Simon Steddon I Neil Ashman I Alistair Chesser John Cunningham OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Nephrology and Hypertension Published and forthcoming Oxford Handbooks Oxford Handbook for the Foundation Oxford Handbook of Genetics Programme 3e Oxford Handbook of Genitourinary Oxford Handbook of Acute Medicine 3e Medicine, HIV and AIDS 2e Oxford Handbook of Anaesthesia 3e Oxford Handbook of Geriatric Oxford Handbook of Applied Dental Medicine 2e Sciences Oxford Handbook of Infectious Oxford Handbook of Cardiology 2e Diseases and Microbiology Oxford Handbook of Clinical and Oxford Handbook of Key Clinical Laboratory Investigation 3e Evidence Oxford Handbook of Clinical Oxford Handbook of Medical Dentistry 5e Dermatology Oxford Handbook of Clinical Oxford Handbook of Medical Imaging Diagnosis 2e Oxford Handbook of Medical Oxford Handbook of Clinical Sciences 2e Examination and Practical Skills Oxford Handbook of Medical Statistics Oxford Handbook of Clinical Oxford Handbook of Neonatology Haematology 3e Oxford Handbook of Nephrology and Oxford Handbook of Clinical Hypertension 2e Immunology and Allergy 3e Oxford Handbook of Neurology 2e Oxford Handbook of Clinical Oxford Handbook of Nutrition and Medicine—Mini Edition 8e Dietetics 2e Oxford Handbook of Clinical Oxford Handbook of Obstetrics and Medicine 9e Gynaecology 3e Oxford Handbook of Clinical Pathology Oxford Handbook of Occupational Oxford Handbook of Clinical Health 2e Pharmacy 2e Oxford Handbook of Oncology 3e Oxford Handbook of Clinical Oxford Handbook of Ophthalmology 2e Rehabilitation 2e Oxford Handbook of Oral and Oxford Handbook of Clinical Maxillofacial Surgery Specialties 9e Oxford Handbook of Orthopaedics Oxford Handbook of Clinical Surgery 4e and Trauma Oxford Handbook of Complementary Oxford Handbook of Paediatrics 2e Medicine Oxford Handbook of Pain Management Oxford Handbook of Critical Care 3e Oxford Handbook of Palliative Care 2e Oxford Handbook of Dental Patient Oxford Handbook of Practical Drug Care Therapy 2e Oxford Handbook of Dialysis 3e Oxford Handbook of Pre-Hospital Oxford Handbook of Emergency Care Medicine 4e Oxford Handbook of Psychiatry 3e Oxford Handbook of Endocrinology Oxford Handbook of Public Health and Diabetes 3e Practice 3e Oxford Handbook of ENT and Head Oxford Handbook of Reproductive and Neck Surgery 2e Medicine & Family Planning 2e Oxford Handbook of Epidemiology for Oxford Handbook of Respiratory Clinicians Medicine 2e Oxford Handbook of Expedition and Oxford Handbook of Rheumatology 3e Wilderness Medicine Oxford Handbook of Sport and Oxford Handbook of Forensic Exercise Medicine 2e Medicine Handbook of Surgical Consent Oxford Handbook of Gastroenterology Oxford Handbook of Tropical and Hepatology 2e Medicine 4e Oxford Handbook of General Practice 4e Oxford Handbook of Urology 3e Oxford Handbook of Nephrology and Hypertension Second edition Simon Steddon Consultant Nephrologist Guy’s and St Thomas’ Hospitals London, UK and Neil Ashman Consultant Nephrologist St Bartholomew’s and the Royal London Hospitals London, UK With Alistair Chesser Consultant Nephrologist St Bartholomew’s and the Royal London Hospitals London, UK and John Cunningham Professor of Nephrology Royal Free & University College Hospitals London, UK 1 3 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press, 2014 The moral rights of the authors have been asserted First edition published 2006 Second edition published 2014 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization.
Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2013943253 ISBN 978–0–19–965161–0 Printed in China by C&C Offset Printing Co. Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work.
Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding. Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work. v Preface to the second edition Much has changed in our specialty since the appearance of the first edi- tion of this Handbook.
Chronic Kidney Disease, a fledgling classification at the time, is now well established internationally and, more recently, acute renal failure has emerged from a comparable makeover as Acute Kidney Injury. Although not without detractors, these re-imaginations have helped to raise general awareness of kidney disease and provided a wel- come platform from which nephrologists have re-engaged with colleagues in both primary and secondary care. International efforts to produce con- sensus guidelines (albeit from disappointingly thin evidence) must also be applauded. However, whilst we may inexplicably struggle to complete sufficient RCTs of good quality, we remain admirable innovators of clinical services.
It is a great privilege to be part of a global renal community best characterized by its restlessness to do things better. You’ll find a little more depth to the information in this edition, although this remains balanced with the more pragmatic advice that was so well received last time out. With unlimited knowledge just a few keyboard strokes away, it seemed even more important to bring essential infor- mation to the fore and present it in as palatable and practical a way as possible. We hope the additional detail will also prove useful during prep- aration for postgraduate examinations and assessments.
This Handbook now sits in a larger family, having been joined by the excellent Oxford Specialist Handbooks of Renal Transplantation and Paediatric Nephrology. Along with the well-established Oxford Handbook of Dialysis and the newer Oxford Desktop Reference of Nephrology, we believe these represent a formidable resource across our entire specialty. The first edition was the idea of a few enthusiastic London trainees, cultivated through animated caffeine-fuelled discussions as their lab experiments simmered nearby. Whilst still enthusiastic (on the whole), said trainees are now undeniably greyer, balder, rounder and grumpier (we’ll let those of you who know us decide which adjective fits each of us best) and it has inevitably proved challenging to complete this new ver- sion around the demands of busy professional and personal lives.
We are therefore extremely grateful to all our contributors as well as to OUP for (almost) being as patient as our families. But, ultimately, it is the support and good humour of the latter that has really allowed us to complete the text you are about to read. It had always been our intention to create a Handbook that makes the practice of renal medicine a little easier and a lot more enjoyable. And on that thought, we offer this new edition to you as meagre thanks for the wonderful fortune that brought our good friend and colleague Shaun Summers, all too briefly, into our lives.
SS & NA, London, 2013 vii Preface to the first edition The ability to recognize and understand renal disease and hypertension is an important part of practice in almost any area of medicine. Acute renal failure, often preventable, occurs in up to 7% of all hospital admissions and remains responsible for much morbidity and mortality. The recent reclassification of chronic kidney disease (CKD) has exposed the scale of a serious public health issue, relevant to all medical practitioners both in pri- mary and secondary care. Furthermore, irrespective of specialist interest, regular clinical contact with patients who are dialysis-dependent or who have undergone renal transplantation is now the norm, not the exception.
Hypertension needs no introduction as the most common indication for prescription drug therapy and the most important cause of premature death in the developed world. Many doctors are nervous of renal disease—there persists a belief that renal patients suffer exclusively from complex, esoteric conditions that can only be managed in a specialist environment and by specialists who are often more difficult and demanding than their patients. Our intention has been to write a concise but robust handbook that is first and fore- most practical: what needs to be done in a busy casualty department or GP surgery several miles from the nearest renal unit. We hope it will be a useful resource not only to doctors, nurses, and other members of the multiprofessional team already engaged in the care of renal patients but also to a broader audience.
For those interested in how renal dis- ease evolves, we’ve provided a good grounding in the fundamentals of nephrology—hopefully dismantling some myths along the way, and giving readers the confidence to manage the day-to-day associated with kidney disease. In line with existing Oxford Handbooks we have attempted to strike a balance between practical information, helpful to those working ‘at the coal face’, and the more detailed knowledge that enables effective ongo- ing care. The authors are all consultants working in busy renal units where theory and practice are balanced to provide effective and efficient care. The book is as up-to-date as possible and a conscious mix of evidence and reality-based medicine.
The book is laid out in twelve chapters, allowing easy access to infor- mation on a particular clinical theme. Clinical importance is measured in space, so diabetic nephropathy is given more attention than, for example, Fanconi’s syndrome. The section on renal replacement therapies gives an overview of the essential elements of both dialysis and transplantation. Those looking for more detailed notes on all aspects of dialysis therapy are referred to our sister volume The Oxford Handbook of Dialysis, or, for general nephrology and transplant topics, our parent text The Oxford Textbook of Nephrology.
For completeness, we have included practical pro- cedures but would ask that these pages are used for guidance only—all must be taught by experienced operators and cannot be learnt solely from a book. viii PREFACE TO THE FIRST EDITION We make no apology for emphasizing the importance of clinical assess- ment. Yes, tubular physiology is here (we are nephrologists after all), but this book is aimed principally at clinicians in training and we still believe that without a detailed history and thorough physical examination it is impossible to order and interpret appropriate laboratory tests or imag- ing, let alone provide good quality care. This seems more important than ever at a time when many lament a diminished sense of enjoyment in the practice of medicine.
We are grateful to all of our colleagues who helped bring this project to fruition as well as to our families for tolerating so many lost evenings and weekends with such good grace. We hope that we have produced a book with personality, and one that brings its subject matter alive. We would like readers to enjoy the highways and byways of renal medicine and that we have avoided, in the words of Mark Twain, a book that ‘everyone wants to have read, but no-one wants to read’.