OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Nephrology and Hypertension Published and upcoming Oxford Handbooks Oxford Handbook of Genetics Oxford Handbook of Genitourinary Oxford Handbook for the Foundation Program 3e Medicine, HIV and AIDS 2e Oxford Handbook of Geriatric Oxford Handbook of Acute Medicine 3e Oxford Handbook of Anesthesia 3e Oxford Handbook of Ap plied Dental Medicine 2e Oxford Handbook of Infectious Diseases and Microbiology Oxford Handbook of Key Clinical Sciences Oxford Handbook of Cardiology 2e Oxford Handbook of Clinical and Laboratory Investigation 3 e Oxford Handbook of Clinical Evidence Oxford Handbook of Medical Dermatology Dentistry 5e Oxford Handbook of Medical Imaging Oxford Handbook of Medical Oxford Handbook of Clinical Diagnosis 2e Sciences 2e Oxford Handbook of Clinical Oxford Handbook of Medical Statistics Oxford Handbook of Neonatology Oxford Handbook of Nep hrology and Examination and Practical Skills Oxford Handbook of Clinical Hematology 3e Hypertension 2e Oxford Handbook of Clinical Immunology and Allergy 3e Oxford Handbook of Clinical Medicine \200\224Mini Edition 8e Oxford Handbook of Clinical Oxford Handbook of Neurology 2e Oxford Handbook of Nutrition and Dietetics 2e Oxford Handbook of Obstetrics and Gynecology 3e Medicine 9e Oxford Handbook of Occupational Oxford Handbook of Clinical Pathology Oxford Handbook of Clinical Health 2e Oxford Handbook of Oncology 3e Oxford Handbook of Ophthalmology 2e Oxford Handbook of Oral and Drugstore 2e Oxford Handbook of Clinical Rehabilitation 2e Maxillofacial Surgery Oxford Handbook of Clinical Oxford Handbook of Orthopedics Specialties 9e and Trauma Oxford Handbook of Clinical Surgery 4e Oxford Handbook of Complementary Oxford Handbook of Pediatrics 2e Oxford Handbook of Pain Management Oxford Handbook of Pall iative Care 2e Oxford Handbook of Practical Drug Medicine Oxford Handbook of Critical Care 3e Oxford Handbook of Dental Patient Therapy 2e Care Oxford Handbook of Pre-Hospital Oxford Handbook of Dialysis 3e Oxford Handbook of Emergency Care Oxford Handbook of Psychiatry 3e Oxford Handbook of Public Health Medicine 4e Oxford Handbook of Endocrinology Practice 3e and Diabetes 3e Oxford Handbook of Reproductive Medicine & Family Planning 2e Oxford Handbook of Respirator y Oxford Handbook of ENT and Head and Neck Surgery 2e Oxford Handbook of Epidemiology for Medicine 2e Clinicians Oxford Handbook of Rheumatology 3e Oxford Handbook of Sport and Oxford Handbook of Expedition and Wilderness Medicine Exercise Medicine 2e Oxford Handbook of Forensic Handbook of Surgical Consent Oxford Handbook of Tropical Medicine Oxford Handbook of Gastroenterology Medicine 4e and Hepatology 2e Oxford Handbook of Urology 3e Oxford Handbook of General Practice 4e Oxford Handbook of Nephrology and Hypertension Second edition Simon Steddon Consultant Nephrologist Guy \200\231s and St Thomas \200\231 Hospitals London , UK and Neil Ashman Consultant Nephrologist St Bartholomew \200\231s and the Royal London Hospi tals London, UK With Alistair Chesser Consultant Nephrologist St Bartholomew \200\231s and the Royal London Hosp itals London, UK and John Cunningham Professor of Nephrology Royal Free & University College Hospitals Londo n, 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 Univer sity \200\231s objective of excellence in research, scholarship, and education by publishin g 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 s ystem, 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 t he appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, a t 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, Ne w York, NY 10016, United States of America British Library Cataloging in Publication Data Data available Library of Congress Control Number: 2013943253 ISBN 978 \200\2230 \200\22319 \200\223965161 \200\2230 Printed in China by C&C Offset Printing Co. Ltd. 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 c linical procedures with the most up-to-date published product information and data sheets p rovided by the manufacturers and the most recent codes of conduct and safety regulations. T he authors and the publishers do not accept responsibility or legal liability for any error s in the text or for the misuse or misapplication of material in this work. Except where ot herwise 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 websit e referenced in this work. v Preface to the second edition Much has changed in our specialty since the appearance of the \201 rst edi- tion of this Handbook. Chronic Kidney Disease, a \202 edgling classi \201 cation 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-imag inations 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 secon dary care. International efforts to produce con- sensus guidelines (albeit from disappointi ngly thin evidence) must also be applauded. However, whilst we may inexplicably struggle to complete suf \201 cient 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 \200\231ll \201 nd a little more depth to the information in this edition, although t his 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 Speci alist Handbooks of Renal Transplantation and Pediatric Nephrology . Along with the well-est ablished Oxford Handbook of Dialysis and the newer Oxford Desktop Reference of Nephrology , we believe these represent a formidable resource across our entire specialty. The \201 rst edition was the idea of a few enthusiastic London trainees, cultivated throu gh animated caffeine-fueled discussions as their lab experiments simmered nearby. Whilst st ill enthusiastic (on the whole), said trainees are now undeniably greyer, balder, rounder a nd grumpier (we \200\231ll let those of you who know us decide which adjective \201 ts ea ch of us best) and it has inevitably proved challenging to complete this new ver- sion arou nd 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. B ut, ultimately, it is the support and good humor of the latter that has really allowed us t o complete the text you are about to read. It had always been our intention to create a Handbook that makes the practice of renal medi cine a little easier and a lot more enjoyable. And on that thought, we offer this new editi on to you as meager thanks for the wonderful fortune that brought our good friend and colle ague Shaun Summers, all too brie \202 y, into our lives. SS & NA, London, 2013 vii Preface to the \201 rst 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 mort ality. The recent reclassi \201 cation of chronic kidney disease (CKD) has exposed the sca le of a serious public health issue, relevant to all medical practitioners both in pri- mar y and secondary care. Furthermore, irrespective of specialist interest, regular clinical co ntact 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 i ndication for prescription drug therapy and the most important cause of premature death in the developed world. Many doctors are nervous of renal disease \200\224there persists a belief that renal patien ts suffer exclusively from complex, esoteric conditions that can only be managed in a speci alist environment and by specialists who are often more dif \201 cult and demanding than t heir patients. Our intention has been to write a concise but robust handbook that is \201 rst and fore- most practical: what needs to be done in a busy casualty department or GP su rgery several miles from the nearest renal unit. We hope it will be a useful resource not o nly 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 rena l dis- ease evolves, we \200\231ve provided a good grounding in the fundamentals of nephrol ogy \200\224hopefully dismantling some myths along the way, and giving readers the con \201 dence to manage the day-to-day associated with kidney disease. In line with existing Oxford Handbooks we have attempted to strike a balance between practi cal information, helpful to those working \200\230at the coal face \200\231, and the more detailed knowledge that enables effective ongo- ing care. The authors are all consultants w orking in busy renal units where theory and practice are balanced to provide effective and ef \201 cient 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 particu lar clinical theme. Clinical importance is measured in space, so diabetic nephropathy is gi ven more attention than, for example, Fanconi \200\231s syndrome. The section on renal repl acement therapies gives an overview of the essential elements of both dialysis and transpla ntation. Those looking for more detailed notes on all aspects of dialysis therapy are refer red to our sister volume The Oxford Handbook of Dialysis , or, for general nephrology and t ransplant 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 o nly \200\224all must be taught by experienced operators and cannot be learned solely from a book. PREFACE TO THE FIRST EDITION viii We make no apology for emphasizing the importance of clinical assess- ment. Yes, tubular ph ysiology is here (we are nephrologists after all), but this book is aimed principally at cl inicians in training and we still believe that without a detailed history and thorough phys ical examination it is impossible to order and interpret appropriate laboratory tests or im ag- 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 matt er 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 \200\230everyone wants to have r ead, but no-one wants to read \200\231. SS, NA, AC, JC London, July 2006 ix Contents Contributors x Symbols and Abbreviations xi 1 Clinical assessment of the renal patient 2 Acute kidney injury (AKI) 3 Chronic kidney dis ease (CKD) 4 Dialysis 5 Transplantation 6 Hypertension 7 Diseases of the kidney 8 The kidne y in systemic disease 9 Essential urology 10 Fluids and electrolytes 11 Pregnancy and the k idney 12 Drugs and the kidney 13 Renal physiology 14 Appendices 1 87 191 273 335 449 529 603 705 777 839 869 913 935 Index 957 x Contributors Conor Byrne Bart \200\231s and the Royal London Hospitals London, UK Kieran McCafferty Bart \200\231s and the Royal London Hospitals London, UK Ananda Chapagain Specialist Registrar London, UK Emma O \200\231Lone Specialist Registrar London, UK Paramit Chowdhury Guy \200\231s and St Thomas \200\231 Hospitals London, UK Marlies Ostermann Guy \200\231s and St Thomas \200\231 Hospitals London, UK Partha Das Specialist Registrar London, UK Taryn Pile Guy \200\231s and St Thomas \200\231 Hospitals London, UK Stanley Fan Bart \200\231s and the Royal London Hospitals London, UK Ben Pullar Specialist Registrar London, UK Michael Robson Guy \200\231s and St Thomas \200\231 Hospitals London, UK Suzanne Forbes Specialist Registrar London, UK Claire Sharpe King \200\231s College Hospital London, UK Scott Henderson Specialist Registrar London, UK Rebecca Suckling Epsom and St Helier University Hospitals Surrey, UK Chris Kirwan Bart \200\231s and the Royal London Hospitals London, UK Matt Varrier Specialist Registrar London, UK Nicola Kumar Guy \200\231s and St Thomas \200\231 Hospitals London, UK Thanks also to Heather Brown, Simon Chowdhury, Sue Cox, Rachel Hilton, Jonathon Olsburgh, E d Sharples, and Raj Thuraisingham for their expert help and advice. xi Symbols and Abbreviations \231\202 \231\200 1 2 i d 2 22 (cid:2) X 6 l n 7 8 > < (cid:2) \211 = & $ + ve \200\223 ve AAA Ab ABD ABPM ACE-I ACR alpha beta male female primary secondary increased decreased important don \200\231 t dawd le warning controversial topic therefore leading to normal degree approximately equal to re gistered trademark greater than less than equal to or greater than equal to or less than eq ual to and pound sterling US dollar positive negative abdominal aortic aneurysm antibody ad ynamic bone disease ambulatory blood pressure monitoring angiotensin-converting enzyme inhi bitor albumin/creatinine ratio SYMBOLS AND ABBREVIATIONS xii ACS abdominal compartment syndrome; acute coronary syndrome activated clotting time adrenocorti cotrophin hormone autosomal dominant antidiuretic hormone asymmetric dimethyl arginine auto somal dominant polycystic kidney disease atrial \201 brillation acid-fast bacilli anion g ap advanced glycation end-product angiotensin II acquired immunode \201 ciency syndrome ac ute interstitial nephritis acute kidney disease acute kidney injury Acute Kidney Injury Net work aluminum albumin alkaline phosphatase alanine transaminase ante meridian antibody-medi ated rejection analgesic nephropathy anti-nuclear antibodies anti-neutrophil cytoplasmic an tibodies atrial natriuretic peptide antigen-presenting cell automated peritoneal dialysis a ntiphospholipid syndrome activated partial thromboplastin time autosomal recessive atherosc lerotic renal artery stenosis aldosterone receptor blocker acute respiratory distress syndr ome autosomal recessive polycystic kidney disease aldosterone \200\223renin ratio atheroscl erotic renovascular disease as soon as possible ACT ACTH AD ADH ADMA ADPKD AF AFB AG AGE A2 AIDS AIN AKD AKI AKIN Al Alb ALP ALT a.m. AMR A N ANA ANCA ANP APC APD APS APTT AR ARAS ARB ARDS ARPKD ARR ARVD ASAP SYMBOLS AND ABBREVIATIONS xiii ASCT ASOT AST ATG ATI ATN ATP AV AVF AVM AVP AXR AZA BAL BAT BBV BC BCG BCR bd BE BEN BHS B M B 2 M BMD BMI BMT BNP BOO BP BPH BVAS BVM Ca 2+ CaCl 2 CAD CAH CAKUT CAN autologous stem cell transplantation anti-streptolysin O titre aspartate aminotransferase a nti-thymocyte globulin acute tubular injury acute tubular necrosis adenosine triphosphate a trioventricular; arteriovenous arteriovenous \201 stula arteriovenous malformation argini ne vasopressin abdominal X-ray azathioprine bronchoalveolar lavage baroreceptor activation therapy blood-borne viruses blood culture basal cell carcinoma; bacille Calmette \200\223Gu rin B cell receptor twice daily base excess Balkan endemic nephropathy British Hypertensi on Society basement membrane beta 2 microglobulin bone mineral density body mass index bone marrow transplantation brain natriuretic peptide bladder outlet obstruction blood pressure benign prostatic hyperplasia Birmingham vasculitis activity score blood volume monitoring calcium ion calcium chloride coronary artery disease congenital adrenal hyperplasia congeni tal abnormalities of the kidney and urinary tract chronic allograft nephropathy SYMBOLS AND ABBREVIATIONS xiv CAPD CAPS CaR CaxP CBPM Cbsa CCB CCF CCPB CCPD CD CDC continuous ambulatory peritoneal dialysis catastrophic antiphospholipid syndrome calcium-se nsing receptor calcium phosphate product clinic BP monitoring cationic bovine serum albumin calcium channel blocker congestive cardiac failure calcium-containing phosphate binder con tinuous cycling peritoneal dialysis collecting duct complement-dependent cytotoxicity; Cent ers for Disease Control continuous equilibrium peritoneal dialysis continuous EPO receptor activator colony-forming unit Cockcroft \200\223Gault Chapel Hill Consensus Conference coro nary heart disease ethanol reticulocyte hemoglobin content ciclosporin carcinoma in situ co ld ischaemic time creatine kinase chronic kidney disease chloride ion chronic lymphocytic l eukemia centimeter cell-mediated immune cytomegalovirus cranial nerve calcineurin inhibitor central nervous system cardiac troponin I cardiac troponin T cardiac output carbon dioxide combined oral contraceptive colloid osmotic pressure CEPD CERA cfu CG CHCC CHD C 2 H 5 OH CHr CIC CIS CIT CK CKD Cl \200\223 CLL cm CMI CMV CN CNI CNS cTnI cTnT CO CO 2 COC COP SYMBOLS AND ABBREVIATIONS xv COX CPAP CPET CPM CPS Cr CRB CrCl CRF CRH CRP CRRT CRS C+S CT CTA CTS CUA CV CVA CVC CVD CV P CVVHD CVVHDF CVVHF CXR d 3D Da DA DBD DBP DCD DCT DDAVP DEXA DFO DGF DHT cyclo-oxygenase continuous positive airway pressure cardiopulmonary exercise testing centra l pontine myelinosis calcium polystyrene sulfate creatinine catheter-related bacteraemia cr eatinine clearance chronic renal failure corticotrophin-releasing hormone C-reactive protei n continuous renal replacement therapy cardiorenal syndrome culture and sensitivity compute d tomography computed tomography angiography carpal tunnel syndrome cal \201 cic uraemic a rteriolopathy cardiovascular cerebrovascular accident central venous catheter cardiovascula r disease central venous pressure continuous veno-venous haemodialysis continuous veno-veno us haemodia \201 ltration continuous veno-venous haemo \201 ltration chest X-ray day thre e-dimensional dalton dopamine donation after brain death diastolic blood pressure donation after cardiac death distal convoluted tubule desmopressin dual-energy X-ray absorptiometry desferrioxamine delayed graft function dihydrotestosterone SYMBOLS AND ABBREVIATIONS xvi DIC DKA dL DM DMARD DN DNA DRA DRE DSA dsDNA DSE DT DTT D&V DVT DW EABV EBCT EBV ECD ECF EC G ECHO EEG EF EG eGFR EGPA ELISA EM EMA EMT EMU ENA ENaC eNOS ENT EPO EPO-R disseminated intravascular coagulation diabetic ketoacidosis decilitre diabetes mellitus di sease-modifying anti-rheumatic drug diabetic nephropathy deoxyribonucleic acid dialysis-rel ated amyloidosis digital rectal examination donor-speci \201 c antibody double-stranded de oxyribonucleic acid dobutamine stress echocardiography distal tubule dithiothreitol diarrhe a and vomiting deep vein thrombosis dry weight effective arterial blood volume electron bea m CT Epstein \200\223Barr virus extended criteria donors extracellular \202 uid electroca rdiogram echocardiography electroencephalogram ejection fraction ethylene glycol estimated glomerular \201 ltration rate eosinophilic granulomatosis with polyangiitis enzyme-linked immunosorbent assay electron microscopy European Medicines Agency epithelial to mesenchyma l transition early morning urine extractable nuclear antigen epithelial Na + channel endoge nous nitric oxide synthase ear, nose, and throat erythropoietin erythropoietin receptor SYMBOLS AND ABBREVIATIONS xvii ERT ESA ESRD EST ESWL FBC FDA FFP FFR FFS FH FISH FMD FMF FOB FPG FSGS FSH g GA GBM GCS Gd GDP GFR GH GI GN GnRH GP GPA G6PD G6PDH GRA G&S GST GTN GUTB h H + enzyme replacement therapy erythropoiesis-stimulating agent end-stage renal disease exercis e stress testing extracorporeal shock wave lithotripsy full blood count Food and Drug Admin istration fresh frozen plasma fractional \202 ow reserve \201 ve factor score family hi story \202 uorescence in situ hybridization \201 bromuscular dysplasia familial Mediter ranean fever fecal occult blood fasting plasma glucose focal and segmental glomeruloscleros is follicle-stimulating hormone gram general anesthesia glomerular basement membrane Glasgo w Coma Score gadolinium glucose degradation product glomerular \201 ltration rate growth hormone gastrointestinal glomerulonephritis gonadotropin-releasing hormone general practiti oner granulomatosis with polyangiitis glucose-6-phosphate de \201 ciency glucose-6-phospha te dehydrogenase glucocorticoid-remediable aldosteronism group and save glutathione S-trans ferase glyceryl trinitrate genitourinary tuberculosis hour hydrogen ion SYMBOLS AND ABBREVIATIONS xviii HAART Hb HBPM HBV HC HCDD HCO 3 \200\223 H 2 CO 3 HCP Hct HCV HD HDF HDL H+E HELLP HF HIT HIV HIVAN HIVICK HIV-TMA HLA H 2 O HoLEP hpf HR HRBC HRCT HRE hrEPO HRS HRT HSP HSV HTA HTL V HUS IAH IAP highly active antiretroviral therapy hemoglobin home blood pressure measurement hepatitis B virus hydroxycarbamide heavy chain deposition disease bicarbonate ion carbonic acid haemop oietic cell phosphatase haematocrit hepatitis C virus haemodialysis haemodia \201 ltration high-density lipoprotein haematoxylin and eosin haemolysis, elevated liver enzymes, and lo w platelet haemo \201 ltration; heart failure heparin-induced thrombocytopenia human immun ode \201 ciency virus HIV-associated nephropathy HIV immune complex kidney disease HIV-ass ociated thrombotic microangiopathy human leucocyte antigen water holmium laser enucleation of the prostate high-powered \201 eld heart rate hypochromic red blood cell high-resoluti on computed tomography hypoxia response element human recombinant erythropoietin hepatorena l syndrome hormone replacement therapy Henoch \200\223Sch nlein purpura herpes simplex vir us Human Tissue Authority human T lymphotropic virus haemolytic uraemic syndrome intra-abdo minal hypertension intra-abdominal pressure SYMBOLS AND ABBREVIATIONS xix IBD IBW IC iCa 2+ ICA ICAM-1 IDH IDL IDPN IE IF IFN Ig IgAN IGF IGFBP IGRA IHD IL IM IMN IM PDH IMWG INHD iNOS INR IP IPSS ITP ITU IU IUGR IV IVC IVDSA IVDU IVI IVIg IVU JBS in \202 ammatory bowel disease ideal body weight immune complex ionized calcium intracrani al aneurysms intercellular adhesion molecule-1 intradialytic hypotension intermediate densi ty lipoprotein intradialytic parenteral nutrition infective endocarditis interstitial \201 brosis interferon immunoglobulin IgA nephropathy insulin-like growth factor insulin-li ke growth factor-binding protein interferon gamma release assays ischaemic heart disease; i ntermittent haemodialysis interleukin intramuscular idiopathic membranous nephropathy inosi ne monophosphate dehydrogenase International Myeloma Working Group in-hospital nocturnal ha emodialysis inducible nitric oxide synthase international normalized ratio intraperitoneal international prostate symptom score idiopathic thrombocytopenic purpura intensive treatmen t unit international unit intrauterine growth restriction intravenous inferior vena cava in travenous digital subtraction angiography intravenous drug user intravenous infusion intrav enous immunoglobulin intravenous urogram Joint British Societies SYMBOLS AND ABBREVIATIONS xx JNC JVP K + kcal KCl KCO kDa KDIGO kg kPa KUB L LA LAKIN LDH LDL L-FABP LFT LH LIDD LMW LMW H LN LP LPS LUTS LV LVF LVH m mAb MAC MACE MAHA MAOI MAP MARS Mb MBD MCD Joint National Committee jugular venous pressure potassium ion kilocalorie potassium chlori de diffusion capacity for carbon monoxide kilodalton Kidney Disease Improving Global Outcom es kilogram kilopascal kidneys \200\223ureter \200\223bladder liter local anesthesia; lupus anticoagulant London AKI Network lactic acid dehydrogenase low-density lipoprotein liver-t ype fatty acid-binding protein liver function test luteinizing hormone; loop of Henle light chain deposition disease low molecular weight low molecular weight heparin lymph node lumb ar puncture lipopolysaccharide lower urinary tract symptoms left ventricular left ventricul ar failure left ventricular hypertrophy meter monoclonal antibody membrane attack complex major adverse cardiovascular events microangiopathic haemolytic anemia monoamine oxidase in hibitor mean arterial pressure molecular absorbent recirculating system myoglobin mineral a nd bone disorder minimal change disease SYMBOLS AND ABBREVIATIONS xxi MCGN MCN M,C+S MCUG MDRD MEN meq MFI mg Mg 2+ MGUS MHC MHRA MI MIDD min mIU mm MMF mmHg mmo l MMR MN mOsmol MPA MPO MPS MR mesangiocapillary glomerulonephritis minimal change nephropathy microscopy, culture, and se nsitivity micturating cystourethrography Modi \201 cation of Diet in Renal Disease multipl e endocrine neoplasia milliequivalent median \202 uorescence intensity milligram magnesiu m ion monoclonal gammopathy of uncertain signi \201 cance major histocompatibility complex Medicines and Healthcare products Regulatory Agency myocardial infarction monoclonal immun oglobulin deposition disease minute milli international unit millimeter mycophenolate mofet il millimeter of mercury millimole mumps, measles, and rubella membranous nephropathy milli osmole mycophenolic acid; microscopic polyangiitis myeloperoxidase myocardial perfusion sca n; mycophenolate sodium magnetic resonance; modi \201 ed release; mineralocorticoid recept or magnetic resonance angiography magnetic resonance imaging meticillin-resistant Staphyloc occus aureus magnetic resonance spectroscopy imaging multiple sclerosis multislice computed tomography midstream urine mammalian target of rapamycin milliunit mitral valve replacemen t molecular weight MRA MRI MRSA MRSI MS MSCT MSU mTOR mU MVR MW SYMBOLS AND ABBREVIATIONS xxii Na + NAC NaCl NADR NAG NaHCO 3 NB NBM NFAT ng NG NGAL NH 4 + NHHD NHL NHS NICE NIH NIPD NK NKF- KDOQI nm NMSC NO NODAT nPCR NR NSAID NSF NSTEMI N+V NYHA O 2 od OSA OSP p PAC PAK sodium ion N-acetylcysteine sodium chloride noradrenaline N-acetyl- B -D-glucosaminidase so dium bicarbonate take note ( nota bene ) nil by mouth nuclear factor of activated T cells n anogram nasogastric neutrophil gelatinase-associated lipocalin ammonium ion nocturnal home haemodialysis non-Hodgkin \200\231s lymphoma National Health Service National Institute for Health and Care Excellence National Institutes of Health night-time intermittent peritonea l dialysis natural killer National Kidney Foundation Kidney Dialysis Outcomes Quality Initi ative nanometer non-melanoma skin cancer nitric oxide new-onset diabetes after transplantat ion normalized protein catabolic rate normal range non-steroidal anti-in \202 ammatory dru g nephrogenic systemic \201 brosis non-ST elevation myocardial infarction nausea and vomi ting New York Heart Association oxygen once daily obstructive sleep apnoea oral sodium phos phate probability pulmonary artery catheter pancreas after kidney SYMBOLS AND ABBREVIATIONS xxiii PAN PaOP PAS PC PCA PCP PCR PCT PD PDGF PEEP PEG PET PEX PFT pg PIGN PIH PIN PlGF plt pmol pmp PNCL PNH PO PO 4 POF POTS PP PPI PR3 PRA PRCA PRES prn PSA PT PTA PTC polyarteritis nodosa pulmonary artery occlusion pressure periodic acid \200\223Schiff pelvi calyceal patient-controlled analgesia pneumocystis pneumonia protein/creatinine ratio; poly merase chain reaction proximal convoluted tubule peritoneal dialysis platelet-derived growt h factor positive end expiratory pressure percutaneous endoscopic gastrotomy; polyethylene glycol peritoneal equilibration test; positron emission tomography plasma exchange pulmonar y function test picogram post-infectious glomerulonephritis pregnancy-induced hypertension prostatic intraepithelial neoplasia placental growth factor platelet picomole per million o f population percutaneous nephrolithotomy paroxysmal nocturnal haemoglobinuria orally phosp hate ion premature ovarian failure postural tachycardia syndrome pulse pressure proton pump inhibitor proteinase 3 panel reactive antibody pure red cell aplasia posterior reversible encephalopathy syndrome as required prostate-speci \201 c antigen prothrombin time pancrea s transplant alone proximal tubular cell; peritubular capillary SYMBOLS AND ABBREVIATIONS xxiv PTFE PTH PTHrP PTLD PTRA PUJ PUV PV PVAN PVD PVP qds RA RAAS RAS RBC RBF RBP RCC RCT R&D RF Rh RhF RI RIJ RLV RN RNA RNP RO RPF RPGN RPLS RR RRT RTA RVD RVT RWMA polytetra \202 uoroethylene parathyroid hormone parathyroid hormone-related peptide post-t ransplant lymphoproliferative disorder percutaneous transluminal renal angioplasty pelvi-ur eteric junction posterior urethral valves per vagina polyomavirus-associated nephropathy pe ripheral vascular disease photoselective vaporization of the prostate four times daily rheu matoid arthritis renin \200\223angiotensin \200\223aldosterone system renin \200\223angiote nsin system red blood cell renal blood \202 ow retinol-binding protein renal cell carcino ma randomized controlled trial research and development radiofrequency rhesus rheumatoid fa ctor resistive index right internal jugular renal-limited vasculitis re \202 ux nephropath y ribonucleic acid ribonuclear protein reverse osmosis retroperitoneal \201 brosis rapidl y progressive glomerulonephritis reversible posterior leucoencephalopathy syndrome respirat ory rate renal replacement therapy renal tubular acidosis renovascular disease renal vein t hrombosis regional wall motion abnormality SYMBOLS AND ABBREVIATIONS xxv s SA SAA SAH S a O 2 SAP SBP SCC SCM SCN SCr ScvO 2 SDHD SE SEP second sinoatrial serum amyloid A subarachnoid hemorrhage oxygen saturation serum amyloid P systolic blood pressure; spontaneous bacterial peritonitis squamous cell carcinoma sternoc leidomastoid sickle cell nephropathy serum creatinine central venous oxygen saturation shor t daily haemodialysis side effect synthetic erythropoiesis protein; sclerosing encapsulatin g peritonitis serum free light chain subjective global assessment secondary hyperparathyroi dism syndrome of inappropriate antidiuretic hormone secretion systemic in \202 ammatory re sponse syndrome systemic lupus erythematosus sustained low-ef \201 ciency dialysis glomeru lar \201 ltration rate of single nephron single nucleotide polymorphism sympathetic nervo us system shortness of breath serum protein electrophoresis simultanous kidney \200\223panc reas species sodium polystyrene sulphonate systemic sclerosis serotonin-speci \201 c reupt ake inhibitor sexually transmitted disease ST elevation myocardial infarction superior vena cava systemic vascular resistance; sustained virologic response temperature half-life tubu lar atrophy SFLC SGA SHPT SIADH SIRS SLE SLED SNGFR SNP SNS SOB SPEP SPK spp. SPS SSc SSRI STD STEMI SV C SVR T t 1/2 TA SYMBOLS AND ABBREVIATIONS xxvi TAC TALH TB TBW TC TCC TCR T1DM T2DM tds TFT THMP TIA TIBC TIMP TIN TINU TIPS TLS TMA TMD T MP TNF TOD TOE TOR TMPT TPN TRUS TSAT TSH TTE TTP TUIP TUMT TUNA TURBT TURP U UAG tacrolimus thick ascending loop of Henle tuberculosis total body water total cholesterol tr ansitional cell carcinoma T cell receptor type 1 diabetes type 2 diabetes three times daily thyroid function test Tamm \200\223Horsfall mucoprotein transient ischaemic attack total i ron-binding capacity tissue inhibitor of metalloproteinases tubulointerstitial nephritis tu bulointerstitial nephritis and uveitis transjugular intrahepatic portosystemic shunt tumor lysis syndrome thrombotic microangiopathy thin membrane disease transmembrane pressure tumo r necrosis factor target organ damage transoesophageal echocardiography target of rapamycin thiopurine methytransferase total parenteral nutrition transrectal ultrasound transferrin saturation thyroid-stimulating hormone transthoracic echocardiography thrombotic thrombocyt openic purpura transurethral incision of the prostate transurethral microwave therapy trans urethral needle ablation transurethral resection of bladder tumor transurethral resection o f the prostate unit urine anion gap SYMBOLS AND ABBREVIATIONS xxvii U&E UF UFH UK UKM UO UPEP Ur URR USA USRDS USS UTI UV VC VDR VDRA VE VEGF VL VPI vs VTE VUR vWF VZV WCC WHO WIT wk WWII yr urea and electrolytes ultra \201 ltration unfractionated heparin United Kingdom urea kinet ic modeling urine output urine protein electrophoresis urea urea reduction ratio United Sta tes of America United States Renal Data System ultrasound scan urinary tract infection ultr aviolet vascular calci \201 cation vitamin D receptor vitamin D receptor agonist vaginal e xamination vascular endothelial growth factor viral load vasopeptidase inhibitor versus ven ous thromboembolism vesicoureteric re \202 ux von Willebrand factor varicella zoster virus white cell count World Health Organization warm ischaemia time week World War II year 1 Chapter 1 Clinical assessment of the renal patient Clinical history: introduction 2 Clinical history: symptoms and social history 4 Clinical h istory: drug, treatment, and family 6 Clinical history: additional factors 8 Physical exami nation 10 Physical examination: the circulation 12 Urine: appearance 14 Urinalysis: chemica l analysis 16 Urinalysis: further tests 18 Urinalysis: protein 20 Urinalysis: red blood cel ls 22 Urinalysis: cells, organisms, and casts 24 Urinalysis: crystals 28 Determining renal function 30 Creatinine 32 eGFR 34 GFR measurement: other methods 36 Renal function in the e lderly 38 Immunological and serological investigation 40 Diagnostic imaging: X-ray 44 Diagn ostic imaging: ultrasound 46 Diagnostic imaging: CT and MRI 50 Diagnostic imaging: IVU 52 D iagnostic imaging: nuclear medicine 54 Diagnostic imaging: angiography and uroradiology 56 Clinical syndromes: proteinuria \200\224 introduction 58 Clinical syndromes: proteinuria 6 0 Clinical syndromes: haematuria \200\224 introduction and classi \201 cation 62 Clinical syndromes: haematuria assessment 64 Clinical syndromes: microscopic haematuria 66 Clinical syndromes: microscopic haematuria screening 68 Clinical syndromes: CKD, AKI, and the nephr itic syndrome 70 Clinical syndromes: pulmonary renal syndromes 72 Clinical syndromes: urine volume and urinary tract pain 74 Clinical syndromes: tubular syndromes 76 Clinical syndrom es: bladder out \202 ow obstruction 78 Renal biopsy: introduction 80 Renal biopsy: indicat ions 82 Renal biopsy: complications 84 CHAPTER 1 Clinical assessment 2 Clinical history: introduction In nephrology, as in all branches of medicine, a competent c linical assess- ment is crucial. This should incorporate symptoms and signs: \200 Arising locally from the kidneys and urinary tract. \200 Resulting from impaired salt and water handling. \200 Caused by failing renal excretory and metabolic function. \200 Relating to a systemic disease, causing or contributing to renal dysfunction. Several additional factors need to be considered: \200 Asymptomatic patients often requir e assessment, following the discovery of an abnormal BP, urinalysis, or eGFR. Symptoms, signs, and investigation \201 ndings are organized into clinically useful syndromes (see Box 1.1). Biochemistry, radiology, and/or histopathology are almost always required for accurate diagnosis (although a thorough clinical assessment will lessen over-r eliance on expensive and potentially invasive tests). Diagnosis is often suggested by treatment, e.g. cessation of a nephrotoxic drug or restoration of adequate circulatory volume. See Table 1.1 for renal disease associations. Box 1.1 Renal clinical syndromes \200 Asymptomatic urinary abnormalities: Proteinuria ( b p. 58). \200 Microscopic haematuria ( b p. 66). Macroscopic haematuria ( b p. 62). \200 Nephritic syndrome ( b p. 71): Rapidly progressive glomerulonephritis (RPGN). Pulmonary renal syndromes ( b p. 72). \200 Nephrotic syndrome ( b p. 554. PCR in mg/mmol. ) \200 Renal tubular syndromes ( b p. 76). \200 Hypertension ( b Chapter 6). \200 Acu te kidney injury (AKI) ( b Chapter 2). \200 Chronic kidney disease (CKD) ( b Chapter 3). Past medical history \200 Urinary tract problems as a child (e.g. infections, ncturnal en uresis). \200 Previously documented renal or urinary tract disease of any kind. Ask speci \201 cally about infections, stone disease, and, in \231\202 , prostatic disease. Hypertension. When diagnosed? Who is responsible for follow-up? Current and historical trea tment? Level of control? Self-monitoring with home BP monitor? Cardiovascular risk factors or disease (e.g. IHD, CVA, PVD, dyslipidaemia). \200 Other re levant systemic disease (e.g. diabetes mellitus, connective tissue disorder, gout, in \202 ammatory bowel disease, sarcoidosis). \200 Insurance or employment medicals can provide invaluable historical benchmarks. Can they recall a past BP check or providing a urine spec imen? Have they had blood tests in the past? CLINICAL HISTORY: INTRODUCTION 3 Table 1.1 Important renal disease associations Medical condition Renal association General Hypertension Hypertensive nephrosclerosis, s i BP is associated with many renal disorders Diabetic nephr opathy CKD, renovascular disease, atheroembolism Diabetes mellitus Cardiovascular disease Liver disease Cirrhosis Hepatitis B and C In \202 ammatory SLE and other connective tissue disorders Sarcoidosis Raynaud \200\231 s Pleurop ericardial disease Haemoptysis Infection Gastroenteritis TB HIV Recurrent UTIs Streptococca l infection Endocarditis Chronic infection Dermatological Cutaneous vasculitis Livedo retic ularis Hepatorenal syndrome Membranous GN, mesangiocapillary GN (MCGN) Lupus nephritis, MCGN, and others Interstitial disease Scleroderma, SLE, cryoglobulinaemia Connective tissue disorders Vascul itis, lupus nephritis, anti-GBM disease Pre-renal AKI, haemolytic uraemic syndrome Urinary tract TB, amyloidosis HIVAN, HIVICK and others Vesicoureteric re \202 ux and chronic pyelonephritis Post-infective GN Post-infecti ve GN Amyloidosis Vasculitis, HSP, IgA nephropathy Antiphospholipid antibody syndrome Cryoglobulinaemia