Urology, Nephrology and Andrology International

Environmental Nephrology: A new discipline that not only explores the interrelations between exposure to the environment and kidney health but also considers the impact of renal health care practices on the environment. Rising evidence suggests that air pollution, heavy metal exposure, agrochemicals, global warming, and water pollution represent important risk factors for acute kidney injuries (AKI) and chronic kidney diseases (CKD). On the other hand, renal health care practices, especially those involving hemodialysis, represent highly water, plastic, and carbon-intensive activities that contribute considerably to water pollution, plastic pollution, as well as increased carbon emissions. This narrative review presents a comprehensive overview of evidence on the environmental determinants of kidney diseases, as well as an assessment of the ecological footprints of kidney replacement therapies, namely hemodialysis, peritoneal dialysis, as well as kidney transplantation, among populations worldwide. In addition, this article presents a comprehensive look at Green Nephrology, case examples, challenges, as well as future perspectives on the integration of concepts of planetary health within Nephrology practices.

Introduction: Ectopic kidneys result from abnormal embryological ascent and are frequently associated with distorted anatomy, predisposing patients to nephrolithiasis and technical challenges during intervention. Fused ectopic kidneys represent an exceptionally rare variant in which altered pelvicalyceal orientation and ureteral curvature further complicate stone management. Retrograde intrarenal surgery (RIRS) has become a standard minimally invasive approach for renal calculi in normal anatomy. However, data regarding its application in fused ectopic kidneys remains scarce. We report successful RIRS guided stone clearance in a uniquely fused ectopic renal system without the use of a ureteral access sheath. Methods: A 29 year old male presented with lower abdominal pain and was initially evaluated with ultrasonography, followed by contrast-enhanced CT urography. Imaging demonstrated a fused ectopic kidney with the right pelvicalyceal system and ureter oriented anterolaterally and the left system posteromedially. Two right renalstonesmeasuring1.4cmand1.3cmwereidenti𿿿edwithpreserveddrainage. StagedRIRSwasperformedundergeneralanesthesiausinga exibleureteroscope and Holmium:YAG laser lithotripsy. Due to marked ureteric angulation, access sheath placement was not feasible. Irrigation and suction were achieved using a three-way extension tubing system. Laser settings ranged from 0.8–1.2 J at 5–10 Hz. Double-J stenting was performed following each session. Results: Complete stone clearance was achieved over two operative sessions without intraoperative complications. Postoperative recovery was uneventful, with discharge on postoperative day one after each procedure. The ureteral stent was removed 15 days following the second intervention, and follow-up imaging con𿿿rmedastone-freestatus. Conclusion: Fusedectopickidneyspresentsigni𿿿cantanatomical challengesfor renal stone management and have traditionally required invasive approaches. This case demonstrates that RIRS with laser lithotripsy can be performed safely and effectively even in complex ectopic fused renal anatomy, including situations where access sheath use is not possible. With careful preoperative planning andtechnicalexpertise,RIRSshouldbeconsideredaviable𿿿rst-lineminimally invasive option for nephrolithiasis in anomalous kidneys.

Cyclophosphamide (CYC) is one of the most commonly used second-line drugs in the treatment of nephrotic syndrome, particularly in patients who are steroid-dependent or have frequent relapses. CYC may rarely cause skin or nail hyperpigmentation (melanonychia), in addition to its well-known adverse effects such as immunosuppression, cytopenias, or hemorrhagic cystitis. We present a patient with steroid-dependent nephrotic syndrome (SDNS) who developed blackish-brown discoloration of nails and periungual skin folds during therapy.