Nephrol. 3 (4): 941–7. doi:10.2215/CJN.00490108. PMC 2440278. PMID 18417748.
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