Director(Nephrology)

Chandan Institute of Nephrology, Urology and Kidney Transplant

Dr. Sant Kumar Pandey

MD (Gold Medal)
DM (Nephrology), BHU, IMS
Ex HOD, Department of Nephrology, KGMU

Director(Urology and Kidney Transplant)

Chandan Institute of Nephrology, Urology and Kidney Transplant

Dr. Manmeet Singh

MS
MCh (Urology & Renal Transplant)
Ex Associate Professor, Department of Urology, KGMU

Nephrology

Nephrology at Chandan Institute of Nephrology, Urology and Kidney Transplant is a specialty of medicine and pediatrics that deals with the kidneys: the study of normal kidney function and kidney disease, the preservation of kidney health, and the treatment of kidney disease, from diet and medication to renal replacement therapy (dialysis and kidney transplantation).

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.

Examination of the urine (urinalysis) allows a direct assessment for possible kidney problems, which may be suggested by appearance of blood in the urine (haematuria), protein in the urine (proteinuria), pus cells in the urine (pyuria) or cancer cells in the urine. A 24-hour urine collection can be used to quantify daily protein loss (see proteinuria), urine output, creatinine clearance or electrolyte handling by the renal tubules.

Basic blood tests can be used to check the concentration of hemoglobin, platelets, sodium, potassium, chloride, bicarbonate, urea, creatinine, calcium, magnesium or phosphate in the blood. All of these may be affected by kidney problems. The serum creatinine concentration can be used to estimate the function of the kidney, called the creatinine clearance or estimated glomerular filtration rate (GFR). More specialized tests can be ordered to discover or link certain systemic diseases to kidney failure such as infections (hepatitis B, hepatitis C), autoimmune conditions (systemic lupus erythematosus, ANCA vasculitis), paraproteinemias (amyloidosis, multiple myeloma) and metabolic diseases (diabetes, cystinosis).

Structural abnormalities of the kidneys are identified with imaging tests. These may include Medical ultrasonography/ultrasound, computed axial tomography (CT), scintigraphy (nuclear medicine), angiography or magnetic resonance imaging (MRI).

In certain circumstances, less invasive testing may not provide a certain diagnosis. Where definitive diagnosis is required, a biopsy of the kidney (renal biopsy) may be performed. This typically involves the insertion, under local anaesthetic and ultrasound or CT guidance, of a core 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 also stage a problem affecting the kidney, allowing some degree of prognostication. In some circumstances, kidney biopsy will also be used to monitor response to treatment and identify early relapse.

Treatments in nephrology can include medications, blood products, surgical interventions (urology, vascular or surgical procedures), renal replacement therapy (dialysisor kidney transplantation) and plasma exchange. Kidney problems can have significant impact on quality and length of life, and so psychological support, health education and advanced care planning play key roles in nephrology.

Chronic kidney disease is typically managed with treatment of causative conditions (such as diabetes), avoidance of substances toxic to the kidneys (nephrotoxins like radiologic contrast and non-steroidal anti-inflammatory drugs), antihypertensives, diet and weight modification and planning for end-stage kidney failure. Impaired kidney function has systemic effects on the body. An erythropoetin stimulating agent may be required to ensure adequate production of red blood cells, activated vitamin D supplements and phosphate binders may be required to counteract the effects of kidney failure on bone metabolism, and blood volume and electrolyte disturbance may need correction.

Auto-immune and inflammatory kidney disease, such as vasculitis or transplant rejection, may be treated with immunosuppression. Commonly used agents are prednisone, mycophenolate, cyclophosphamide, ciclosporin, tacrolimus, everolimus, thymoglobulin and sirolimus. Newer, so-called "biologic drugs" or monoclonal antibodies, are also used in these conditions and include rituximab, basiliximab and eculizumab. Blood products including intravenous immunoglobulin and a process known as plasma exchange can also be employed.

When the kidneys are no longer able to sustain the demands of the body, end-stage kidney failure is said to have occurred. Without renal replacement therapy, death from kidney 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 an organ donor and inducing immunologic tolerance of that organ with immunosuppression. 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.

Most kidney conditions are chronic conditions and so long term followup with a nephrologist is usually necessary.

Ureteroscopy & Cystoscopy

Ureteroscopy is an examination of the upper urinary tract, usually performed with a ureteroscope that is passed through the urethra and the bladder, and then directly into the ureter; usually the lower 2/3 of the ureter is accessible by this procedure. The procedure is useful in the diagnosis and treatment of disorders such as kidney stones. Smaller stones in the bladder or lower ureter can be removed in one piece, while bigger ones are usually broken before removal during ureteroscopy.

Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.

In pyeloscopy, the endoscope is designed to reach all the way to the renal pelvis (also called pyelum), thereby allowing visualisation of the entire drainage system of the kidney. Kidney stones up to 2 cm in size can be treated by pyeloscopy.

Medical uses:

Cystoscopy may be recommended for any of the following conditions:

  • Urinary tract infections
  • Blood in the urine (hematuria)
  • Loss of bladder control (incontinence) or overactive bladder. Although, The American Urogynecologic Society does not recommend that cystoscopy, urodynamics, or diagnostic renal and bladder ultrasound are part of initial diagnosis for uncomplicated overactive bladder.
  • Unusual cells found in urine sample
  • Need for a bladder catheter
  • Painful urination, chronic pelvic pain, or interstitial cystitis
  • Urinary blockage such as from prostate enlargement, stricture, or narrowing of the urinary tract
  • Stone in the urinary tract
  • Unusual growth, polyp, tumor, or cancer

Percutaneous Nephrolithotomy-

Percutaneous nephrolithotomy (PCNL) is a minimally-invasive procedure to remove stones from the kidney by a small puncture wound (up to about 1 cm) through the skin. It is most suitable to remove stones of more than 2 cm in size and which are present near the pelvic region. It is usually done under general anesthesia or spinal anesthesia.

Procedure

A retrograde pyelogram is done to locate the stone in the kidney. With a small 1 centimeter incision in the loin, the percutaneous nephrolithotomy (PCN) needle is passed into the pelvis of the kidney. The position of the needle is confirmed by fluoroscopy. A guide wire is passed through the needle into the pelvis. The needle is then withdrawn with the guide wire still inside the pelvis. Over the guide wire the dilators are passed and a working sheath is introduced. A nephroscope is then passed inside and small stones taken out. In case the stone is big it may first have to be crushed using ultrasound probes and then the stone fragments removed.

The most difficult portion of the procedure is creating the tract between the kidney and the flank skin. Most of the time this is achieved by advancing a needle from the flank skin into the kidney, known as the 'antegrade' technique. A 'retrograde' technique has recently been updated wherein a thin wire is passed from inside the kidney to outside the flank with the aid of a flexible ureteroscope. This technique may reduce radiation exposure for patient and surgeon.


Kidney Transplantation

Kidney transplantation at Chandan is the organ transplant of a kidney into a patient with end-stage renal disease. Kidney transplantation is typically classified as deceased-donor or living-donor transplantation depending on the source of the donor organ. Living-donor renal transplants are further characterized as genetically related (living-related) or non-related (living-unrelated) transplants, depending on whether a biological relationship exists between the donor and recipient.

Indications

The indication for kidney transplantation is end-stage renal disease (ESRD), regardless of the primary cause. This is defined as a glomerular filtration rate below 15 ml/min/1.73 m2. Common diseases leading to ESRD include malignant hypertension, infections, diabetes mellitus, and focal segmental glomerulosclerosis; genetic causes include polycystic kidney disease, a number of inborn errors of metabolism, and autoimmune conditions such as lupus. Diabetes is the most common known cause of kidney transplantation, accounting for approximately 25%. The majority of renal transplant recipients are on dialysis (peritoneal dialysis or hemodialysis) at the time of transplantation. However, individuals with chronic kidney disease who have a living donor available may undergo pre-emptive transplantation before dialysis is needed. If a patient is put on the waiting list for a deceased donor transplant early enough, they may also be transplanted pre-dialysis.

Sources of kidneys

Since medication to prevent rejection is so effective, donors do not need to be similar to their recipient. Most donated kidneys come from deceased donors and 47% of donated kidneys are from living donors.

Living donors

Potential donors are carefully evaluated on medical and psychological grounds. This ensures that the donor is fit for surgery and has no disease which brings undue risk or likelihood of a poor outcome for either the donor or recipient. The psychological assessment is to ensure the donor gives informed consent and is not coerced. We ensure that a donation has not resulted from a financial transaction.

Deceased donors

Deceased donors can be divided in two groups:

  • Brain-dead (BD) donors
  • Donation after Cardiac Death (DCD) donors

Although brain-dead (or 'heart beating') donors are considered dead, the donor's heart continues to pump and maintain circulation. This makes it possible for surgeons to start operating while the organs are still being perfused (supplied blood). During the operation, the aorta will be cannulated, after which the donor's blood will be replaced by an ice-cold storage solution, such as UW (Viaspan), HTK, or Perfadex. Depending on which organs are transplanted, more than one solution may be used simultaneously. Due to the temperature of the solution, and since large amounts of cold NaCl-solution are poured over the organs for a rapid cooling, the heart will stop pumping.

Donation after Cardiac Death' donors are patients who do not meet the brain-dead criteria but, due to the unlikely chance of recovery, have elected via a living will or through family to have support withdrawn. In this procedure, treatment is discontinued (mechanical ventilation is shut off). After a time of death has been pronounced, the patient is rushed to the operating room where the organs are recovered. Storage solution is flushed through the organs. Since the blood is no longer being circulated, coagulation must be prevented with large amounts of anti-coagulation agents such as heparin. Several ethical and procedural guidelines must be followed; most importantly, the organ recovery team should not participate in the patient's care in any manner until after death has been declared.

Compatibility

In general, the donor and recipient should be ABO blood group and crossmatch (human leukocyte antigen — HLA) compatible. If a potential living donor is incompatible with their recipient, the donor could be exchanged for a compatible kidney. Kidney exchange, also known as "kidney paired donation" or "chains" have recently gained popularity.

In an effort to reduce the risk of rejection during incompatible transplantation, ABO-incompatible and densensitization protocols utilizing intravenous immunoglobulin (IVIG) have been developed, with the aim to reduce ABO and HLA antibodies that the recipient may have to the donor. The level of sensitization to donor HLA antigens is determined by performing a panel reactive antibody test on the potential recipient.

Kidney transplant

In most cases the barely functioning existing kidneys are not removed, as removal has been shown to increase the rates of surgical morbidity. Therefore, the kidney is usually placed in a location different from the original kidney. Often this is in the iliac fossa so it is often necessary to use a different blood supply:

  • The renal artery of the new kidney, previously branching from the abdominal aorta in the donor, is often connected to the external iliac artery in the recipient.
  • The renal vein of the new kidney, previously draining to the inferior vena cava in the donor, is often connected to the external iliac vein in the recipient.

The donor ureter is anastomosed with the recipient bladder.

Imaging

Post operatively, kidneys are periodically assessed by ultrasound to assess for the imaging and physiologic changes that accompany transplant rejection. Imaging also allows evaluation of supportive structures such as the anastomosed transplant artery, vein, and ureter, to ensure they are stable in appearance. The major sonographic scale in quantitative ultrasound assessment is with a multipoint assessment of the resistive index (RI), beginning at the main renal artery and vein and ending at the arcuate vessels. It is calculated as follows: RI = (peak systolic velocity – end diastolic velocity ) / peak systolic velocity The normal value is ≈ 0.60, with 0.70 being the upper limits of normal.

Diet

Kidney transplant recipients are discouraged from consuming grapefruit, pomegranate and green tea products. These food products are known to interact with the transplant medications, specifically tacrolimus, cyclosporin and sirolimus; the blood levels of these drugs may be increased, potentially leading to an overdose. Acute rejection occurs in 10–25% of people after transplant during the first 60 days. Rejection does not necessarily mean loss of the organ, but it may necessitate additional treatment and medication adjustments.

Prognosis

Kidney transplantation is a life-extending procedure. The typical patient will live 10 to 15 years longer with a kidney transplant than if kept on dialysis. The increase in longevity is greater for younger patients, but even 75-year-old recipients (the oldest group for which there is data) gain an average four more years of life. People generally have more energy, a less restricted diet, and fewer complications with a kidney transplant than if they stay on conventional dialysis. Some studies seem to suggest that the longer a patient is on dialysis before the transplant, the less time the kidney will last.

Percutaneous Nephrolithotomy

Percutaneous nephrolithotomy (PCNL) is a minimally-invasive procedure to remove stones from the kidney by a small puncture wound (up to about 1 cm) through the skin. It is most suitable to remove stones of more than 2 cm in size and which are present near the pelvic region. It is usually done under general anesthesia or spinal anesthesia.

Procedure

A retrograde pyelogram is done to locate the stone in the kidney. With a small 1 centimeter incision in the loin, the percutaneous nephrolithotomy (PCN) needle is passed into the pelvis of the kidney. The position of the needle is confirmed by fluoroscopy. A guide wire is passed through the needle into the pelvis. The needle is then withdrawn with the guide wire still inside the pelvis. Over the guide wire the dilators are passed and a working sheath is introduced. A nephroscope is then passed inside and small stones taken out. In case the stone is big it may first have to be crushed using ultrasound probes and then the stone fragments removed.

The most difficult portion of the procedure is creating the tract between the kidney and the flank skin. Most of the time this is achieved by advancing a needle from the flank skin into the kidney, known as the 'antegrade' technique. A 'retrograde' technique has recently been updated wherein a thin wire is passed from inside the kidney to outside the flank with the aid of a flexible ureteroscope. This technique may reduce radiation exposure for patient and surgeon.