Management of Kidney Diseases

Foreword
Preface
Contents
1: The Approach to the Patient with Kidney Disease
Introduction
Common Kidney Patient Presentations
Common Kidney Syndromes and Definitions
Anatomical Localisation of Kidney Diseases
Aetiology of Kidney Syndromes
Approach to a Patient with Kidney Disease
Radiological Abnormalities
Haematuria
Presentation of Kidney Failure Patients on Kidney Replacement Therapy
Conclusions
Questions
References
2: Investigating Kidney Disease
Introduction
Blood Tests
Serum Biochemistry
Urea and Electrolytes
Urea and Creatinine
The Glomerular Filtration Rate (GFR)
Urine Tests
Appearance
Radiological Imaging
Plain Radiography
Chest X-Ray
Abdominal X-Ray
Intravascular Contrast Studies
Ultrasound
Renal Doppler Ultrasound Scans
What Is the Resistive Index (RI)?
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Nephrogenic Systemic Fibrosis
Nuclear Medicine Imaging: Renal Scintigraphy
Histopathology
Kidney Biopsy
Indications
Light and Electron Microscopy
Light Microscopy (LM)
Immunohistochemistry
Electron Microscopy
Tissue Examination and Interpretation of the Histopathological Report
Conclusions
Questions
References
3: Proteinuria and Haematuria
Proteinuria
Introduction
Pathophysiology
Glomerular Barrier
Tubular Reabsorption and Secretion
Definitions
Measurement of Protein Excretion
Urine Dipstick Test
Timed Urine Collections
Spot Urine Measurements (Albumin or Total Protein to Creatinine Ratio)
Clinical Associations
Microalbuminuria
Isolated, Asymptomatic Proteinuria
Glomerular Proteinuria
Tubular Proteinuria
Overflow Proteinuria
Management
Prognosis
Haematuria
Introduction
History
Investigation of Haematuria
Dipstick Testing of Urine [5]
Microscopic Examination of the Urinary Sediment
Imaging Investigations
Cystoscopy
Microscopic Haematuria
Macroscopic Haematuria
Causes of Haematuria
Glomerular Disease
Cancer
Schistosoma Haematobium Infection (Bilharzia): [18, 19]
Sickle Cell Disease and Trait
Conclusions
Questions
References
4: Acute Kidney Injury
Introduction
AKI, AKD, CKD and NKD
Epidemiology, Aetiology, and Risk Assessment
Clinical Presentation
Investigations
Differential Diagnosis
Management
General Management Principles
Sepsis
Hypovolaemia
Toxins
Obstruction
Parenchymal
Managing AKI Complications
Hyperkalaemia
Acidosis
Hypervolaemia
Symptomatic Uraemia
Kidney Replacement Therapy (KRT) in AKI
Indications
Modalities
Discontinuation of KRT
Palliative Care
AKI and KRT Worldwide
Outcomes and Follow-up for AKI Patients
Conclusions
Questions
References
5: Chronic Kidney Disease (CKD): Evaluation of the Cause and Prevention of Progression
Introduction
The Epidemiology of Chronic Kidney Disease
Pathophysiology of Chronic Kidney Disease
The Classification of Chronic Kidney Disease
Progression and Complications of Chronic Kidney Disease
Prevention of CKD
Conclusions
Questions
References
6: CKD: Management and Prognosis
Introduction
Epidemiology and Causes
Investigations
Management
Treatment of Reversible Causes of Kidney Failure
Slowing the Progression of Kidney Disease
Other Treatments
Treatment of CKD Complications
Drug Dosing and Adjustments in CKD
Identification and Adequate Preparation of the Patient in Whom Kidney Replacement Therapy Will Be Required
Conclusions
Questions
References
7: Management of Anaemia in Chronic Kidney Disease
Introduction
Definition of Anaemia in CKD
Prevalence
The Patient in the Clinical Scenario Has Diabetes, and Is Therefore more Likely to Have Anaemia
What Factors Might Contribute to Anaemia
Why Treat this Patient’s Anaemia of CKD?
Investigations for Iron Deficiency in CKD in our Patient
Prescribing Intravenous (IV) Iron
Potential Adverse Effects of Iron
Other Potential Risks of IV Iron
Infection Risk
Oxidative Stress
The Patient’s Symptoms Improved with IV Iron, But His Haemoglobin Remains Low; Should He Start an ESA?
Practical Administration of ESA
Despite Our Patient’s History, He Is on the Transplant List: Why Should One Aim to Avoid Transfusions?
Future Therapies
Conclusions
Questions
References
8: Blood Pressure in CKD
Introduction
Clinic Blood Pressure and the ‘White-Coat’ Effect
Treating to a Target Blood Pressure
Slowing the Progression of CKD
Effect on Cardiovascular and All-Cause Mortality
Potential Exceptions to a Lower Target
Management of Hypertension
Lifestyle and Blood Pressure
Dietary Salt Restriction
Barriers to a Healthy Diet
Exercise
Pharmacological Treatment of Hypertension in CKD
Non-Diabetics
Diabetics
Monitoring a Patient on an ACEi or ARB
Other Agents
Mineralocorticoid Receptor Antagonist
Calcium Channel Blockers, Beta-Blockers, Alpha Blockers and Diuretics
Blood Pressure Treatment in Dialysis Patients
Blood Pressure Management in Peritoneal Dialysis (PD) Patients
Blood Pressure Management in Transplant Patients
Conclusions
Questions
References
9: Mineral and Bone Disorder in CKD
Introduction
Epidemiology
Pathogenesis
Pathogenesis of Mineral Metabolism Abnormalities and Bone Diseases (Fig. 9.2)
Pathogenesis of Vascular Calcification (Fig. 9.4)
Clinical Presentation
Investigations
Management
Overview
Phosphate Restriction
Phosphate Binders
Native Vitamin D
Active Vitamin D
Calcimimetics
Parathyroidectomy
Magnesium
Calcium
Future Perspectives
Conclusions
Questions
References
10: Diabetes and CKD
Introduction
Epidemiology and Causes
Clinical Presentation
Investigations
Differential Diagnosis
Diabetes Management
Glycaemic Control
Antihyperglycaemic Therapy
Lifestyle Changes
First-Line Therapy
Augmenting Therapy
GLP-1 Receptor Antagonists
DPP-4 Inhibitors
Sulfonylureas
Thiazolidinediones
Meglitinides
Post-transplant Diabetes Mellitus
Management of Hypertension in DKD [for details see Chap. 8]
Type 1 Diabetes
Antihypertensive Medication in T1DM
Type 2 Diabetes Mellitus
Conclusions
Questions
References
11: Cardiovascular Complications of CKD
Introduction
Coronary Artery Disease
Clinical Presentation
Investigations
Management
Lipid Modification
Revascularisation
Acute Coronary Syndromes
Clinical Presentation
Investigation and Diagnosis
Revascularisation in Acute Coronary Syndromes
ST Elevation Myocardial Infarction (STEMI)
Non-ST Elevation Myocardial Infarction (NSTEMI)
Contrast Induced AKI (CI-AKI)
Heart Failure
Arrythmias
Atrial Fibrillation
Anticoagulation/Avoid stroke
Better Symptom Control
Cardiovascular Risk Factors and Concomitant Diseases
Ventricular Arrhythmias
Prevention of Death from Ventricular Arrhythmias
Valvular Heart Disease
Assessing VHD in CKD Patients
Prevention of VHD
Aortic Stenosis
Management of Severe Aortic Stenosis
Follow Up Post Valve Replacement (Transcatheter and Surgical)
Mitral Regurgitation
Investigation
Management of Severe Mitral Regurgitation
Choice of Prosthesis
Investigating the Pre-transplant Patient
Conclusions
Questions
References
Further Reading
12: Primary Glomerular Disease
Introduction
Minimal Change Disease
Introduction
Epidemiology and Aetiopathogenesis
Clinical Presentation and Laboratory Findings
Pathology
Treatment
Focal Segmental Glomerulosclerosis
Introduction
Epidemiology and Aetiopathogenesis
Clinical Presentation and Laboratory Findings
Pathology
Treatment
Membranous Nephropathy
Introduction
Epidemiology and Aetiopathogenesis
Clinical Presentation and Laboratory Findings
Pathology
Treatment
IgA Nephropathy
Introduction
Epidemiology and Aetiopathogenesis
Clinical Presentation and Laboratory Findings
Pathology
Treatment
Membranoproliferative Glomerulonephritis
Introduction
Epidemiology and Aetiopathogenesis
Clinical Presentation and Laboratory Findings
Pathology
Treatment
Post Streptococcal Glomerulonephritis
Introduction
Epidemiology and Aetiopathogenesis
Clinical Presentation and Laboratory Findings
Pathology
Treatment
Anti-glomerular Basement Membrane (GBM) Antibody Glomerulonephritis
Management of Anti-glomerular Basement Membrane (GBM) Antibody Glomerulonephritis
Conclusions
Questions
References
13: Secondary Glomerular Disease and Renal Vasculitis
Introduction
Anti-Neutrophil Cytoplasmic Antibody (ANCA) Associated Vasculitis
Introduction
Epidemiology and Causes
Clinical Presentation
Investigations
Differential Diagnosis
Management
Other Forms of Vasculitis and the Kidney
Lupus Nephritis
Introduction
Epidemiology and Causes
Clinical Presentation
Investigations
Differential Diagnosis
Management
Antiphospholipid Syndrome
Cryoglobulinaemia
Introduction
Epidemiology and Causes
Clinical Presentation
Investigations
Differential Diagnosis
Management
Protein Deposition Diseases
Introduction
Epidemiology and Causes
Clinical Presentation
Investigations
Differential Diagnosis
Management
Other Forms of Protein Deposition Disease
Thrombotic Microangiopathies (TMAs)
Introduction
Epidemiology and Causes
Clinical Presentation
Differential Diagnosis
Investigation and Management
Conclusions
Questions
References
14: Infections and the Kidney
Introduction
Bacterial Infections and Kidney Disease
Mechanisms of Bacterial Infection-Related Kidney Diseases
Direct Injury to the Kidney
Urinary Tract Infections (UTIs)
Reflux Nephropathy
Aetiology
Background
Clinical Management
Investigations
Clinical Features in Adults
Mycobacterial Infections
Tuberculosis
Classical Uro-Genital Tuberculosis (UGTB)
Clinical Features
Investigations
Treatment
Tuberculous Interstitial Nephritis
End-Stage Kidney Disease
Leprosy
Clinical Features
Treatment
Leptospirosis
Indirect or Immune-Mediated Damage to the Kidney
Bacterial Infection-Related Glomerulonephritis (B-IRGN)
Post-streptococcal GN (PSGN)
Kidney Injury as Part of Ongoing Sepsis
Nephrotoxic Damage from Medications, Used in Patients with Infection
Viral Infections and the Kidney
Dengue Virus
Hantavirus
Ebola Virus
Parvovirus
Polyoma Virus
Cytomegalovirus
Varicella Infections
Hepatitis E Virus
Hepatitis A
Hepatitis B Virus
Hepatitis C Virus
HIV
Severe Acute Respiratory Syndrome Coronavirus-2 [SARS-CoV-2]
Protozoal and Parasitic Infections and the Kidney
Malaria
Kidney Disease with Malaria
Diagnosis
Treatment
Schistosomiasis
Clinical Features
Kidney Disease
Diagnosis
Treatment
Prevention and Control
Fungal Infections and Kidney Disease
Conclusions
Questions
References
15: Genetic Kidney Diseases
Introduction
Monogenic and Polygenic Kidney Disease
Genetic Testing
An Approach to Genetic Testing
Classification of Genetic Kidney Diseases
Monogenic Kidney Diseases
Cystic Kidney Disease
Interstitial Kidney Diseases
Tumourous Kidney Diseases
Glomerular Diseases
Kidney Tubular and Metabolic Diseases
Nephrolithiasis
Congenital Abnormalities of Kidney and Urinary Tract (CAKUT)
Hereditary Systemic Amyloidosis
Conclusions
Questions
References
16: Kidney Cancer
Introduction
Epidemiology and Causes
Genetic Basis of Kidney Cancer
Clinical Presentation
Investigations
Renal Tumour Biopsy
Diagnosis and Classification
Management
Surgery
Adrenalectomy
Lymph Node Dissection (LND)
Alternatives to Surgery
Watchful Waiting & Active Surveillance
Cryoablation
Radiofrequency Ablation (RFA)
Systemic Therapy
Prognosis
Follow up
Conclusions
Appendix 1
Questions
References
17: Hemodialysis in Clinical Practice
Introduction
Basic Principles of Dialysis
Diffusion
Ultrafiltration
Convection
Clearance
Components of the Haemodialysis Machine and Extracorporeal Blood Circuit
Extracorporeal Blood Circuit (ECC)
Dialysate Preparation & Monitoring
Ultrafiltration Control Systems
Water Treatment Systems
Dialyser Membranes and its Performance
Hemodialysis Techniques
Prescribing Hemodialysis
Standard Prescription
Anticoagulation in Haemodialysis
Acute Heparin Free/Minimal Anticoagulant Dialysis
Ultrafiltration (UF) and Residual Renal Function (RRF)
Connecting and Commencing Treatment
Optimizing Dialysis Prescription
Other HD Techniques
Isolated Ultrafiltration (Iso UF)
Machine in Bypass and Recirculation Mode
Single Needle Hemodialysis (SNHD)
Dialyser Reuse
Home Hemodialysis
Buttonhole Cannulation
Haemodialysis Governance and Quality Assurance
Personalized Dialysis: Future and Emerging Opportunities
Conclusions
Questions
References
18: Complications of Haemodialysis
Introduction
Cardiovascular Complications of Haemodialysis
Intradialytic Hypotension
Intradialytic Hypertension
Cardiac Arrhythmias, Sudden Cardiac Arrest, and Sudden Cardiac Death
Dialysis Pericarditis
Dialysis Access Ischemia Steal Syndrome
Neurological Complications of Haemodialysis
Seizures
Headache
Dialysis Dementia
Dialysis-Related Muscle Cramps
Haematologic Complications of Haemodialysis
Intra-Dialytic Haemolysis
Haemorrhage
Thrombocytopaenia and Other Platelet Function Abnormalities
Other Complications of Haemodialysis
Dialysis-Associated Pruritus
Post-Dialysis Fatigue
Infections in Hemodialysis Patients
Priapism
Hearing Loss
Conclusions
Questions
References
19: Peritoneal Dialysis
Introduction
Assessing and Preparing Kidney Failure Patients for PD
Choice in PD Modality
PD Catheter Placement
Urgent Start PD
Initiation of PD Therapy for End-Stage Kidney Disease
PD Modalities
PD Solutions
Constituents of PD Solutions
Types of PD Solutions
Glucose-Based Solutions
Adverse Effects of Glucose-Based PD Solution
Glucose Polymer Solution or Icodextrin
Neutral pH Low-GDP Solutions
Amino Acid Solutions
PD Prescription in Terms of Choice of PD Modality, PD Solutions and Doses
Key Principles in PD Care Delivery
Residual Kidney Function
Preserving Residual Kidney Function in PD Patients
Assessment of RKF
Assessment of Indices of Dialysis Adequacy
Estimation of Normalized Protein Nitrogen Appearance (nPNA)
Peritoneal Equilibration Test (PET)
Is There a Target for Small Solute Clearance?
Evaluation of Patients with Low Delivered Urea/Creatinine Clearance Values
General Principles in Adjusting PD Prescription
Ultrafiltration and Volume Control as a Treatment Target
High Transporters
Low Transporters
Acute Peritoneal Membrane Dysfunction
Ultrafiltration Failure (UFF)
Conclusions
Questions
Further Reading
20: Complications of Peritoneal Dialysis: Prevention and Management
Introduction
Infective Complications
Prevention of Infection
Diagnosis of Infection
Catheter-Related Infections
Peritonitis
Treatment of Infections
Catheter-Related Infection
Peritonitis
Initial Management of Suspected Peritonitis
Specific Organisms and Their Treatment
Prognosis
Non-Infective Complications
PD Catheter Obstruction
Prevention of PD Catheter Obstruction
Management of PD Catheter Obstruction
Hernia and Leak
Hernias
Hernia Prevention and Management
Leaks
Hydrothorax
Management of Hydrothorax
Encapsulating Peritoneal Sclerosis (EPS)
Conclusions
Questions
References
21: Kidney Transplantation: The Pre-Transplantation Recipient & Donor Work-Up
Introduction
Recipient Evaluation
Referral for Kidney Transplantation
Recipient Evaluation Team
Transplant Recipient Testing
Comorbid Conditions in Renal Transplant Recipient
Cardiovascular Disease
Cerebrovascular Disease
Peripheral Vascular Disease
Malignancy
Obesity
Age
Infections—HIV, Hepatitis B, Hepatitis C, Tuberculosis
HIV
Hepatitis B
Hepatitis C
Tuberculosis
Pulmonary Disorder
Hematologic Disorders
Living Donor Evaluation
Kidney Donation Evaluation
Donor History
Risk of Donation
Surgical Risk
Medical Risk
Pre-Eclampsia
Special Considerations in Kidney Donors
Glomerular Filtration Rate
Albuminuria
Hematuria
Prediabetes
BMI >35
Hypertension
Gout
Older Donors
APOL1 Genetic Testing
Family History of Polycystic Kidney Disease
Conclusions
Questions
References
22: Management of the Patient After Kidney Transplantation
Introduction
Pre Transplant Evaluation and Factors that Influence Post-Transplant Care
Aetiology of Kidney Disease
Co-Morbidities that Affect Post-Transplant Care
Assessment of the Immunological Risk of Transplantation
Donor Factors that May Influence Post-Transplant Management
Donor Related Factors that Can Influence Post-Transplant Management Include
Peri-Operative Events Which Affect Post-Operative Care
Surgical Complications that May Affect Post-Transplant Management
Discharge and Education
Post-Discharge Care
Care Plan at a Post-Transplant Clinic Visit
Obtaining Standardized Clinical and Laboratory Data at Each Encounter
Post Clinic Visit Lab Review and Follow-Up
Common Clinical and Laboratory Abnormalities and Triage
Clinical
Complete Blood Count
Blood Chemistry
Microbiology
Imaging Abnormalities
Ultrasound with Doppler
Pharmacology of Transplant care:
Immunosuppression
Post-Transplant Infections
Urinary Tract Infections
Pneumonia
Fungal
Viral
BK Virus
Cytomegalovirus
Systemic Infections
Localized Infections
Evaluation of Fever in Transplant Recipient
Thrombotic Microangiopathy
Rapid Recurrence or Occurrence of Major Allograft Pathology
Special Considerations in Post Transplant follow Up
Recipients of High-Risk Donor Organs
Recipients of HCV Positive Donor Organs
Recipients with Known Major Psychiatric Illnesses
Recipients with Known History of Neoplasia
Preventive Measures
Cardiovascular Risk Reduction
Dermatology Surveillance
Ophthalmology Follow Up
Cancer Screening
Vascular Access in a Successful Transplant Recipient
Vaccination
Travelers
Failing Kidney Allograft and Kidney Replacement Therapy
The ‘Difficult-to-care-for’ Kidney Transplant Patient
Long Term Continuum of Care of Kidney Disease Patients
Conclusions
Questions
References
23: Complications of Kidney Transplantation
Introduction
Outcomes: Patient and Graft survival
Surgical Complications of Kidney Transplantation
Urological Complications
High drain output post kidney transplant surgery
Hydronephrosis of the Transplant Kidney
Vascular Complications
Oliguria post kidney transplant
Medical Complications of Kidney Transplantation
Infections
Cytomegalovirus (CMV)
Epstein–Barr Virus (EBV) and Post-Transplant Lymphoproliferative Disorders (PTLD)
BK Virus (BKV)
Pneumocystis Jiroveccii (Carinii)
Mycobacterium Tuberculosis (MTB)
Pre-transplant Screening for Latent Mycobacterium Tuberculosis (LMTB)
Treatment of latent and active Mycobacterium Tuberculosis (MTB)
Fungal Infections in Kidney Transplant Recipients
Diagnosis and Management of Fungal Infections
COVID-19 Infection and Kidney Transplant Recipients
Other Common Infections and Vaccinations Post-Transplant
Post-Transplant Diabetes
Acute and Chronic Rejection
Calcineurin Inhibitor Nephrotoxicity
Delayed Graft Function (DGF)
Chronic Allograft Failure
Cancer
Questions
References
24: An Approach to Obstetric Nephrology
Introduction
Chronic Kidney Disease
Preparation for Pregnancy
Antenatal Care
Management of Hypertension in the Preconception, Antenatal and Postnatal Period
Diagnosing Pre-Eclampsia in the Context of Pre-Existing Kidney Disease
Dialysis and Pregnancy
Kidney Transplantation and Pregnancy
Contraception in Women with CKD
Acute Kidney Injury (AKI) in Pregnancy
Specific Conditions and Their Management
Pre-eclampsia
HELLP Syndrome
Thrombotic Microangiopathies (TMAs)
Thrombotic Thrombocytopaenic Purpura (TTP)
Atypical Haemolytic Uraemic Syndrome (aHUS)
Postpartum Haemorrhage (PPH)
Conclusions
Questions
References
25: Transitional Care of Adolescents and Young Adult Patients with Kidney Disease
Introduction
Transitional Care
What Makes Healthcare for the Young Adult Population Different?
What Makes Adolescents and Young Adults on the Kidney Unit Different?
How Can We Improve Outcomes for Young People in the Kidney Unit?
Impact of Young Adult Care and Transition on Caregivers
Global Perspectives of Young Adult Care and Transition
Conclusions
Appendix 1: The Transitional Care Referral Form
Questions
References
26: Conservative Care for Patients with Chronic Kidney Disease
Introduction
What is Conservative Care?
Why do we Require a Conservative Care Pathway?
Variations in Conservative Care Provision
What Are the Key Elements of the Conservative Care Pathway?
Training and Empowering the Clinical Team
Assessment, Education, Choice and Shared Decision Making
Measures to Prevent Progression of CKD
Excellent Symptom Control
Drug Chart Review
Wider Needs Assessments
Creating a Network of Care
Palliative Care Teams
Primary Care/General Practitioners/Family Medicine
Social Work
District Nursing/Community Nursing Teams
Social Care/Home Health Aides
Advance Care Planning
Family Support After Bereavement
Conclusions
Questions
References
27: Electrolytes & Acid Base Disorders
Introduction
Hyponatremia
Treatment of hyponatraemia
Hypernatremia
Etiology
Diagnosis
Treatment of Hypernatraemia
Hypokalemia
Treatment of Hypokalaemia
Hyperkalemia
Metabolic Alkalosis
Metabolic Acidosis
Conclusions
Questions
References
28: The Role of Renal Registries
Introduction
Renal Registries Around the World
Which Questions Can Be Answered by Renal Registries?
Establishing Renal Registries
Identifying Stakeholders and Building the Registry Team
Clarifying the Purpose, Scope and Minimum Outputs
Defining and Finding Cases
A Minimum Dataset and the Data Dictionary
Collecting Data and Ensuring Data Quality
Data Ownership and Access, and Dissemination of Findings
Ethical Considerations
Impact of Registries
Improving Access to Care
Embedding Interventional Studies in Renal Registries
Conclusions
Questions
References
Index