Novel Nephrology

Merriam-Webster’s online dictionary defines the adjective “novel” as

  1. new and not resembling something formerly known or used, or
  2. original or striking, especially in conception or style.

Both definitions apply to the topics covered in this special section, which include noninvasive or minimally invasive diagnostic techniques as well as new interventions to treat disease, all of which can be performed by nephrologists.

Ambulatory blood pressure monitoring is sufficiently new that many insurers authorize payment only for the “exclusion of white coat hypertension.” Jones eloquently discusses the role of ambulatory blood pressure monitoring in white coat hypertension and its opposite, masked hypertension, and the significance of the nocturnal “dip” in blood pressure with regard to long-term prognosis and end organ damage. This noninvasive technique can help predict which type I diabetic patients are at risk for kidney disease and which patients need to be monitored for left ventricular hypertrophy.

Gosmanova and O’Neill discuss the benefits of renal ultrasonography performed by nephrologists to both the patient and the practice of nephrology. Nephrologist-performed ultrasonography is convenient and provides that “clinical correlation recommended” routinely by interpreting radiologists, thus improving patient care. Equipment costs are relatively low, training and certification are available, and it’s fun!

Vats explains how molecular diagnostics can elucidate the pathophysiology of genetic kidney diseases, specifically nephrotic syndrome and cystic kidney disease. Rapid and specific diagnosis of viral transplant infections using quantitative PCR assays is already improving patient care, and genetic advances may lead to personalized care and point-of-contact diagnosis in the future.

Sherbotie delivers a brief but comprehensive review of continuous renal replacement therapies, including which systems can be used for pediatric patients or therapeutic plasma exchange.

Since 2000, the American Society of Diagnostic and Interventional Nephrology (ASDIN) has worked to establish best coding practices and a comprehensive coding manual for dialysis and vascular access procedures. Pflederer outlines how the ASDIN has worked to improve the quality of care that patients receive related to vascular access, peritoneal dialysis access, and ultrasonography. He also discusses ASDIN’s Procedure Outcomes Registry, an Internet database that is also available to nonmembers. Procedural certification is available through the ASDIN.

While not yet standard of care, each of these novel techniques is likely to rapidly become “best practice.” A common theme is the issue of cost and reimbursement by third party payers. Costs will need to be weighed against long-term benefits as our nation’s health care programs evolve. We’ve made considerable progress since Kolff constructed the prototypical dialysis machine from sausage casings and an automobile water pump during World War II. The techniques discussed in this section suggest that the best is yet to come. It’s an exciting time to be a nephrologist.