Introduction to Diagnosis and Treatment
The Department of Nephrology mainly provides medical treatment for kidney disease, hypertension (essential/ secondary), maintenance dialysis, peritoneal dialysis, and acute blood purification.
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About Kidney Disease
Chronic kidney disease (CKD) means that clinical findings of renal disorder or renal dysfunction are observed chronically. Left untreated, CKD can trigger renal failure, which requires artificial dialysis, peritoneal dialysis or renal transplantation. Additionally, CKD is not only a risk factor for end-stage renal disease, which has been explained just before this section, but also is a risk factor for the onset of stroke and cardiovascular disease, such as ischemic heart disease.
There are various causes of CKD, each requiring its unique diagnosis and treatment.
- Diabetic Nephropathy
Diabetic nephropathy develops after diabetes is present for a certain period. At first, no abnormalities are detected on normal urinalysis (microalbuminuria period). Then, proteinuria is noted in urinalysis (overt nephropathy period). Gradually, blood tests show decreased kidney function (renal failure period). Eventually, symptoms of renal failure occur and the patient requires treatment that replaces lost kidney function.
Nephrosclerosis leads to poor blood circulation in the renal tissue and results in hardening caused by hypertension and aging, and so on. It has been considered to be a benign condition; however, it can certainly develop into end-stage renal disease. In fact, the proportion of patients with nephrosclerosis as an underlying disease among those starting dialysis has been observed to increase over the last 5 years.
- Chronic Glomerulonephritis
In our country, this is the most common nephritis leading to chronic glomerulonephritis. IgA nephropathy has been perceived as nephritis that develops slowly, with a relatively good prognosis. However, several reports have pointed out that prolonged IgA nephropathy frequently cause renal impairment. The underlying etiology is the generation of antigen–immune complexes from an immunoglobulin called IgA, which are deposited in the kidney. These deposits cause inflammation, resulting in a renal disorder. The disease typically affects young individuals, from junior high school students to people in their early thirties, but this is not necessarily always true.
It is important to confirm the diagnosis with a renal biopsy and to decide the appropriate course of treatment based on the assessment of the patient’s needs.
- Nephrotic Syndrome
Nephrosis is defined as follows.
1)Persistent albuminuria ≥ 3.5 g/day
2)Serum protein ≤ 6.0 g/dL (serum albumin ≤ 3.0 g/dL in case of hypoalbuminemia)
3)Hyperlipidemia with serum cholesterol ≤ 250 mg/dL
4)Presence of edema
In patients with the nephrotic syndrome, a large amount of protein is excreted in the urine, and the plasma oncotic pressure involving the protein called albumin, present in the blood, diminishes. This causes systemic edema (especially severe eyelid and pretibial edema). In the liver, albumin synthesis increases to compensate for the diminished albumin levels; however, this also leads to hyperlipidemia and thrombotic tendency, since low-density lipoprotein (LDL) cholesterol and coagulation factors are simultaneously synthesized by the liver.
- Membranous nephropathy
This disorder appears most commonly as a primary disease of nephrotic syndrome, which is explained later, typically in middle-aged patients. It is classified into sporadic or secondary types. In the sporadic type, the M-type phospholipase A2 receptor has been reported as a causative antigen. The secondary type is important as the development of this disorder is associated with malignancy. Therefore, a complete physical examination for detecting malignant tumors is necessary.
About 30% of patients with membranous nephropathy have spontaneous resolution. Persistent albuminuria is observed in others; treatment for this disorder involves steroid as the primary therapy, combined with an immunosuppressive agent, such as cyclosporine, if needed.
- Minimal change nephrotic syndrome（MCNS）
The characteristic feature of this disorder is its rapid pattern of development, with sudden onset of edema. The age of onset ranges widely, and MCNS can affect individuals of all ages; however, its pathological features indicate that it develops most commonly among children. Although its cause remains unknown, some type of immunoreaction is considered to be associated. Diagnostic therapy with corticosteroids is offered in advance because corticosteroids work exceedingly well in treating this disorder; while the treatment is relatively easy, a high risk of recurrence is, unfortunately, one of the features of MCNS.
- Membranoproliferative glomerulonephritis(MPGN)
This confusing name is based on the pathological appearance of this disease. As evidenced by optical microscopy, its pathological characteristics are thickening of the glomerular capillary wall and segmental cell proliferative lesions. It is classified from types I to III through further observation by optical microscopy. This disease is also divided into sporadic or secondary types. It is reported that the likelihood of developing sporadic MPGN is limited to the age group of 8–30 years. Its occurrence in older individuals is recognized as secondary type.
Half of these patients experience nephrotic syndrome as a complication, but various other clinical conditions, such as bloody urine, hypertension, renal failure, and so on, are also observed.
- Membranous nephropathy
- Rapidly Progressive Glomerulonephritis
Rapidly progressive glomerulonephritis is defined as the development of hematuria, proteinuria, and anemia, with rapid progression to renal failure. This disease is often accompanied by complications in the other organs. There are several causative disorders; however, anti-neutrophil cytoplasmic antibody (ANCA)-associated nephritis appears to be the most frequent cause of this disease. Histopathologically, in necrotizing crescentic glomerulonephritis, a typical histological finding in many glomeruli is crescent formation. , it is important to initiate an early treatment using adrenocorticosteroid hormone and/or immunosuppressants such as cyclophosphamide if the need arises.
- Polycystic Kidney
Polycystic kidney disease is one of the most common hereditary renal diseases. No valid method for its treatment has been established till date. Almost half of the patients with polycystic kidney disease develop end-stage renal failure before the age of 60 years. It not only leads to renal hypofunction but also to risks of complications due to cerebral aneurysm, valvular heart disease, cyst infection, and liver dysfunction (liver cyst). This illness requires a systemic therapy. In April 2014, a new drug named Tolvaptan was approved for polycystic kidney disease. It is now possible to slow down the progression of this disease. Based on the abovementioned information and development of novel treatments, this disorder is now classified as an intractable disease in our country. Financial support is provided by the government if the diagnosis is confirmed by a designated physician and the application procedure for medical expenses are fulfilled.
It is said that there are 40 million patients with hypertension in Japan. However, currently, the rates of untreated patients are high since they have no subjective symptoms.
Hypertension is a known risk factor for cardiovascular diseases such as stroke and ischemic heart disease. As a matter of fact, in about 90% of patients, the cause cannot be identified. This is called essential hypertension. However, excessive intake of salt and obesity are strongly associated with the onset of hypertension. Therefore, first, dietary improvements such as initiation of a low-salt diet and calorie restriction, and exercise therapy, are important in treating essential hypertension. In cases where lifestyle improvements are insufficient for achieving normal blood pressure, medication is needed.
On the other hand, there is secondary hypertension wherein the cause can be identified. This type of hypertension can be cured by eliminating the underlying cause clarified in an initial diagnostic. Further, primary aldosteronism, which is caused by adrenal hyperplasia and adrenal tumor, is not rare; it is estimated that this disease affects 1 of 20 hypertension patients. Moreover, the incidence of renovascular hypertension, which is caused by narrowing of renal arteries, is also increasing.
Medical checkup in our department is recommended if the following conditions are observed:
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Are there any symptoms associated with kidney dysfunction?
In renal insufficiency, symptoms include body swelling (edema), foam or bubbles seen in urine (proteinuria), and increased frequency of urination. However, often, no symptoms are observed in the early stage.
Every year, an abnormal result has been reported in my health check. Should I visit a doctor?
In many cases, people do not visit a doctor even though hematuria and abnormal urinary protein levels are seen in health checkup results, especially when no symptoms are seen. It is highly recommended that you seek medical attention and undergo a detailed examination if these results are abnormal.
My blood pressure is high. Does it indicate an abnormality?
Hypertension often remains untreated as it is asymptomatic. Hypertension is an important risk factor for critical cardiovascular diseases such as stroke and myocardial infarction. Moreover, if renal function is impaired, hypertension develops as a complication, and hypertension further exacerbates renal dysfunction. A vicious circle is thus initiated. It is important to seek medical advice if the blood pressure is high.
What is renal biopsy?
Renal biopsy is an examination wherein a fine needle is inserted into the kidney and tissue is extracted for examination. A renal biopsy is associated with the risk of bleeding since the kidney is an organ rich in blood vessels. Therefore, this examination should be performed by an experienced renal specialist. The examination itself takes only about a little over half an hour, but hospitalization is necessary.
Medical Service Organization
In our department, medical services are provided by Professor Kashihara, Professor Sasaki, Program-Specific Professor Kanda 5 Assistant Professors, 7 Senior Residents, and several residents.
Our department is a specialized, high-level, medical service system that can provide treatments for all types of patients, ranging from those with abnormal urinalysis results to those with end-stage renal failure following long-term renal disease.
In our ward, each patient receives care from 4–5 staff including a professor. These include a supervisory doctor in the ward, a physician in charge of the ward, and residents. Medical care for each hospital inpatient is provided as follows: a professor has a weekly round and views are exchanged via a chart conference, renal biopsy conference, and morning conference on a daily basis.
Our outpatient services provide highly professional medical care for patients with renal disorder and hypertension. We also provide outpatient treatments for peritoneal dialysis and blood access (shunt) patients. Our hospital has a favorable environment for doctors to cooperate easily with each other through consultations across various departments.