CHAPTER 14 Appendices 936 Insertion of temporary haemodialysis catheters Indications Temporary haemodialysis catheter s should be temporary \200\224ideally no line should remain in situ for longer than a few days. The risk of infection increases signi \201 cantly if in place for longer \200\224con sider switching to a tun- nelled line if continuing access is required ( b p. 296). Routes of insertion \200 The right internal jugular vein is the preferred route. It is super \201 cial, technically easy to cannulate (in a \200\230virgin \200\231 neck), and joins the SVC in a straight line. The left internal jugular is an alternative, but the guidewire and line have to curve in order to reach the SVC. The risk of malposition and malfunction (and perforati on of the vein) is 6 greater. The femoral veins are suitable for short-term use and may be the safest and quickest option in an emergency (see b p. 180). \200 The subclavian route shou ld be avoided: there is a higher risk of subsequent central venous stenoses, potentially re ndering the ipsilateral arm unsuitable for permanent access in the form of an AVF. Pre-insertion \200 Is the line really needed? Check that dialysis is required and whether the patient is suitable for a tunneled line ( b p. 296) or a PD catheter insertion. Check FBC and clotting. \200 The operator should obtain consent from the patient (verbal and/or a family member if too unwell). Warn about potential complications: \200 Failure t o cannulate vein. \200 Haematoma 9 arterial puncture. \200 Pneumothorax, haemothorax (a nd potential need for a chest drain). \200 Air embolus. \200 Catheter malfunction. \200 Infection and its complications. Equipment: every renal unit should have a dedicated room for line insertion. It should be a sterile environment, containing a 2D ultrasound probe to fac ilitate vein cannulation. You will need: \200 An assistant. \200 Sterile gown, gloves, drapes, and towels. Iodine or chlorhexidine to clean the skin. An ultrasound device to guide line insertion. \200 Dressing pack, with a supply of syring es, swabs, and needles. \200 Sterile saline for injection. \200 Lidocaine (1 or 2%): 10 mL. \200 Line pack (if pre-packed, will contain introducer needle, guidewire, and the lin e itself). Choose a shorter line (e.g. 15cm) for the RIJ route, longer line (e.g. 20cm) for the left side or the larger patient. Tri-sodium citrate lock (Citralock ) (46.7%) or Duralock have largely replaced heparin (5,000 units/mL) to \200\230lock \200\231 the line once it is in situ . INSERTION OF TEMPORARY HAEMODIALYSIS CATHETERS 937 Wash and dry hands, as for a surgical procedure; wear sterile gown, mask, and sterile gloves. Position the patient slightly head down (for right-sided insertion). \200 Clean a wide ar ea of skin around the insertion site. Lay out sterile drapes on all sides. Prime both lumens of the line with sterile normal saline solution. Tips for problematic line insertions \200 Stop insertion if the patient is in pain . Seek senior assistance. Pain probably indicates that the guidewire or line is in the wrong location. Venous blood looks darker than arterial blood and does not \201 ll a syringe with its own pressure: if in doubt, put a 5mL syringe on either hub, and see if it \201 lls in a pulsatile fashion. If still in doubt, perform an ABG. 1 Do not take the lin e out yet (see later in this list). Inadvertent arterial puncture with an 18-gauge needle can usually be controlled by pressure for 5 \200\22315min. If the larger introducer needle punctures the artery, it is often saf est to abandon the procedure. Do not attempt the other side of the neck after signi \201 c ant arterial puncture and haematoma (risk of airway obstruction, if bilateral). \200 1 If an artery is accidentally cannulated (i.e. the line is inserted), or if the vein is traver sed such that the line tip is found to lie outside the vein, then leave the line in situ an d seek expert help . \200 Check FBC, clotting, and cross-match blood. \200 Con \201 rm your concern by aspirating blood (if possible) for ABG from both lumens. If unable to aspirate, you are in the wrong place. \200 Perform a C XR. \200 If there is a rapid deterioration in the patient s condition, a haemothorax or pneumothorax is likely, and an urgent chest drain may be required prior to C XR. Monitor closely: pulse BP, and O 2 saturation. \200 Find out where the line is: either a CT or a contrast examination through the line to determine its location. The line must be removed under controlled conditions, with vascular/thoracic surgical input. Insertion technique \200 Establish anatomical landmarks and the planned point of cannulat ion (see Figs 14.1 to 14.3). Ultrasound-guided insertion is now the technique of choice. \200 Insert local anesthetic under the skin. Always attempt to aspirate before injecting lidocaine to avoid inadvertent IV injection. Once the needle is in the vein, use a Seldinger technique. Pass the guidewire through the n eedle ( there should be no resistance \200\224if resistance is felt, do not force it, but remove the guidewire, and check the needle position. Do not advance the guidewire beyond th e line length, i.e. 15/20cm, to avoid arrhythmias. Remove the needle, leaving the guidewire in situ . CHAPTER 14 Appendices 938 Use a scalpel blade to make a small nick in the skin. Pass the dilator over the guidewire u ntil it is in the vein. Remove the dilator, keeping the guidewire in position. Without dela y, pass the line over the guidewire until it is in position. Remove the guidewire. Vein localization Ultrasound-guided cannulation Most probes have a sterile disposable cover . Follow the manufac turer \200\231s instructions. After in \201 ltration of local anesthe tic, identify the vein with the probe. The introducer needle can be inserted with real-time guidance. Blind insertion (no longer recommended) The approach can be medial to SCM muscle, between t he two heads, or lateral to the muscle. Local practice and expertise will dictate the optim al route. \200 Palpate the carotid artery with one hand (the left for a right-sided insertion). Insert the needle just lateral to the carotid pulse, aiming at 45 * to the skin, in the direction of the ipsilateral nipple. Aspirate gently on the syringe, as yo u go, until the vein is reached. If unsuccessful, withdraw the needle slowly (continuing with attempted aspiration \200\224you may have traversed the vein). Reinsert, varying the angle of insertion slightly to the medial side. If still unsuccessful, invite a colleague or seni or to have a go before you (and the patient) lose con \201 dence. Once the vein is identi \201 ed with a green needle, pass the introducer needle down the s ame track, in the same manner, into the vein, palpating the carotid pulse at the same time. Check the \202 ows in both lumens. A 20mL syringe should \201 ll easily with minimal as piration (general rule of thumb: 20mL should aspirate in <5s (= 240mL/min). Flush both lume ns with saline (which should also be easy), and then lock with Citralock , Duralock , or heparin. The priming volume should be written on the line (typically 1.3 \200\2232.0mL/ lumen). Put caps on the lumens, and suture the line in position. Arrange a CXR and review it yourself: look for line position (tip should be in SVC), and do uble-check there is no pneumothorax. INSERTION OF TEMPORARY HAEMODIALYSIS CATHETERS 939 Sternal head Sternal head Clavicular head Sternocleidomastoid muscle External jugular vein Fig. 14.1 Anatomical landmarks for internal jugular vein cannulation. Surface anatomy of ex ternal and internal jugular veins. Reproduced with permission from Ramrakha, P, and Hill, J , Oxford Handbook of Acute Medicine 2e (2004), with permission from Oxford University Press . Fig. 14.2 Anatomical landmarks for internal jugular vein cannulation. Anterior approach: th e chin is in the midline and the skin puncture is over the sternal head of the sternocleido mastoid muscle. Reproduced with permission from Ramrakha, P, and Hill, J, Oxford Handbook o f Acute Medicine 2e (2004), with permission from Oxford University Press. Fig. 14.3 Anatomical landmarks for internal jugular vein cannulation. Central approach: the chin is turned away and the skin puncture is between the two heads of sternocleidomastoid. Reproduced with permission from Ramrakha, P, and Hill, J, Oxford Handbook of Acute Medicin e 2e (2004), with permission from Oxford University Press. CHAPTER 14 Appendices 940 Femoral line insertion Advantages over neck line \200 Super \201 cial vein, usually rela tively easy to cannulate. \200 Relatively safe (haematoma can be controlled by pressure, no risk of airway obstruction or pneumothorax). No CXR required post-procedure (saves time in an emergency). Disadvantages over neck line \200 Femoral line function can be highly positional, particu larly in obese patients. Patients are also relatively immobilized. 1 High risk of infection \200\224lines should only be left in for 2 \200\2233 days max. In sertion technique \200 The technique is identical as that for neck line insertion. Ultras ound guidance should be used. Position the patient horizontally or with feet slightly down. The hips should be partially abducted. Do not shave insertion site; if necessary, hair should be rem oved by clipping. Wear gown and gloves, prepare the skin, and use sterile drapes. \200 For the right femora l vein, the \201 ngers of the left hand should be used to palpate the femoral pulse. Take care to remain below the inguinal ligament so that a haematoma can be controlled with pres sure. The vein runs just medial to this. In \201 ltrate local anesthetic, and try to ident ify the vein with a green needle. Use the track of the 18-gauge needle to insert the introd ucer needle into the vein. Angle the introducer needle towards the head to facilitate the p assing of the guidewire. The remainder of the procedure is as for the internal jugular line. Tunneled dialysis catheters \200 The dual lumen line is inserted into the internal jugula r vein (usually), with a subcutaneous tunnel that acts as a barrier to infection. Tunneled catheters may be used as semi-permanent access whilst awaiting maturation of an AV \201 stula, or as permanent access for the patient unsuitabl e for an AVF or PTFE graft. Long-term complications include poor \202 ows (and thus inadequate dialysis), infection, and venous stenosis. A trained operator should insert tunneled lines; ideally, under X-ray screening to ensure the tip of the line lies in the SVC. The complications of insertion are similar to the insertion of any central line. INSERTION OF TEMPORARY HAEMODIALYSIS CATHETERS 941 CHAPTER 14 Appendices 942 Preparing renal patients for theater Any patient with renal failure is a high-risk patient for surgery. Extreme care should be taken when preparing for theater. Pre-admission \200 Full history. Focus on cardiac and respiratory history, dialysis regim en (if appropriate), and details about previous anesthesia. Full drug history. \200 Can t he procedure be done under local or regional anesthesia (this may be the case for an AV \201 stula)? Examination. Listen for murmurs and bruits (carotids); examine peripheral pulses; check lung \201 elds are clear; assess volume status; measure BP, incl uding postural BP (and check BP charts, if available). The anesthetist will prefer a BP of <150/95mmHg. Investigations. FBC (? anemia which could be corrected pre-op, if possible), SCr, U&E ( i K + ), LFT, Ca 2+ , ECG (any patient with advanced CKD), CXR if bre athless or abnormal cardiorespiratory examination. Echocardiogram if any new murmur or sugg estion of poor LV function. Liaise with anesthetist if any doubt about \201 tness for anesthesia or if further investigations are necessary. Liaise with the patient s dialysis unit, if relevant. Plan dialysis around the surgery (oft en the day before and the day after the procedure). On admission \200 Repeat full physical examination, including BP and assessment of volume status. If for creation of vascular access, avoid phlebotomy and cannulas in the limb targeted for surgery. Send bloods pre-op and after last dialysis session. U&E, FBC, clotting, G&S (and cross-match, according to nature of surgery). The anesthetist will prefe r a K + <5.5mmol/L. Write up drugs to be given pre-op or at induction (e.g. antibiotics). Post-operative care \200 Avoid nephrotoxic drugs (e.g. NSAIDs, gentamicin), even in dialy sis patients if they still pass urine . Ensure adequate analgesia is given, but be aware of risks of opioid toxicity ( b pp. 271 and 897). Check volume status and BP. If IV \202 uids are required, prescribe 0.5 \200\2231L, and then reassess the patient. 3 Measure SCr and U&E post-op in any patient with signi \201 cant renal impairment (depola rizing anesthetic agents lead to muscle K + release and may precipitate dangerous i K + ). If an AVF or PTFE graft have been formed, check for a thrill over the \201 stula, and avo id any compression ( 1 BP) or blood tests in that limb. \200 Consider d or no heparin ant icoagulation during next HD treatment (discuss with the surgeon). PREPARING RENAL PATIENTS FOR theater 943 Bowel preparation See Tables 14.1 and 14.2. A UK consensus guideline is available at M http ://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/ obca_12.pdf Table 14.1 Types of bowel preparation Group Brand Caution Picolax CitraFleet In all patients, there is a risk of hyponatraemia with excess water ingestion. In patients with CKD, there is a risk of hypermagnesaemia. Sodium picosulfate with magnesium citrate Klean-Prep Moviprep Polyethylene glycol (PEG) Fleet Acute phosphate nephropathy; should not be used for patients with eGFR <60mL/min. Oral sodium phosphate (OSP) Citramag Magnesium carbonate with citric acid In all patients, there is a risk of hyponatraemia with excess water ingestion. In patients with CKD, there is a risk of hypermagnesaemia. CHAPTER 14 Appendices 944 Table 14.2 Bowel preparation preference, according to renal modality Stage/modality Optimal Acceptable Avoid Notes Klean-Prep Moviprep Picolax CitraFleet Citramag Fleet CKD 3 Klean-Prep Moviprep Picolax CitraFleet Citramag Fleet Klean-Prep is made up into 4L. Moviprep is made up into 3L. Choose according to \202 uid status. CKD 4 Klean-Prep Moviprep Fleet Picolax CitraFleet Citramag Klean-Prep is made up into 4L. Moviprep is made up into 3L. Choose according to \202 uid status. CKD 5 Picolax CitraFleet Haemodialysis Despite contraindication in CKD 4/5 pre-dialysis, these agents can be used safely once on d ialysis. Picolax CitraFleet Fleet Peritoneal dialysis Caution to avoid hypovolaemia, as may be detrimental to CAPD patients who often rely on res idual urine output. Fleet Renal transplant According to eGFR According to eGFR Avoid OSP, regardless of eGFR. PREPARING RENAL PATIENTS FOR theater 945 CHAPTER 14 Appendices 946 Acute coronary syndrome (ACS) in CKD Introduction ACS is classically divided into ST elevat ion MI (STEMI), non-ST elevation MI (NSTEMI), and unstable angina, depending on the combina tion of car- diac chest pains, ECG \201 ndings, and cardiac enzyme elevations. The underlying pathology is atherosclerosis, unstable plaque, and in situ thrombosis format ion. The CKD population has a high burden of tradi- tional risk factors (e.g. i BP, DM, i l ipids, smoking, advanced age). In addition, the pathology may differ in advanced CKD with d iffuse, calci \201 c coronary arteries and microvascular disease. Vessels may be stiff and una- ble to compensate for changes in haemodynamics (e.g. d BP, tachycardia), leaving the myocardium more vulnerable to ischaemic injury (even in the absence of thrombosis). 2 CKD p redicts mortality in ACS (and vise versa), but the secure diag- nosis of ACS, especially in CKD 5, can be challenging due to a number of factors. \200 Atypical presentation \200 \224atypical chest pain, \200\230silent MI \200\231, and hypotension/ collapse are more common. Atypical ECG \200\224 typical ischaemic changes, including ST elevation, are less likely. LVH (and strain) may complicate interpretation. New regional wall motion a bnormalities on echo may be required to con \201 rm diagnosis. Interpretation of cardiac enzymes (see Box 14.2). Joint management between a nephrologist and a cardiologist, experienced with renal patients , is ideal. Management Broadly speaking, the treatment of suspected ACS is the same, but it is importan t to remember that patients with advanced CKD are often excluded from large cardiology tria ls and have an inherently increased bleeding risk (uraemic platelet dysfunction), and that the underlying pathology may be fundamentally different. \200 Give O 2 to maintain normal saturations. \200 Treat pain with opiate analgesia. If repeated dosing is required, consider fentanyl or oxycodone to reduce accumulation ( b p. 271). Nitrates (sublingual or IV), titrated to pain and BP. \200 Aspirin and clopidogrel are ad ministered at standard doses. Glycoprotein IIa/IIIb inhibitors require dose reduction. One meta-analysis suggests that clopidogrel and glycoprotein IIa/IIIb inhibitors may increase b leeding risk without improving mortality in CKD, 1 but the current consensus is to administ er them for standard indications. ACUTE CORONARY SYNDROME (ACS) IN CKD 947 LMWHs are renally excreted. 50% dose reduction is required if GFR <30mL/min (e.g. enoxaparin 1mg/kg od) or use unfractionated heparin instead ( b p. 892). Beta-blockers (may require dose reduction \200\224 b p. 892) should be titrated to pulse and BP. ACE-I/ARBs should be carefully introduced once haemodynamically stable and no further angiography/surgery is planned. Statins ( b p. 893) have not been prospectively evaluated post-ACS in CKD. Standard practice is to prescribe them. Anemia is a predictor of poor outcome in ACS. There is no strong evidence that transfusing patients improves outcomes, and the potential bene \201 ts need to be weighed against the risks of volume loading and hyperkalaemia (dialysis may be requir ed). However, it is standard practice to target an Hb 10 \200\22311g/dL. ACS commonly causes a deterioration in SCr in CKD. Temporary RRT may be required. Both acut e and chronic HD patients may be better on CVVHF or SLED initially ( b p. 174). STEMI: the standard of care is emergency PCI (see Box 14.1). If unavailable, thrombolysis c an be performed. Common renal contraindications include recent renal biopsy, recent line in sertion (esp. if arterial puncture occurred), uncontrolled BP >200/100mmHg, uraemic pericar ditis. Box 14.1 Angiography and PCI Commonly performed. Standard contrast nephropathy precautions apply, including for dialysis patients with residual function ( b p. 148). It is vital to monitor renal function for 72 hours post-procedure. Dialysis dependence may be precipitated. Calci \201 c disease is less amenable to stenting, and rates of restenosis are higher. Thi s may be reduced by drug-eluting stents, but prolonged dual antiplatelet therapy is require d, which may complicate subsequent access procedures or transplant listing. Reference 1. Palmer SC, Di Micco L, Razavian M, et al. (2012). Effects of antiplatelet ther apy on mortality and cardiovascular and bleeding outcomes in persons with chronic kidney di sease: a systematic review and meta-analysis. Annals of Internal Medicine , 156 , 445 \200 \22359. CHAPTER 14 Appendices 948 Box 14.2 Cardiac biomarkers in CKD Troponin Cardiac troponin T (cTnT) and I (cTnI) are prot eins present in car- diac myocytes that may be detectable in serum when released following myocardial injury. Elevated serum troponin (esp. cTnT) is commonly found, even in asymptomatic patients, and d oes not necessarily indicate acute ischaemia. Contributing factors include LVH, the uraemic milieu itself, endothelial dysfunction, and reduced renal excretion. cTnI is more speci \201 c for ischaemia. Elevated troponins are not an inevitable conse- quence of renal impai rment and are a poor prognostic marker, even in the absence of ACS. If ACS is suspected, it is best to measure serum troponin as soon as possible and again 12 hours post-event, as dynamic changes are generally more helpful than absolute values. Creatine kinase (CK) CK is frequently elevated in advanced CKD. Causes include myopathy, vi tamin D or carnitine de \201 ciency, and reduced renal clearance. Neither total CK, nor th e more speci \201 c CK-MB, are reliable for the diagnosis of ACS. Brain natriuretic peptide (BNP) BNP is released from the cardiac ventricles in response to volume load- ing and promotes salt and water excretion. BNP and its physiologically inert b y-product NT-proBNP have been used in the diagnosis, progno- sis, and monitoring of heart f ailure. BNP and NT-proBNP are commonly elevated in renal failure for a number of reasons, e.g. salt and water handling is impaired, leading to volume overload and ventricular stretch, chroni c i BP and LVH, reduced renal excretion (esp. of NT-proBNP). As such, their utility in CKD is very limited. ACUTE CORONARY SYNDROME (ACS) IN CKD 949 CHAPTER 14 Appendices 950 Plasma exchange Introduction A technique in which plasma is separated from the rest of the blood so that it can be removed and replaced. There are two main methods (see Fig. 14.4): \200 Centrifugation: removing plasma by centrifuging the blood. \200 Filtration: uses hi ghly permeable membranes through which blood is pumped at 7 100 \200\223150mL/min. Plasma r eadily passes through the membrane pores (MW cut-off 7 2,000kDa), but cells do not. In gene ral, all immunoglobulins will pass through the membrane. A third technique involves two pumps and membranes and selectively removes large molecules, including antibodies ( \200\230double \201 ltration \200\231). This may be used when the re is no doubt about the molecule that needs removing, such as anti-HLA antibodies in trans plantation. However, in other diseases, such as ANCA-associated vasculitis, this is not so clear, and one of the non-selective methods is recommended. Anticoagulation of the extracorporeal circuit with heparin (e.g. 30 \200\22360IU/ kg loadin g dose, followed by 1,000IU/h) or citrate ( b p. 186) is required. Indications \200 Diseases in which plasma exchange is used include: Anti-GBM disease. \200 ANCA-associated vasculitis. \200 HUS/TTP. \200 Cryoglobulinaem ia. \200 Hyperviscosity syndrome. \200 Recurrent FSGS post-transplant. \200 Treatment of highly sensitized transplant recipients. \200 Treatment of antibody-mediated transpla nt rejection. \200 Non-renal conditions, including Guillain \200\223Barr syndrome and myasthaenic crises. Replacement \202 uid and coagulation monitoring Approximately 60mL/kg, up to a maximum of 4L, of plasma is usually removed during an exchange. The major replacement \202 uid in m ost cases is 5% human albumin solution. A single exchange will lower plasma mac- romolecule s by 7 60% ( 7 90% after \201 ve exchanges). In some conditions, such as HUS/TTP, the rep lacement \202 uid is fresh frozen plasma (FFP) or Octaplas , as this provides part of the therapeutic effect. 1 If albumin is the major replacement \202 uid, then 1 \200\2232L FFP or Octaplas may be needed at the end of the exchange if there has been a recent bio psy or pulmonary hemorrhage. In all cases, coagulation should be monitored (clotting factors are removed) and FFP or Oct aplas given, as indicated. Cryoprecipitate or \201 brinogen should be administered if \201 brinogen levels are low. Liaise with your hematology team. PLASMA EXCHANGE 951 Potential complications \200 Hypotension (usually related to volume depletion). \200 Hy pocalcaemia: related to the use of citrate as an anticoagulant (and FFP contains citrate). Can be prevented or treated by calcium administration during th e exchange, e.g. 2 \200\2234mL 10% calcium gluconate added to 500mL 5% human albumin. Clotting abnormalities and bleeding (see \200\230Replacement \202 uid and coagulation monitoring \200\231). Complications of central venous catheter insertion and use: pneumothorax, haemothorax, infe ction ( b p. 936). Anaphylactic reactions to FFP ( 7 2%), infection from plasma products. \200 Alkalosis fro m the metabolism of citrate. \200 Dilutional d K + . Immunoadsorption A technique that selectively removes immunoglobulin. This may be useful in particular circumstances, e.g. removal of anti-HLA antibody pre-transplantation. Replaceme nt \202 uids are not required, and there is no depletion of clotting factors. Uses protei n A columns that bind IgG (mostly) via the Fc domain. Plasma is \201 rst \201 ltered, p rior to being run through columns containing immunosorbent-coated beads. Antihuman IgG anti body-coated columns are highly speci \201 c for human Ig but are very expensive. Protein A columns can be reused. CHAPTER 14 Appendices 952 (a) Membrane plasma filtration Arterial To patient Plasma collection Colloid replacement (b) Centrifugal cell separation Colloid replacement From patient To patient Spinning bowl Plasma collection Fig. 14.4 Techniques of plasmapheresis. (a) Membrane plasma \201 ltration: blood \202 o w 100 \200\223150mL/min. Highly permeable membrane (MW cut-off 2,000kDa) \200\224most Igs a re removed, but some larger immune complexes and cryoglobulins may not be well cleared. Cel ls, along with \202 uid replacement, are returned to the patient. (b) Centrifugation: pla sma is removed by centrifugation, using a spinning bowl. Blood is (synchronously or intermi ttently) returned to the patient, along with replacement \202 uid. No upper limit to the size of protein which can be removed. Can be performed via an antecubital vein. Reproduced with permission from Levy J, Morgan J, Brown E (2004) Oxford Handbook of Dialysis , 2nd edn . Oxford: Oxford University Press. PLASMA EXCHANGE 953 CHAPTER 14 Appendices 954 Useful resources The number of organizations, educational resources, patient groups, and bl ogs in the \201 eld of nephrology is increasing exponentially. A selection of high-qualit y resources and respective websites is provided here. The Renal Association (RA) This is the professional body for UK renal physicians and scient ists. It pro- motes research, disease prevention, and welfare. It sets standards for all as pects of renal care against which data are collected and analyzed by the renal registry. M http://www.renal.org/Clinical/GuidelinesSection/Guidelines.aspx The Renal Registry The UK Renal Registry was established by the Renal Association as a reso urce for the development of patient care in renal disease. UK units submit data on disease categories and against audit standards applicable to dialysis and transplantation. It produ ces annual reports and enables com- parisons between units. Its website provides a huge qua ntity of informa- tion and now has the facility for visitors to generate customized data. M http://www.renalreg.com/index.html M http://www.renalreg.com/n_portal/pages/main/registryportal.php The British Renal Society (BRS) This is a multidisciplinary society, with members across al l professions, providing care to renal patients. Its aims are the promotion and delivery of effective, patient-centered care. Its website contains educational resources for both prof essionals and patients. M http://www.britishrenal.org/Home.aspx The British Transplant Society This is the professional body for UK transplant physicians, surgeons, and scientists. It promotes clinical standards, research, and access to transplan tation. M http://www.bts.org NHS blood and transplant organ donation (formerly UK transplant) Provides a 24-hour service for the matching and allocation of donated organs throughout the UK. It also maintains the NHS organ donor reg- ister. The website includes detailed information on the matching sche me and points allocation, success rates, waiting times, and FAQs for patients. M http://www.organdonation.nhs.uk/ USEFUL RESOURCES 955 The kidney patient guide This website is a collaboration of healthcare professions, IT expe rts, and renal patients and their carers. It provides a broad range of information, encompa ssing the physical, social, \201 nancial, and emotional aspects of kid- ney disease, and is aimed at patients and those close to them. It also has an interactive forum. M http://www.kidneypatientguide.org.uk/contents.php The American Association of Kidney Patients \200\230The independent voice of kidney patien ts since 1969 \200\231, whose aims are to provide education, advocacy, and community to kid ney patients and their carers. They have wide range of educational resources, divided into transplantation, CKD, and dialysis. M http://www.aakp.org/ British Kidney Patient Association This charity aims to improve the lives of kidney patient s through informa- tion, advice, and active \201 nancial support. They give grants to ind ividual patients as well as to renal units to improve their services. M http://www.britishkidney-pa.co.uk National Institute for Health and Care Excellence (NICE) NICE produces evidence-based guida nce to help to resolve uncertainty about which medicines, treatments, procedures, and devic es represent the best quality care and offer the best value for money for the NHS. Guidelin es relevant to nephrology include those for CKD and hyperten- sion management. M http://www .nice.org.uk/ The International Society of Nephrology (ISN) The ISN is dedicated to advancing the diagnos is, treatment, and preven- tion of kidney diseases in the developing and developed world. A s well as supporting research and producing the journal Kidney International, it coordinate s global charitable work in nephrology, including the Renal Disaster Relief Task Force. M h ttp://www.theisn.org National Kidney Foundation (NKF) and KDOQI This large, American voluntary organization is d edicated to preventing kidney and urinary tract diseases, improving the health and well-bei ng of individuals and families affected by kidney disease, and increasing the avail- abilit y of all organs for transplantation. A major focus is producing clinical guidelines for the management of kidney patients. It has been produc- ing them via KDOQI \200\224Kidney Disea se Outcomes Quality Initiative, since 1997. It produces the American Journal of Kidney Dise ases. M http://www.kidney.org/index.cfm M http://www.kidney.org/professionals/KDOQI/guideli nes_commentaries. cfm CHAPTER 14 Appendices 956 Kidney Disease: Improving Global Outcomes (KDIGO) Initially developed by the NKF, this is a multinational committee to develop international evidence-based guidelines for the managem ent of renal disease. These guidelines are becoming the international benchmark in many ren al diseases. M http://www.kdigo.org The American Society of Nephrology (ASN) The ASN aims to educate health professionals, shar e new knowledge, advance research, and advocate the highest quality care for kidney patient s. The ASN kidney week is the largest annual nephrology conference in the world. It produce s the Journal of the American Society of Nephrology (JASN) and the Clinical Journal of the American Society of Nephrology (CJASN). M http://www.asn-online.org/ Peritoneal dialysis academy Sponsored by Baxter, this free educational resource was authore d by two internationally recognized experts in PD. Its online modules cover all aspects of PD, and a certi \201 cate is awarded for completion of all sections. M http://www.pdacademy.org.uk/ Reference 1. Palmer SC, Di Micco L, Razavian M , et al. (2012). Effects of antiplatelet the rapy on mortality and cardiovascular and bleeding outcomes in persons with chronic kidney d isease: a systematic review and meta-analysis. Annals of Internal Medicine , 156 , 445 \200 \22359. 957 Index imaging 120 urinalysis 116 \200\223 17 complications 129 contrast-induced 148 \200\223 51 , 618 de \201 nition 88 \200\223 9 , 90 rhabdomyolysis 152 \200\223 3 , A AA amyloidosis 630 \200\223 1 AASK trial 494 \200\223 5 abdominal compartment syndrome 162 \200\223 3 ABO incompatibility in 154 \200\223 5 sepsis 166 \200\223 7 , 168 \200\223 70 tubular necrosis see acute tubular necrosis tumor lysis syndrome AKIN classi \201 cation 88 KDIGO AKI 88 , 89 RIFLE criteria 88 160 \200\223 1 transplantation 444 \200\223 5 acute tubular injury see acarbose 894 ACE inhibitors 486 , 508 \200\223 9 , acute tubular necrosis acute tubular necrosis 106 \200\223 7 infective endocarditis 694 pa thophysiology 108 \200\223 9 developing world 164 \200\223 5 drug-induced 7, 898 523 , 893 CKD 203 diabetic nephropathy 614 gadolinium 51 metformin 52 epidemiology 92 \200\223 3 haemoglobinuric 155 intrinsic renal 105 ADAMTS13 576 ADPKD see autosomal dominant polycystic kidney disease acebutolol 503 N -acetyl- -D- glucosaminidase 95 N-acetylcysteine 145 , 150 aciclovir 889 adrenal function, CKD 262 adrenal hyperplasia, congenital 478 clinical assessment 114 \200\223 15 management 147 anemia 138 bleeding 138 checklist 122 \200\223 3 electroly tes and acidosis nephrotoxicity 898 acid-base balance 814 \200\223 16 adynamic bone disease 234 , buffering 814 , 818 excretion 818 \200\223 19 mixed disturbances 235 , 240 management 249 AKI see acute kidney injury AL amyloid 628 \200\223 9 alcohol, and hypertension 834 \200\223 5 136 \200\223 7 models of 815 , 816 nomogram 835 see also acidosis; alkalosis hyperkalaemia 130 \200\223 3 infection 139 myths 144 \200\223 5 nutrition 140 \200\223 1 , 142 \200\223 3 pulmonary oedema 472 \200\223 3 aldosterone 457 , 931 aldosterone antagonists, and acidosis CKD 205 , 215 lactic 828 \200\223 9 metabolic 137 \200\223 40 , 834 renal tubular 76 \200\223 8 , 826 respiratory 822 , 834 hyperkalaemia 797 alemtuzumab 383 \200\223 4 alkalosis 830 \200\223 2 134 \200\223 5 volume replacement 124 \200\223 5 , 126 \200\223 9 chloride-losing 830 hypokalaemic 830 metabolic 830 , 834 respiratory 831 , 834 allergic per itonitis 321 ALLHAT study 494 \200\223 5 , 505 allopurinol 895 allorecognition 346 \200 \223 7 , 348 -blockers 486 , 504 \200\223 5 , mortality 93 organ cross-talk 109 perioperative risk reduction 99 acromegaly 475 acute coronary syndrome 946 \200\223 8 acute fatty liver of pregnancy 845 phases of 146 pre-renal 102 \200\223 3 causes 104 clinical assessment 114 acute interstitial nephritis 694 acute kidney disease 523 , 892 pregnancy 844 \200\223 5 prevention 98 \200\223 101 , 154 STOP AKI checklist (AKD) 90 acute kidney injury (AKI) 87 \200\223 92 benign prostatic hyperplasia 761 bladder out \202 ow 100 \200\223 1 priorities 112 \200\223 13 prognosis 92 \200\223 3 recognition of 110 \200\223 1 renal biopsy 82 renal replacement therapy abdominal compartment syndrome 162 \200\223 3 symptoms 505 Alport syndrome 420 , biomarkers 94 \200\223 5 causes 96 \200\223 7 , 97 , 164 \200\223 5 568 , 570 kidney transplant 569 infective 164 \200\223 5 non-infective 165 aluminum toxicity 247 , 308 aluminum-based phosphate 172 \200\223 4 in cirrhosis see hepatore- binders 248 anticoagulation 182 \200\223 4 , nal syndrome classi \201 cation 96 \200\223 7 clinical assessment 114 \200\223 15 ambulatory blood pressure monitoring 458 \200\223 9 , 460 186 \200\223 7 modalities 174 \200\223 5 , 176 \200\223 7 peritoneal dialysis amikacin 395 dose 885 blood tests 118 \200\223 19 histology 121 188 \200\223 9 amiloride 792 , 931 prescription 178 \200\223 181 INDEX INDEX 958 dose 883 \200\223 9 peritonitis 322 \200\223 3 in pregnancy 843 prescribing 882 prophylac tic 395 see also individual drugs antiphospholipid antibodies anti-streptolysin O titres 119 amino acid reabsorption 925 anti-thymocyte globulin aminoaciduria 76 , 77 aminoglycosides 880 amiodarone 893 ammonium 819 amoxicillin 883 ampho tericin B 395 383 , 384 anti-tumor necrosis factor agents 668 antibiotics see antimicrobials antibodies 119 , 665 antiphospholipid syndrome ANCA 119 anti-glomerular basement dose 891 664 \200\223 5 amyloid/amyloidosis see antiplatelet drugs 357 pre-transplantation membrane 119 anti-HLA 361 \200\223 2 , 363 anti-nuclear 119 antiphospholipid 119 depleting 383 \200\223 5 donor-speci \201 c 361 non-depleting 382 non-HLA 362 panel reactive 362 renal amyloid anemia management 394 AKI 138 CKD 205 , 216 \200\223 17 differential diagnosis 217 prevalence 216 antipsychotics 896 antivirals 885 nephrotoxicity 898 anuria 74 aortic coarctation 475 , 483 apolipoprotein AI 632 Aranesp see analgesia live donors 379 patient-controlled 380 post-operative 395 \200\223 6 analgesic nephropathy 584 , antibody-mediated rejection 409 \200\223 10 darbepoetin A anticholinergic agents, benign prostatic hyperplasia 762 anticoagulants 357 584 \200\223 5 argatroban 291 arterial blood gasses 118 arterial stiffness 455 arteriovenous \201 stula 292 ASCOT study 494 \200\223 5 asparagus urine 15 aspirin 485 , 892 ANCA 119 , 642 and pathogenesis 643 ANCA-associated vasculitis pre-transplantation 640 \200\223 2 management 394 Birmingham vasculitis activ- ity score (BVAS) 641 anticoagulation renal replacement therapy in pregnancy 858 , 866 , 867 ASTRAL trial 172 asymptomatic bacteriuria investigations 642 \200\223 3 relapse 646 \200\223 7 , 648 renal biopsy 647 treatment 644 , 644 \200\223 5 182 \200\223 3 , 184 citrate regional 186 \200\223 7 haemodialysis 182 \200\223 3 anticonvulsants 854 , 897 an tidiuretic hormone see 706 , 710 angiography 947 angiotensin II 453 , 456 angiotensin II receptor pregnancy 843 atenolol 503 , 523 atherosclerotic renal artery vasopressin antiemetics 379 antifungals 879 \200\223 80 , 890 \200\223 1 blockers 486 , 510 \200\223 11 stenosis 586 CKD 203 diabetic nephropathy 614 nephrotoxicity 898 atrial natriuretic peptides antigens 22 antihypertensive therapy 145 , 931 angiotensin receptor autoregulation 920 autosomal dominant poly- blockers with neutral endopeptidase inhibition (ARNi) 513 anidulofungin 891 anion gap 820 a ntacids 896 antegrade 484 \200\223 6 , 489 ACE inhibitors 486 , 508 \200\223 9 , 523 -blockers 486 , 504 \200\223 5 , 523 cystic kidney disease 553 , 592 \200\223 593 complications 594 \200\223 5 , 596 CKD 594 cyst hemorrhage 594 cyst infection 594 extrarenal cysts 595 hypertension 594 intrac ranial angiotensin receptor blockers 486 , 510 \200\223 11 -blockers 486 , 502 \200\223 3 , 523 calcium channel bl ockers 486 , 506 \200\223 7 , 523 ureteropyelography 57 anti-glomerular basement membrane antibody 119 , 656 CKD 204 clinical trials 492 \200\223 3 , 494 \200\223 7 diuretics 498 \200\223 9 , 500 \200\223 1 , 523 guidelines 488 \200\223 9 mineralocorticoid antagonists 501 pre-transplan tation aneurysms 594 nephrolithiasis 594 anti-glomerular basement membrane disease see Goodpasture s syndrome management 595 pregnancy 857 Ravine criteria 593 autosomal recessive polycystic kidney dise ase 598 avosentan 617 azathioprine 380 , 390 , 866 nephritic syndrome 543 anti-HLA antibodies 361 \200\223 2 , 363 HLA antibody testing 363 screening for 362 tissue typing 360 \200\223 1 management 394 special situations 490 \200\223 1 see also individual drugs