The Nephrology ([ nefrologiː ], from ancient Greek νεφρός " kidney " and λόγος "word, doctrine": "kidney teaching") is a subspecialty of internal medicine , covering a broad range of subjects. Basically, nephrology deals with the prevention , diagnosis , conservative (non-operative) therapy and aftercare of kidney and high blood pressure diseases . The implementation of all extracorporeal blood purification procedures (dialysis, apheresis, immunoadsorption) as well as the care of patients with a transplanted kidney also fall within the specialist field of nephrology.
Nephrology is still relatively young as a specialist discipline ; Franz Volhard (1872–1950) and Georg Haas (1886–1971) are considered the founders of modern nephrology . Dialysis treatments were carried out experimentally in some clinics as early as the 1950s. Curt Moeller in Hamburg was a pioneer of hemodialysis treatment in Germany . The establishment of nationwide dialysis care proceeded slowly. So the largest non-profit dialysis provider, the Kuratorium für Dialysse und Nierentransplantation e. V. (KfH) in 1969, because at that time there was still a medical emergency for dialysis patients in Germany. Today, high-quality dialysis care is guaranteed throughout Germany. Even if nephrology is still a relatively young academic subject, it has been one of the core areas since the beginning of medicine.
The urine inspection has been an integral part of medicine since Galen of Pergamon (approx. 1st – 2nd century AD). The urine glass (matula) was a symbol of the medical guild in the Middle Ages. The central importance of the kidneys for general health is even proverbially anchored in German usage, we put it through its paces "(Psalm 7: 9).
Nephrologist is a legally protected designation that may only be used by specialists in internal medicine who have successfully completed specialist training . The children Nephrology is an independent branch of Pediatrics .
- System diseases with renal involvement and / or high blood pressure: collagen diseases ( lupus erythematosus , scleroderma , CREST syndrome , dermatomyositis -Polymyositis, Sjogren's syndrome , mixed connective tissue disease ( Sharp syndrome ) / undifferentiated connective tissue diseases), vasculitis ( Takayasu's arteritis , giant cell arteritis , polyarteritis , Kawasaki- syndrome , granulomatosis with polyangiitis ( Wegener's disease ), eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss syndrome ), microscopic polyangiitis , Henoch-Schonlein purpura , essential kryoglobulinämische vasculitis, Goodpasture's syndrome ), other systemic diseases ( amyloidosis , Behcet's disease , Familial Mediterranean fever , Raynaud's syndrome , hemolytic uremic syndrome , thrombotic-thrombocytopenic purpura , HELLP syndrome )
- Glomerular diseases that are not part of a systemic disease: Glomerulonephritis , glomerular diseases without a known histological diagnosis: acute nephritic syndrome , rapid-progressive glomerulonephritis, recurrent and persistent hematuria , chronic nephritic syndrome, nephrotic syndrome , isolated proteinuria as a result of tumor diseases (, including hepatitis ) or gestation of pregnancy
- Tubulointerstitial disorders: tubulointerstitial nephritis , obstructive uropathy and Refluxuropathie , drug and heavy metal-induced tubulointerstitial and tubular conditions, renal tubulo-interstitial diseases in other diseases, more tubulointerstitial renal diseases (for example, Balkan nephropathy , renal abscess , perinephric abscess, analgesic nephropathy )
- Nephrolithiasis (kidney stone disease)
- The body's own ( endogenous ) poisoning by uremic toxins and nephrotoxins
- External ( exogenous ) poisoning caused by various kidney toxins (for example in analgesic nephropathy )
- Hereditary diseases: Alport syndrome , autosomal dominant or recessive cystic kidneys , Von-Hippel-Lindau syndrome (Hippel-Lindau disease), nephronophthisis , tuberous sclerosis
- Tumor diseases: renal cell carcinoma (kidney cancer), renal sarcoma and Wilms' tumor (nephroblastoma), plasmacytoma (multiple myeloma) and malignant neoplasm of plasma cells, tumor lysis syndrome
- Acute renal failure : In acute renal failure (. English acute kidney injury; AKI) there is a rapid decrease in glomerular filtration rate. Acute kidney failure occurs if the serum creatinine rises from a measured or assumed baseline value by at least 50% within seven days or if it rises above a measured baseline value by at least 0.3 mg / dl within 48 hours. In addition, there is acute kidney failure with a measured urine output of less than 0.5 ml / kg / h in six hours.
- Chronic kidney failure : According to the KDIGO recommendations, chronic kidney disease exists if there is kidney damage and / or the glomerular filtration rate (GFR) is less than 60 ml / min / 1.73 m² for presumably more than three months.
- Acute kidney disease: As neither the definition of ANV nor the definition of chronic kidney disease apply to some patients with kidney disease, the KDIGO working group proposes the definition of a further entity, the so-called "acute kidney disease" (AKD) in front.
- Concomitant diseases of chronic kidney disease: Renal anemia , secondary hyperparathyroidism (sHPT), CKD-MBD ("Chronic Kidney Disease - Mineral Bone Disease"), uremic bleeding tendency, uremic encephalopathy , uremic pericarditis and neuropathy , nephrogenic systemic fibrosis (NSF)
- Clinical conditions in kidney disease: overhydration and desiccosis, electrolyte disorders, disorders of the acid-base balance (acidosis, alkalosis), itching (pruritus), thirst, malnutrition, uremia
- Metabolic disorders: gout , hyperlipoproteinemia (HLP) or hyperlipidemia , obesity , protein metabolism disorders ( hypoproteinemia , hypoalbuminemia ), diabetes mellitus
- Hypertension and vascular diseases: essential hypertension, secondary hypertension, gestational hypertension
- Diseases of the cardiovascular system accompanying or as a result of kidney disease ( cardiorenal syndrome , hepatorenal syndrome ): coronary artery disease , angina pectoris , acute myocardial infarction , diseases of the heart valves , heart failure , peripheral arterial disease , thrombosis and embolism of the renal artery, thrombosis and embolism of the Renal vein
- Pulmonary complications: pleural effusion and noncardiac pulmonary edema , congestive pneumonia
- Infections: urethritis , tubulointerstitial nephritis , urinary tract infection , systemic inflammatory response syndrome (SIRS) / sepsis , hepatitis , tuberculosis , CMV infection, MRSA / multi-resistant pathogens (multi-drug resistance), influenza , enterohaemorrhagic Escherichia coli (EHEC), Hantavirus
- Treatment of other complications: Neurological complications / uremic neuropathy, osteoporosis , sexual dysfunction, symptoms of intoxication, complications of dialysis access ( steal syndrome , catheter thrombosis)
- The extrarenal kidney syndromes according to Wilhelm Nonnenbruch , i.e. renal insufficiency even without kidney disease
- Also, kidney worms and other parasites damage the kidney tissue.
- Diseases in which extracorporeal therapy methods can be used: familial essential hypercholesterolemia , disorders of calcium metabolism , hyperviscosity syndrome , multiple myeloma (plasmacytoma), acute myeloblastic leukemia (AML), acute lymphocytic leukemia (ALL), chronic myeloid leukemia (CML), BCR / BCR ABL-positive, chronic lymphocytic leukemia of the B-cell type (CLL), Guillain-Barré syndrome / polyradiculoneuritis, myasthenia gravis , acute liver failure, alcohol-toxic liver failure, toxic liver disease with liver necrosis, adult respiratory distress syndrome (ARDS), dilated cardiomyopathy , Sudden hearing loss , senile macular degeneration , inhibitory hemophilia , rheumatoid arthritis
Renal replacement therapies
- Dialysis : hemodialysis, hemofiltration, hemodiafiltration, peritoneal dialysis
- Kidney transplantation : kidney transplant follow-up care, therapy of functional disorders, failure, rejection of a kidney transplant, evaluation of the recipient and, in the case of living donation, of the donor
Extracorporeal blood purification procedures
- Plasmapheresis , double filtration plasmapheresis
- Plasma exchange
- Immune adsorption
- Cell apheresis , LDL apheresis , apheresis of soluble, FMS-like tyrosine kinase 1
- Liver replacement therapy
Nephrology has many interfaces with other subjects. Interdisciplinary work is therefore part of everyday clinical practice for nephrologists.
- General medicine : The aging of society and the increasing incidence of diseases that damage the kidneys (diabetes mellitus, hypertension) will increase the prevalence of chronic kidney disease (CKD). For these challenges, the cooperation between general practitioners / general practitioners and nephrologists is important. The common goal is to stratify patients who require early nephrological care in order to stop / slow down CKD progression.
- Cardiology : Cardiac and renal insufficiency are mutually dependent, one also speaks of the cardiorenal syndrome . Therefore, there is a close interdisciplinary collaboration between these two disciplines. The subjects of high blood pressure, atherosclerosis and anemia are also overlapping. The therapy of severely heart failure patients (without kidney involvement) with peritoneal dialysis, which the nephrologist performs, testifies to the close cooperation between the two disciplines.
- Diabetology : CKD as a consequence of diabetes mellitus: More than 30% of all terminal kidney failure can be traced back to diabetes, which is why nephrological prevention has also been anchored in the Diabetes Disease Management Program. Cooperation between diabetologists and nephrologists is therefore essential in the care of diabetic patients.
- Urology : The interfaces between the two disciplines are: urinary tract infections, kidney tumors, postrenal kidney failure - and of course kidney transplantation. The urologist (or another transplant doctor / surgeon) carries out the operation, the preparation, assessment of the patient (or of the donor and recipient in the case of living donation) and follow-up care are in the hands of the nephrologist.
- Vascular surgery : With the implantation of shunts (cimino shunts, dialysis fistulas) and dialysis catheters, there is also close cooperation between nephrologists and vascular surgeons in the care of dialysis patients.
- Intensive care medicine : In acute kidney failure, nephrologists and intensive care physicians work together on an interdisciplinary basis.
- Rheumatology : In rheumatoid arthritis, renal damage can occur as part of the disease, but also due to iatrogren (gold and penicillamine nephropathy). Secondary amyloidosis as a result of rheumatoid arthritis can also lead to kidney damage. With these clinical pictures as well as with gout (hyperuricemia), sarcoidosis or systemic lupus erythematosus (SLE), interdisciplinary work between rheumatologists and nephrologists may be necessary.
- Hematology and Oncology : Retroperitoneal lymphomas and metastases can lead to hydronephrosis with renal insufficiency. In addition, proteinuria or nephrotic syndrome can occur in numerous tumors (melanoma, bronchial carcinoma , gastrointestinal tumors, hypernephroma , squamous cell carcinoma). Tumor therapy can also cause kidney damage, in some cases acute kidney failure can occur. In addition, kidney involvement can be demonstrated in around 50% of patients with multiple myeloma. Oncology and nephrology therefore have a large overlap.
- Pharmacology : Many drugs are nephrotoxic and can lead to kidney failure, especially if the kidneys are damaged. In view of the demographic change, the cooperation between the two disciplines is important: The population is getting older and kidney function impairments are therefore more common. These patients have different pharmacokinetics than those with healthy kidneys.
- Gastroenterology : Gastroenterologists and nephrologists work closely together in the treatment of patients with liver disease with a hepatorenal syndrome (HRS) and in the implementation of extracorporeal liver replacement procedures ( liver dialysis ).
- Pulmonary medicine : Many lung diseases reduce (according to the Euler-Liljestrand mechanism ) the cardiac output and thus the glomerular filtration rate. Renal replacement procedures may be necessary even without kidney disease. In addition, renal tuberculosis is treated by pulmonologists .
Innovations from nephrology
Numerous medical innovations and comprehensive scientific findings come from the field of nephrology:
- the use of dialysis procedures to treat heart failure
- the use of extracorporeal blood purification procedures for infectious diseases such as enterohaemorrhagic Escherichia coli (EHEC) or Ebola
- the use of extracorporeal blood purification procedures for lipid disorders such as familial essential hypercholesterolemia
- Findings on the mineral balance and its importance, such as the knowledge that hyperphosphataemia is associated with risks even in people with healthy kidneys.
- Findings on the mechanisms of human aging (investigated using the extreme phenotype of uremia)
- Findings on extraosseous calcification
- Development of innovative drugs with indications outside of nephrology such as erythropoietin ("Epo") or calcimimetics.
The further training period is 72 months with a further training officer at a further training facility, of which 36 months in inpatient basic further training in the field of internal medicine and a further 36 months in nephrology, six months of which in internal intensive medicine, which can also be completed during basic further training, and six months in dialysis. Up to 18 months can be completed in the outpatient area.
The German Society for Nephrology (DGfN) is the specialist society for clinical and scientific nephrology and, as an umbrella organization, bundles the interests of all German doctors and scientists working in this field. The DGfN currently has 2350 members. In addition to providing optimal care for patients with kidney and hypertension diseases, their core tasks are to strengthen nephrological research and provide advanced and advanced training in nephrology.
The Austrian Nephrologists are represented by the Austrian Society for Nephrology.
On a European level, the DGfN and the Austrian Society for Nephrology work closely with the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) on an international level with the American Society of Nephrology (ASN) and the International Society of Nephrology (ISN) .
In Germany, the Nephrologists Association of German Kidney Centers (DN) e. V. organized. represents all resident specialists for internal medicine with a nephrological focus on the political level, vis-à-vis authorities and health insurance companies, within professional medical organizations and in public.
The German Kidney Foundation is responsible for informing patients and relatives as well as educating the population about the prevention of kidney diseases.
- Coding guide. Version 2014. A guide to clinical practice. Published by the German Society for Nephrology (DGfN)
- Ulrich Kuhlmann, Joachim Böhler, Friedrich C. Luft , Mark Dominik Alscher , Ulrich Kunzendorf (Eds.): Nephrology, 6th edition, Georg Thieme Verlag, Stuttgart, New York 2015, ISBN 978-3-13-700206-2 .
- German Society of Internal Medicine e. V. Further training in the field of internal medicine. 2nd edition 2012.
- “Put an end to wickedness and promote the righteous; for you, righteous God, test hearts and minds. ”Psalm 7: 9.
- KDIGO recommendations for definition and therapy can be found at www.kdigo.org .
- Wilhelm Nonnenbruch : The bilateral kidney diseases - Brightii disease , Ferdinand Enke Verlag, Stuttgart 1949.
- Günter Thiele (ed.): Handlexikon der Medizin , Urban & Schwarzenberg, Munich, Vienna, Baltimore no year, Volume 3 (L − R), p. 1735.
- German Society for Internal Medicine e. V. Further training in the field of internal medicine. 2nd Edition. 2012. p. 54.
- German Society for Nephrology (DGfN) www.dgfn.eu
- Austrian Society for Nephrology www.niere-hochdruck.at/266
- Association of German Kidney Centers (DN) e. V. http://www.dnev.de
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) http://www.era-edta.org
- American Society of Nephrology (ASN) www.asn-online.org
- International Society of Nephrology (ISN) http://www.theisn.org
- German Kidney Foundation http://www.nierenstiftung.de