A PRACTICAL MANUAL OF RENAL MEDICINE Nephrology, Dialysis and Transplantation This page intentionally left blank A PRACTICAL MANUAL OF RENAL MEDICINE Nephrology, Dialysis and Transplantation edited by Kar Neng Lai The University of Hong Kong, Hong Kong World Scientific N E W J E R S E Y • L O N D O N • S I N G A P O R E • B E I J I N G • S H A N G H A I • H O N G K O N G • TA I P E I • C H E N N A I Published by World Scientific Publishing Co. 5 Toh Tuck Link, Singapore 596224 USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601 UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. A PRACTICAL MANUAL OF RENAL MEDICINE Nephrology, Dialysis and Transplantation Copyright © 2009 by World Scientific Publishing Co. All rights reserved.
This book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the Publisher. For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy is not required from the publisher. Disclaimer: Every effort has been made to ensure that drug doses and other information are accurately portrayed in this book.
However, the responsibility for all prescriptions rests with the physician. Neither the publisher nor the editor/authors can be held responsible for errors or any consequences arising from the information contained herein. Please consult the standard prescribing information and instructions on use that are issued by the manufacturers and available in each country. ISBN-13 978-981-283-871-1 (pbk) ISBN-10 981-283-871-6 (pbk) Typeset by Stallion Press Email: enquiries@stallionpress.com Printed in Singapore.
XiaoLing - A Practical Manual.pmd 1 10/7/2009, 5:05 PM b730_FM.qxd 6/2/2009 3:15 PM Page v This book is dedicated to my parents and my brother, Ka Siu LAI, MD b730_FM.qxd 6/2/2009 3:15 PM Page vii Preface Most textbooks of kidney diseases provide comprehensive informa- tion on etiology, epidemiology, physiology, pathology, pathogenetic mechanisms, symptomatology, investigation and management. While the importance of an understanding of the pathophysiology of dis- ease is pivotal in our clinical practice, most physicians, fellows and medical residents value handy, updated, instructive, and evidence- based practical manual during their bedside duty. A Practical Manual of Renal Medicine: Nephrology, Dialysis and Transplantation is written explicitly for practising clinicians with primary emphasis on thera- peutic approach. The objective of this Manual is to provide a set of updated and well-accepted information to guide those who provide acute and long-term management to patients with kidney diseases.
The topics covered include common problems in clinical nephrology such as electrolyte and fluid disturbance, acute renal failure, hypertension, urinary tract infection, glomerular diseases, pregnancy-related renal dysfunction and renal imaging. The sections on dialysis and trans- plantation place major emphasis on making correct clinical decision, appropriate therapeutic approach and step-by-step treatment proto- cols. With expert contributors from different countries, the recommended therapeutic approach will be gauged at an interna- tional standard applicable to most regional referral centers. These treatment protocols are by no means exhaustive but serve as an effec- tive and accountable guide for patient management worldwide.
The absence of discussions of pathophysiology in most chapters is not meant to diminish its critical role in the understanding and practice of renal medicine. I feel that it is more important to con- serve space for management thrust of this Manual while keeping down the size for this Manual to be carried in the pocket conve- niently. For easy reading and rapid reference, bullet points, short vii b730_FM.qxd 6/2/2009 3:15 PM Page viii viii Preface notes, tables and diagrams are used throughout the Manual instead of lengthy texts. My sincere thanks to all contributing authors of this Manual not only because of their expertise in the science of medicine, but because they are physicians who are able to translate and apply their scientific knowledge in a practical way to allow for a systematic and evidence- based plan of therapy and treatment in the best interests of our patients.
Kar Neng LAI MD, DSc, FRCPath, FRCP, FRACP Yu Chiu Kwong Chair of Medicine and University Chair of Nephrology University of Hong Kong February 2009 b730_FM.qxd 6/2/2009 3:15 PM Page ix Contents Preface vii List of Contributors xix Part 1 General Management of Renal Patients 1 Chapter 1 Assessment of Patients with Renal Diseases 3 Sydney C.2 Interpretation of Laboratory Tests 6 1.3 Renal Biopsy 11 Chapter 2 Acid-Base Disturbances 15 Orly F. Kohn and Todd S.1 Simple Acid-Base Disturbances 15 2.2 Mixed Acid-Base Disturbances 18 2.5 Combined Metabolic Acidosis 35 and Metabolic Alkalosis 2.6 Respiratory Acid-Base Disturbances 36 in Renal Patients Chapter 3 Potassium Disturbances 39 James C.4 Potassium Homeostasis 43 ix b730_FM.qxd 6/2/2009 3:15 PM Page x x Contents Chapter 4 Sodium and Water Disturbances 45 Ramin Sam and Todd S.1 Urinary Dilution and Concentration 45 4.2 Diseases of Urinary Concentration 52 and Dilution 4.4 Complications of Hyponatremia 65 4.5 Risk Factors for Hyponatremic 65 Encephalopathy 4.6 Treatment of Hyponatremias (Other 66 than Translocational Hyponatremia) 4.7 Hypernatremia 70 Chapter 5 Hypercalcemia, Hypocalcemia, 81 and Hypomagnesemia Peter G.4 Hypomagnesemia 86 Chapter 6 Acute Renal Failure 89 Kar Neng Lai 6.2 Incidence and Prevalence 91 6.3 Classification and Causes 91 6.6 Prevention and What to Avoid 105 6.7 Recovery from Acute Tubular Necrosis 106 6.9 Future Novel Treatments 107 Chapter 7 Selected Glomerular Disorders 109 Kar Neng Lai 7.1 Minimal Change Nephropathy (MCN) 109 7.2 Idiopathic Membranous Nephropathy 111 7.3 Focal Segmental Glomerulosclerosis 114 (FSGS) b730_FM.qxd 6/2/2009 3:15 PM Page xi Contents xi 7.7 Anti-Neutrophil Cytoplasmic Antibody 124 (ANCA)-Associated Systemic Vasculitis (AASV) Chapter 8 Hypertension and Renal Disease in Pregnancy 127 Susan Hou 8.1 Hypertension in Pregnancy 127 8.2 Renal Disease in Pregnancy 132 Chapter 9 Selected Problems in General Nephrology 137 Kar Neng Lai 9.2 Contrast-Induced Nephropathy (CIN) 142 9.4 ARF in Hematopoetic Cell Transplant 146 (HCT) Chapter 10 Urinary Tract Infections 149 Evan J.5 Infection Associated with 152 Obstruction or Stones 10.6 Infection Associated with 154 Urinary Catheters Part II Chronic Renal Failure and Dialysis 155 Chapter 11 Principle of Management for Patients 157 with Chronic Kidney Disease Meguid El Nahas and Mohsen El Kossi 11.2 Detection of CKD 158 11.3 Referral of Patients to 160 Nephrology Centers b730_FM.qxd 6/2/2009 3:15 PM Page xii xii Contents 11.4 Interventions Aimed at Slowing 161 the Progression of CKD 11.5 Slowing the Progression of CKD 163 11.6 Interventions Aimed at Reducing CKD 164 Complications 11.7 Preparation of Patients for 166 Renal Replacement Therapy (RRT) 11.8 Conclusion 166 Chapter 12 Acceptance into the Chronic Dialysis Program 169 Dae-Suk Han 12.1 Criteria for Acceptance into the 169 Chronic Dialysis Program 12.2 Clinical Indications for Commencing 173 Dialysis Chapter 13 Peritoneal Dialysis — Management 175 of Tenckhoff Catheter and Ultrafiltration Problems Wai-Kei Lo 13.2 Peritoneal Dialysis Catheter — 175 Tenckhoff Catheter 13.3 Tenckhoff Catheter Exit-Site Infection 178 13.5 Peritoneal Equilibration Test (PET) 184 Chapter 14 Management of CAPD-Related Peritonitis 191 Philip K. Li and Kai-Ming Chow 14.3 Organisms for Peritonitis 192 14.6 Prevention 197 Chapter 15 Hemodialysis 201 Bharathi Reddy and Alfred K.1 Mechanisms of Solute Transport 201 15.2 Hemodialysis Membranes 202 b730_FM.qxd 6/2/2009 3:15 PM Page xiii Contents xiii 15.7 Chronic Hemodialysis Prescription 223 Chapter 16 Hemofiltration and Hemodiafiltration 227 Matthew K.2 Hemofiltration versus Hemodialysis 227 16.3 Technical Requirements for 228 Hemofiltration and Hemodiafiltration 16.4 Evolution for Hemodiafiltration 228 16.5 Evidence for Clinical Efficacy in 229 Hemofiltration and Hemodiafiltration 16.6 Potential Complications and Drawbacks 230 16.7 Indications for Hemofiltration/ 230 Hemodiafiltration 16.8 Prescription 231 Chapter 17 Adequacy of Dialysis and Dietary Advice 235 Simon J. Davies and Barbara Engel 17.1 Adequacy of Dialysis 235 17.2 Measuring Small-Solute Clearance 236 17.3 Present Strategy for Achieving 237 Adequate Dialysis 17.4 Protein Catabolic Rate (PCR) or 240 Normalized Protein Nitrogen Appearance (nPNA) Rate 17.5 Dietary Advice 241 Chapter 18 Prevention and Management of Renal 251 Osteodystrophy David B.2 Renal Osteodystrophy: Classification 251 18.3 Renal Osteodystrophy: Diagnostic Tests 259 18.4 Treatment of Hyperparathyroidism 259 18.qxd 6/2/2009 3:15 PM Page xiv xiv Contents 18.6 Treatment of Hypercalcemia in 270 Dialysis Patients 18.7 Other Components of 272 Renal Osteodystrophy 18.8 Use of Low-Calcium Dialysate 278 Chapter 19 Treatment of Renal Anemia 283 Bruce A.
Pussell and Rowan G.1 Causes of Anemia in CKD 283 19.3 Target Levels for Hemoglobin 285 19.4 Failure to Respond to ESAs 287 19.5 Hemoglobin Variability 289 Chapter 20 Bleeding Tendency and Hepatitis B Vaccination 293 Bo-Ying Choy and Kar Neng Lai 20.1 Management of Bleeding Tendency 293 in Dialysis/Uremic Patients 20.2 Hepatitis B Vaccination 296 Chapter 21 Routine Investigations for Dialysis Patients 301 Sydney C.2 Routine Investigations During 302 Maintenance Dialysis 21.3 Assessment of Suitability for 302 Kidney Transplantaion Part III Renal Transplantation 307 Chapter 22 Pretransplantation Donor and 309 Recipient Workup Laurence K. Chan and Siu-Kim Chan 22.1 Recipient Selection and Pretransplant 309 Evaluation 22.2 Live Donor Evaluation 324 22.3 Deceased (Cadaver) Donor Evaluation 331 b730_FM.qxd 6/2/2009 3:15 PM Page xv Contents xv Chapter 23 Management Guidelines Peritransplantation 341 Jeremy R.1 The Recipient Before Transplantation 341 23.2 Investigations After Renal 348 Transplantation 23.4 Highly Sensitized Recipients 358 23.5 Other Prophylactic Measures 360 23.6 Checklist When Discharging the 362 Patient from the Ward Chapter 24 Prophylaxis, Monitoring, and Preemptive 365 Therapy for Potential Complications After Renal Transplantation Sing-Leung Lui 24.1 Prophylaxis Against Peptic Ulceration 365 24.2 Prophylaxis and Treatment of Tuberculosis 365 24.3 Prophylaxis and Treatment 367 of Candidiasis 24.4 Prophylaxis and Treatment 368 of Pneumocystis Pneumonia 24.5 Monitoring and Preemptive Therapy 369 for Cytomegalovirus Disease Chapter 25 Medical Complications After Renal 373 Transplantation Daniel T.3 Chronic Renal Allograft Dysfunction 379 25.5 Graft Renal Artery Stenosis 381 25.6 Malignancies and Posttransplant 381 Lymphoproliferative Disorder (PTLD) 25.8 Cardiovascular Complications 383 and Hypertension 25.9 Erythrocytosis and Anemia 384 25.10 Hyperparathyroidism, Renal 384 Osteodystrophy, and Osteoporosis b730_FM.qxd 6/2/2009 3:15 PM Page xvi xvi Contents Part IV Special Renal Investigations 387 Chapter 26 Diagnosis of Renal Tubular Acidosis 389 James C.2 Classification of RTA 390 26.4 Laboratory Measurements 394 in Diagnosing RTA 26.5 Diagnostic Approach 397 Chapter 27 Treatment of Renal Tubular Acidosis 401 James C.1 Treatment of Type 1 and Type 2 401 Renal Tubular Acidosis (RTA) 27.2 Treatment of Type 4 RTA 402 Part V Radiology in Renal Patients 405 Chapter 28 Imaging and Interventional Treatment 407 of Nephrological Problems Andrew S. Lai and Ferdinand S.1 Deranged Renal Function 407 28.2 Urinary Tract Infection (UTI) 408 28.3 Stone Disease and Renal Colic 409 28.8 Complications of Contrast Imaging 419 in Renal Patients Chapter 29 Imaging and Interventional Treatment 423 of Dialysis-Related Problems Andrew S. Lai and Ferdinand S.1 Temporary and Tunneled Catheter Access 423 29.2 Tunneled Catheter Failure 426 29.3 Pre-arteriovenous Fistula Workup 427 29.4 Poor Flow in Arteriovenous Fistula 428 or Polytetrafluoroethylene (PTFE) Graft b730_FM.qxd 6/2/2009 3:15 PM Page xvii Contents xvii 29.5 Complications Related to Continuous 429 Ambulatory Peritoneal Dialysis (CAPD) Chapter 30 Imaging and Interventional Treatment 433 of Renal Transplant-Related Problems Ferdinand S.
Chu and Andrew S.1 Imaging of the Donor 433 30.2 Imaging of the Recipient 434 30.3 Graft Dysfunction and Other 434 Graft Problems 30.4 Surgical Complications of Graft Kidneys 435 30.5 Arteriovenous Fistula (AVF) 440 and Pseudoaneurysm Part VI Drug Use in Renal Patients 443 Chapter 31 Drug Doses in Patients with Renal Impairment 445 Siu-Kim Chan and Laurence K.1 Influence of Renal Impairment 445 on Drug Absorption and Bioavailability 31.2 Influence of Renal Impairment 446 on Volume of Distribution and Protein Binding 31.3 Influence of Renal Impairment 447 on Drug Elimination 31.4 Dosing of Drugs in the Presence 448 of Renal Impairment 31.