kidney with diabetic nephropathy
Unlike many other specialities of internal medicine, most historians agree on who was the father (Richard Bright, 1789-1858) of nephrology and when (Bright’s 1827 publication of Reports of Medical Cases) it was born. The modern equivalent of what Bright described, which was characterized by edema, albuminuria, hypertension and heart disease and later known as Bright’s disease* is far less certain.
*Bright’s description of the disease included a gallimaufry of nephropathies includling acute and chronic nephritis, glomerulonephritis, nephrotic syndrome and vascular nephropathy, explaining why the term has been abandoned.
The field of nephrology remained in its infancy until the mid-1950s, given the lack of effective therapy. It shed its diapers shortly thereafter with the development of hemodialysis, an outpatient procedure required when the functional capacity of the kidneys falls below 15% (top image, kidney with diabetic nephropathy). Like healthy kidneys, dialysis removes urea, creatinine, potassium and excess fluid, leaving intravascular cells and components intact. However, whilst hemodialysis is lifesaving, patients are often miserable, given that it typically takes 4 hours, three times per week and, in contrast to renal transplantation (RT), is associated with a much shorter lifespan (15 years for hemodialysis, 30 for RT.
The 1950s saw not only widespread adoption of hemodialysis, but also the first fruit of the field of transplant surgery. In 1954, JE Murray performed the first successful renal transplant between twins at the Peter Bent Brigham Hospital in Boston (image, right), for which he won the Nobel prize in 1990.
Early renal transplant
Problems with immune rejection, the bête noire of transplantation have been largely addressed over the ensuing years, with advances in tissue typing–resulting in better matching of donor and recipient blood and tissue types; improved and more effective immunosuppressants and improved organ preservation with physiologic fluids; and recognition that organs from live donors functioned post-transplant far longer (average 40 years) than from cadaveric donors (30 years).
Nephrologists have between 5 and 8 years of post-medical school training and are typically first board-certified in internal medicine or pediatrics–which requires 3 years of training, followed by 2 to 5 of years nephrology training, at the end of which they take an exam and are boarded certified by their country’s college of nephrology. The so-called meat and potatoes diseases managed by nephrologists include diabetic nephropathy, glomerulonephritis, focal segmental glomerulosclerosis, IgA nephropathy, nephrotic syndrome, minimal change disease, and polycystic kidney disease, some of which the nephrologist will refer to surgical colleagues for further management.