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Oxford Handbook of Nephrology and Hypertension

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edi-in both primary and secondary care International efforts to produce sensus guidelines (albeit from disappointingly thin evidence) must also be applauded However, whilst we may inexplicably struggle to complete suffi 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.

con-You’ll fi nd a little more depth to the information in this edition, although this remains balanced with the more pragmatic advice that was so well received last time out With unlimited knowledge just a few keyboard strokes away, it seemed even more important to bring essential infor-mation to the fore and present it in as palatable and practical a way as possible We hope the additional detail will also prove useful during prep-aration for postgraduate examinations and assessments

This Handbook now sits in a larger family, having been joined by

the excellent Oxford Specialist Handbooks of Renal Transplantation and Paediatric Nephrology Along with the well-established Oxford Handbook of

Dialysis and the newer Oxford Desktop Reference of Nephrology , we believe

these represent a formidable resource across our entire specialty

The fi rst edition was the idea of a few enthusiastic London trainees, cultivated through animated caffeine-fuelled discussions as their lab experiments simmered nearby Whilst still enthusiastic (on the whole), said trainees are now undeniably greyer, balder, rounder and grumpier (we’ll let those of you who know us decide which adjective fi ts each of us best) and it has inevitably proved challenging to complete this new ver-sion around the demands of busy professional and personal lives We are therefore extremely grateful to all our contributors as well as to OUP for (almost) being as patient as our families But, ultimately, it is the support and good humour of the latter that has really allowed us to complete the text you are about to read

It had always been our intention to create a Handbook that makes the practice of renal medicine a little easier and a lot more enjoyable And

on that thought, we offer this new edition to you as meagre thanks for the wonderful fortune that brought our good friend and colleague Shaun Summers, all too briefl y, into our lives

SS & NA, London, 2013

Preface to the

fi 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 mortality The recent reclassifi cation of chronic kidney disease (CKD) has exposed the scale of a serious public health issue, relevant to all medical practitioners both in pri-mary and secondary care Furthermore, irrespective of specialist interest, regular clinical contact with patients who are dialysis-dependent or who have undergone renal transplantation is now the norm, not the exception Hypertension needs no introduction as the most common indication for prescription drug therapy and the most important cause of premature death in the developed world

Many doctors are nervous of renal disease—there persists a belief that renal patients suffer exclusively from complex, esoteric conditions that can only be managed in a specialist environment and by specialists who are often more diffi cult and demanding than their patients Our intention has been to write a concise but robust handbook that is fi rst and fore-most practical: what needs to be done in a busy casualty department or

GP surgery several miles from the nearest renal unit We hope it will

be a useful resource not only to doctors, nurses, and other members of the multiprofessional team already engaged in the care of renal patients but also to a broader audience For those interested in how renal dis-ease evolves, we’ve provided a good grounding in the fundamentals of nephrology—hopefully dismantling some myths along the way, and giving readers the confi 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 practical information, helpful to those working ‘at the coal face’, and the more detailed knowledge that enables effective ongo-ing care The authors are all consultants working in busy renal units where theory and practice are balanced to provide effective and effi 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 mation on a particular clinical theme Clinical importance is measured in space, so diabetic nephropathy is given more attention than, for example, Fanconi’s syndrome The section on renal replacement therapies gives an overview of the essential elements of both dialysis and transplantation Those looking for more detailed notes on all aspects of dialysis therapy

infor-are referred to our sister volume The Oxford Handbook of Dialysis , or, for general nephrology and transplant topics, our parent text The Oxford

Textbook of Nephrology For completeness, we have included practical

pro-cedures but would ask that these pages are used for guidance only—all must be taught by experienced operators and cannot be learnt solely from

a book

We make no apology for emphasizing the importance of clinical ment Yes, tubular physiology is here (we are nephrologists after all), but this book is aimed principally at clinicians in training and we still believe that without a detailed history and thorough physical examination it is impossible to order and interpret appropriate laboratory tests or imag-ing, let alone provide good quality care This seems more important than ever at a time when many lament a diminished sense of enjoyment in the practice of medicine

We are grateful to all of our colleagues who helped bring this project to fruition as well as to our families for tolerating so many lost evenings and weekends with such good grace We hope that we have produced a book with personality, and one that brings its subject matter alive We would like readers to enjoy the highways and byways of renal medicine and that

we have avoided, in the words of Mark Twain, a book that ‘everyone wants to have read, but no-one wants to read’

SS, NA, AC, JC London, July 2006

Contributors x

Symbols and Abbreviations xi

1 Clinical assessment of the renal patient 1

2 Acute kidney injury (AKI) 87

3 Chronic kidney disease (CKD) 191

4 Dialysis 273

5 Transplantation 335

6 Hypertension 449

7 Diseases of the kidney 529

8 The kidney in systemic disease 603

9 Essential urology 705

10 Fluids and electrolytes 777

11 Pregnancy and the kidney 839

12 Drugs and the kidney 869

13 Renal physiology 913

14 Appendices 935 Index 957

Contents

Thanks also to Heather Brown, Simon Chowdhury, Sue Cox, Rachel Hilton, Jonathon Olsburgh, Ed Sharples, and Raj Thuraisingham for their expert help and advice.

 equal to or greater than

≤ equal to or less than

ABD adynamic bone disease

ABPM ambulatory blood pressure monitoring

ACE-I angiotensin-converting enzyme inhibitor

ACR albumin/creatinine ratio

Symbols and

ACS abdominal compartment syndrome; acute coronary

syndrome

ACT activated clotting time

ACTH adrenocorticotrophin hormone

AD autosomal dominant

ADH antidiuretic hormone

ADMA asymmetric dimethyl arginine

ADPKD autosomal dominant polycystic kidney disease

AIDS acquired immunodefi ciency syndrome

AIN acute interstitial nephritis

AKD acute kidney disease

AKI acute kidney injury

AKIN Acute Kidney Injury Network

Al aluminium

Alb albumin

ALP alkaline phosphatase

ALT alanine transaminase

a.m ante meridian

AMR antibody-mediated rejection

AN analgesic nephropathy

ANA anti-nuclear antibodies

ANCA anti-neutrophil cytoplasmic antibodies

ANP atrial natriuretic peptide

APC antigen-presenting cell

APD automated peritoneal dialysis

APS antiphospholipid syndrome

APTT activated partial thromboplastin time

AR autosomal recessive

ARAS atherosclerotic renal artery stenosis

ARB aldosterone receptor blocker

ARDS acute respiratory distress syndrome

ARPKD autosomal recessive polycystic kidney disease ARR aldosterone–renin ratio

ARVD atherosclerotic renovascular disease

ASAP as soon as possible

ASCT autologous stem cell transplantation

ASOT anti-streptolysin O titre

AST aspartate aminotransferase

ATG anti-thymocyte globulin

ATI acute tubular injury

ATN acute tubular necrosis

ATP adenosine triphosphate

AV atrioventricular; arteriovenous

AVF arteriovenous fi stula

AVM arteriovenous malformation

AVP arginine vasopressin

AXR abdominal X-ray

AZA azathioprine

BAL bronchoalveolar lavage

BAT baroreceptor activation therapy

BEN Balkan endemic nephropathy

BHS British Hypertension Society

BM basement membrane

B 2 M beta 2 microglobulin

BMD bone mineral density

BMI body mass index

BMT bone marrow transplantation

BNP brain natriuretic peptide

BOO bladder outlet obstruction

BP blood pressure

BPH benign prostatic hyperplasia

BVAS Birmingham vasculitis activity score

BVM blood volume monitoring

Ca 2+ calcium ion

CaCl 2 calcium chloride

CAD coronary artery disease

CAH congenital adrenal hyperplasia

CAKUT congenital abnormalities of the kidney and urinary tract CAN chronic allograft nephropathy

CAPD continuous ambulatory peritoneal dialysis

CAPS catastrophic antiphospholipid syndrome

CaR calcium-sensing receptor

CaxP calcium phosphate product

CBPM clinic BP monitoring

Cbsa cationic bovine serum albumin

CCB calcium channel blocker

CCF congestive cardiac failure

CCPB calcium-containing phosphate binder

CCPD continuous cycling peritoneal dialysis

CD collecting duct

CDC complement-dependent cytotoxicity; Centers for Disease

Control

CEPD continuous equilibrium peritoneal dialysis

CERA continuous EPO receptor activator

cfu colony-forming unit

CG Cockcroft–Gault

CHCC Chapel Hill Consensus Conference

CHD coronary heart disease

C 2 H 5 OH ethanol

CHr reticulocyte haemoglobin content

CIC ciclosporin

CIS carcinoma in situ

CIT cold ischaemic time

CNI calcineurin inhibitor

CNS central nervous system

cTnI cardiac troponin I

cTnT cardiac troponin T

CO cardiac output

CO 2 carbon dioxide

COC combined oral contraceptive

COP colloid osmotic pressure

COX cyclo-oxygenase

CPAP continuous positive airway pressure

CPET cardiopulmonary exercise testing

CPM central pontine myelinosis

CPS calcium polystyrene sulphate

CTA computed tomography angiography

CTS carpal tunnel syndrome

CUA calfi cic uraemic arteriolopathy

CV cardiovascular

CVA cerebrovascular accident

CVC central venous catheter

CVD cardiovascular disease

CVP central venous pressure

CVVHD continuous veno-venous haemodialysis

CVVHDF continuous veno-venous haemodiafi ltration

CVVHF continuous veno-venous haemofi ltration

DBD donation after brain death

DBP diastolic blood pressure

DCD donation after cardiac death

DCT distal convoluted tubule

DIC disseminated intravascular coagulation DKA diabetic ketoacidosis

dL decilitre

DM diabetes mellitus

DMARD disease-modifying anti-rheumatic drug

DN diabetic nephropathy

DNA deoxyribonucleic acid

DRA dialysis-related amyloidosis

DRE digital rectal examination

DSA donor-specifi c antibody

dsDNA double-stranded deoxyribonucleic acid DSE dobutamine stress echocardiography

DT distal tubule

DTT dithiothreitol

D&V diarrhoea and vomiting

DVT deep vein thrombosis

DW dry weight

EABV effective arterial blood volume

EBCT electron beam CT

EBV Epstein–Barr virus

ECD extended criteria donors

ECF extracellular fl uid

EM electron microscopy

EMA European Medicines Agency

EMT epithelial to mesenchymal transition EMU early morning urine

ENA extractable nuclear antigen

ENaC epithelial Na + channel

eNOS endogenous nitric oxide synthase ENT ear, nose, and throat

EPO erythropoietin

EPO-R erythropoietin receptor

ERT enzyme replacement therapy

ESA erythropoiesis-stimulating agent

ESRD end-stage renal disease

EST exercise stress testing

ESWL extracorporeal shock wave lithotripsy

FBC full blood count

FDA Food and Drug Administration

FFP fresh frozen plasma

FMF familial Mediterranean fever

FOB faecal occult blood

FPG fasting plasma glucose

FSGS focal and segmental glomerulosclerosis

FSH follicle-stimulating hormone

g gram

GA general anaesthesia

GBM glomerular basement membrane

GCS Glasgow Coma Score

Gd gadolinium

GDP glucose degradation product

GFR glomerular fi ltration rate

GPA granulomatosis with polyangiitis

G6PD glucose-6-phosphate defi ciency

G6PDH glucose-6-phosphate dehydrogenase

GRA glucocorticoid-remediable aldosteronism

G&S group and save

HAART highly active antiretroviral therapy

Hb haemoglobin

HBPM home blood pressure measurement

HBV hepatitis B virus

HC hydroxycarbamide

HCDD heavy chain deposition disease

HCO 3 – bicarbonate ion

H+E haematoxylin and eosin

HELLP haemolysis, elevated liver enzymes, and low platelet

HF haemofi ltration; heart failure

HIT heparin-induced thrombocytopenia

HIV human immunodefi ciency virus

HIVAN HIV-associated nephropathy

HIVICK HIV immune complex kidney disease

HIV-TMA HIV-associated thrombotic microangiopathy HLA human leucocyte antigen

H 2 O water

HoLEP holmium laser enucleation of the prostate hpf high-powered fi eld

HR heart rate

HRBC hypochromic red blood cell

HRCT high-resolution computed tomography

HRE hypoxia response element

hrEPO human recombinant erythropoietin

HRS hepatorenal syndrome

HRT hormone replacement therapy

HSP Henoch–Schönlein purpura

HSV herpes simplex virus

HTA Human Tissue Authority

HTLV human T lymphotropic virus

HUS haemolytic uraemic syndrome

IAH intra-abdominal hypertension

IAP intra-abdominal pressure

IBD infl ammatory bowel disease

IBW ideal body weight

IC immune complex

iCa 2+ ionized calcium

ICA intracranial aneurysms

ICAM-1 intercellular adhesion molecule-1

IDH intradialytic hypotension

IDL intermediate density lipoprotein

IDPN intradialytic parenteral nutrition

IE infective endocarditis

IF interstitial fi brosis

IFN interferon

Ig immunoglobulin

IgAN IgA nephropathy

IGF insulin-like growth factor

IGFBP insulin-like growth factor-binding protein

IGRA interferon gamma release assays

IHD ischaemic heart disease; intermittent haemodialysis

IL interleukin

IM intramuscular

IMN idiopathic membranous nephropathy

IMPDH inosine monophosphate dehydrogenase

IMWG International Myeloma Working Group

INHD in-hospital nocturnal haemodialysis

iNOS inducible nitric oxide synthase

INR international normalized ratio

IP intraperitoneal

IPSS international prostate symptom score

ITP idiopathic thrombocytopenic purpura

ITU intensive treatment unit

IU international unit

IUGR intrauterine growth restriction

IV intravenous

IVC inferior vena cava

IVDSA intravenous digital subtraction angiography

IVDU intravenous drug user

IVI intravenous infusion

IVIg intravenous immunoglobulin

IVU intravenous urogram

JBS Joint British Societies

JNC Joint National Committee

JVP jugular venous pressure

LMW low molecular weight

LMWH low molecular weight heparin

LVF left ventricular failure

LVH left ventricular hypertrophy

m metre

mAb monoclonal antibody

MAC membrane attack complex

MACE major adverse cardiovascular events MAHA microangiopathic haemolytic anaemia MAOI monoamine oxidase inhibitor

MAP mean arterial pressure

MARS molecular absorbent recirculating system

Mb myoglobin

MBD mineral and bone disorder

MCD minimal change disease

MCGN mesangiocapillary glomerulonephritis

MCN minimal change nephropathy

M,C+S microscopy, culture, and sensitivity

MCUG micturating cystourethrography

MDRD Modifi cation of Diet in Renal Disease

MEN multiple endocrine neoplasia

meq milliequivalent

MFI median fl uorescence intensity

mg milligram

Mg 2+ magnesium ion

MGUS monoclonal gammopathy of uncertain signifi cance

MHC major histocompatibility complex

MHRA Medicines and Healthcare products Regulatory Agency

MPS myocardial perfusion scan; mycophenolate sodium

MR magnetic resonance; modifi ed release; mineralocorticoid

receptor

MRA magnetic resonance angiography

MRI magnetic resonance imaging

MRSA meticillin-resistant Staphylococcus aureus

MRSI magnetic resonance spectroscopy imaging

MS multiple sclerosis

MSCT multislice computed tomography

MSU midstream urine

mTOR mammalian target of rapamycin

mU milliunit

MVR mitral valve replacement

MW molecular weight

Na + sodium ion

NAC N-acetylcysteine

NaCl sodium chloride

NADR noradrenaline

NAG N-acetyl- B -D-glucosaminidase

NaHCO 3 sodium bicarbonate

NB take note ( nota bene )

NHS National Health Service

NICE National Institute for Health and Care Excellence NIH National Institutes of Health

NIPD night-time intermittent peritoneal dialysis

NSAID non-steroidal anti-infl ammatory drug

NSF nephrogenic systemic fi brosis

NSTEMI non-ST elevation myocardial infarction

N+V nausea and vomiting

NYHA New York Heart Association

O 2 oxygen

od once daily

OSA obstructive sleep apnoea

OSP oral sodium phosphate

p probability

PAC pulmonary artery catheter

PAK pancreas after kidney

PAN polyarteritis nodosa

PaOP pulmonary artery occlusion pressure

PAS periodic acid–Schiff

PC pelvicalyceal

PCA patient-controlled analgesia

PCP pneumocystis pneumonia

PCR protein/creatinine ratio; polymerase chain reaction

PCT proximal convoluted tubule

PD peritoneal dialysis

PDGF platelet-derived growth factor

PEEP positive end expiratory pressure

PEG percutaneous endoscopic gastrotomy; polyethylene glycol PET peritoneal equilibration test; positron emission tomography PEX plasma exchange

PFT pulmonary function test

pg picogram

PIGN post-infectious glomerulonephritis

PIH pregnancy-induced hypertension

PIN prostatic intraepithelial neoplasia

PlGF placental growth factor

POF premature ovarian failure

POTS postural tachycardia syndrome

PP pulse pressure

PPI proton pump inhibitor

PR3 proteinase 3

PRA panel reactive antibody

PRCA pure red cell aplasia

PRES posterior reversible encephalopathy syndrome

prn as required

PSA prostate-specifi c antigen

PT prothrombin time

PTA pancreas transplant alone

PTC proximal tubular cell; peritubular capillary

PTFE polytetrafl uoroethylene

PTH parathyroid hormone

PTHrP parathyroid hormone-related peptide

PTLD post-transplant lymphoproliferative disorder PTRA percutaneous transluminal renal angioplasty PUJ pelvi-ureteric junction

PUV posterior urethral valves

PV per vagina

PVAN polyomavirus-associated nephropathy

PVD peripheral vascular disease

PVP photoselective vaporization of the prostate qds four times daily

RA rheumatoid arthritis

RAAS renin–angiotensin–aldosterone system

RAS renin–angiotensin system

RBC red blood cell

RBF renal blood fl ow

RBP retinol-binding protein

RCC renal cell carcinoma

RCT randomized controlled trial

R&D research and development

RPGN rapidly progressive glomerulonephritis

RPLS reversible posterior leucoencephalopathy syndrome

RR respiratory rate

RRT renal replacement therapy

RTA renal tubular acidosis

RVD renovascular disease

RVT renal vein thrombosis

RWMA regional wall motion abnormality

s second

SA sinoatrial

SAA serum amyloid A

SAH subarachnoid haemorrhage

S a O 2 oxygen saturation

SAP serum amyloid P

SBP systolic blood pressure; spontaneous bacterial peritonitis SCC squamous cell carcinoma

SCM sternocleidomastoid

SCN sickle cell nephropathy

SCr serum creatinine

ScvO 2 central venous oxygen saturation

SDHD short daily haemodialysis

SE side effect

SEP synthetic erythropoiesis protein; sclerosing encapsulating

peritonitis

SFLC serum free light chain

SGA subjective global assessment

SHPT secondary hyperparathyroidism

SIADH syndrome of inappropriate antidiuretic hormone secretion SIRS systemic infl ammatory response syndrome

SLE systemic lupus erythematosus

SLED sustained low-effi ciency dialysis

SNGFR glomerular fi ltration rate of single nephron

SNP single nucleotide polymorphism

SNS sympathetic nervous system

SOB shortness of breath

SPEP serum protein electrophoresis

SPK simultaneous kidney–pancreas

spp species

SPS sodium polystyrene sulphonate

SSc systemic sclerosis

SSRI serotonin-specifi c reuptake inhibitor

STD sexually transmitted disease

STEMI ST elevation myocardial infarction

SVC superior vena cava

SVR systemic vascular resistance; sustained virologic response

T temperature

t 1/2 half-life

TA tubular atrophy

tds three times daily

TFT thyroid function test

THMP Tamm–Horsfall mucoprotein

TIA transient ischaemic attack

TIBC total iron-binding capacity

TIMP tissue inhibitor of metalloproteinases TIN tubulointerstitial nephritis

TINU tubulointerstitial nephritis and uveitis TIPS transjugular intrahepatic portosystemic shunt TLS tumour lysis syndrome

TMA thrombotic microangiopathy

TMD thin membrane disease

TMP transmembrane pressure

TNF tumour necrosis factor

TOD target organ damage

TOE transoesophageal echocardiography TOR target of rapamycin

TMPT thiopurine methytransferase

TPN total parenteral nutrition

TRUS transrectal ultrasound

TSAT transferrin saturation

TSH thyroid-stimulating hormone

TTE transthoracic echocardiography

TTP thrombotic thrombocytopenic purpura TUIP transurethral incision of the prostate TUMT transurethral microwave therapy

TUNA transurethral needle ablation

TURBT transurethral resection of bladder tumour TURP transurethral resection of the prostate

U unit

UAG urine anion gap

URR urea reduction ratio

USA United States of America

USRDS United States Renal Data System

USS ultrasound scan

UTI urinary tract infection

VTE venous thromboembolism

VUR vesicoureteric refl ux

vWF von Willebrand factor

VZV varicella zoster virus

WCC white cell count

WHO World Health Organization

WIT warm ischaemia time

wk week

WWII World War II

yr year

Clinical assessment of the renal patient

Clinical history: introduction 2

Clinical history: symptoms and social history 4

Clinical history: drug, treatment, and family 6

Clinical history: additional factors 8

Physical examination 10

Physical examination: the circulation 12

Urine: appearance 14

Urinalysis: chemical analysis 16

Urinalysis: further tests 18

Urinalysis: protein 20

Urinalysis: red blood cells 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 elderly 38

Immunological and serological investigation 40

Diagnostic imaging: X-ray 44

Diagnostic imaging: ultrasound 46

Diagnostic imaging: CT and MRI 50

Diagnostic imaging: IVU 52

Diagnostic imaging: nuclear medicine 54

Diagnostic imaging: angiography and uroradiology 56

Clinical syndromes: proteinuria — introduction 58

Clinical syndromes: proteinuria 60

Clinical syndromes: haematuria — introduction and

classifi cation 62

Clinical syndromes: haematuria assessment 64

Clinical syndromes: microscopic haematuria 66

Clinical syndromes: microscopic haematuria screening 68 Clinical syndromes: CKD, AKI, and the nephritic syndrome 70 Clinical syndromes: pulmonary renal syndromes 72

Clinical syndromes: urine volume and urinary tract pain 74 Clinical syndromes: tubular syndromes 76

Clinical syndromes: bladder outfl ow obstruction 78

Renal biopsy: introduction 80

Renal biopsy: indications 82

Renal biopsy: complications 84

Chapter 1

Clinical history: introduction

In nephrology, as in all branches of medicine, a competent clinical ment is crucial This should incorporate symptoms and signs:

Box 1.1 Renal clinical syndromes

• Chronic kidney disease (CKD) ( b Chapter 3)

Past medical history

• Hypertension When diagnosed? Who is responsible for follow-up? Current and historical treatment? Level of control? Self-monitoring with home BP monitor?

• Insurance or employment medicals can provide invaluable historical benchmarks Can they recall a past BP check or providing a urine specimen? Have they had blood tests in the past?

Table 1.1 Important renal disease associations

Medical condition Renal association

General

Hypertension Hypertensive nephrosclerosis, s i BP is associated

with many renal disorders Diabetes mellitus Diabetic nephropathy

Cardiovascular disease CKD, renovascular disease, atheroembolism

Liver disease

Hepatitis B and C Membranous GN, mesangiocapillary GN (MCGN) Infl ammatory

SLE and other connective

tissue disorders

Lupus nephritis, MCGN, and others

Sarcoidosis Interstitial disease

Raynaud ’ s Scleroderma, SLE, cryoglobulinaemia

Pleuropericardial disease Connective tissue disorders

Haemoptysis Vasculitis, lupus nephritis, anti-GBM disease

Infection

Gastroenteritis Pre-renal AKI, haemolytic uraemic syndrome

Recurrent UTIs Vesicoureteric refl ux and chronic pyelonephritis Streptococcal infection Post-infective GN

Endocarditis Post-infective GN

Chronic infection Amyloidosis

Dermatological

Cutaneous vasculitis Vasculitis, HSP, IgA nephropathy

Livedo reticularis Antiphospholipid antibody syndrome

Cryoglobulinaemia Malignancy

Solid organ tumours Membranous GN, thrombotic microangiopathy Lymphoma Minimal change disease, FSGS, fi brillary GN

Myeloma Light chain disease, amyloid, cast nephropathy Other

ENT problems Granulomatosis with polyangiitis (Wegener ’ s)

Ophthalmic conditions Retinopathy and anterior lenticonus in Alport ’ s

Cystine deposits in cystinosis Retinitis pigmentosa in Senior–Løken syndrome Retinal oxalate deposition in hyperoxaluria Chronic pain Analgesic nephropathy

Thrombotic tendency Antiphospholipid antibody syndrome

Clinical history: symptoms and

• Lower urinary tract symptoms (LUTS):

• Obstructive (voiding) symptoms:

— Impaired size or force of the urinary stream

— Hesitancy or abdominal straining

— Intermittent or interrupted fl ow

— Post-micturition dribble

— A sensation of incomplete emptying

— Acute retention of urine

• Storage (fi lling) symptoms:

Renal diseases are often chronic disorders, incurring appreciable social morbidity Factors, such as social isolation, accommodation, and work situation, are hugely important In ESRD, social circumstance will exert

an important infl uence on choice of, and ability to cope with, a ticular dialysis modality Livelihood may also be affected — one of the goals of RRT, wherever possible, should be to keep an individual in employment Quality of life must never be forgotten amidst all the blood tests

Clinical history: drug, treatment,

Table 1.2 Inherited kidney diseases

Cystic kidney diseases Adult and juvenile polycystic kidney disease

Primary glomerular Alport ’ s syndrome and

variants IgA nephropathy (occasionally) FSGS (rarely) Others (rarely) Metabolic diseases with

renal involvement

Non-glomerular Cystinosis, primary

hyperoxaluria, inherited urate nephropathy

Non-metabolic disease Non-glomerular Nephronophthisis

syndrome, nail-patella syndrome Benign and malignant

tumours

Tuberous sclerosis (renal angiomyolipoma) von Hippel – Lindau (renal cell carcinoma) Tubular disorders Cystinuria, various inherited tubular defects

Disorders with a Vesicoureteric refl ux, haemolytic uraemic syndrome,

Box 1.2 Important nephrotoxins ( b see Chapter 11)

‘Pre-renal’ renal insuffi ciency

Diuretics

Any antihypertensive agent (esp

ACE-Is and ARBs that aggravate other

pre-renal states)

Haemodynamically mediated

NSAIDs and COX-2 inhibitors

ACE-Is and ARBS

Carbon tetrachloride and other organic

solvents (e.g glue sniffi ng)

Silica dust (? granulomatosis with

Tubular crystal formation

Aciclovir and other antivirals

Ethylene glycol (antifreeze)

Amphotericin Ifosfamide Foscarnet Antivirals:

Adefovir Cidofovir Tenofovir Cisplatin Heavy metals (arsenic, mercury, and cadmium)

Herbal remedies Interleukin-2 Intravenous immunoglobulin (previously with sucrose-containing formulations)

Paracetamol Paraquat Pentamidine X-ray contrast agents Interstitial nephritis (these and many, many others) Antibiotics:

Penicillins Cephalosporins Quinolones Rifampicin Sulfonamides Allopurinol Cimetidine (rarely ranitidine) NSAIDs and COX-2 inhibitors Diuretics

5-aminosalicylates (sulfasalazine and mesalazine)

Proton pump inhibitors, e.g

omeprazole Chronic interstitial disease Lead

Lithium Analgesics Chinese herbs

Clinical history: additional factors

Sexual, gynaecological, and obstetric history

Ethnicity and renal disease

Approach to the patient on renal replacement therapy

When managing a dialysis or transplant patient, there are a few direct questions that will help you to get to grips with (and reassure the patient that you are familiar with) their treatment It will also facilitate discussion with the patient ’ s renal unit

The patient on haemodialysis

• What is the patient ’ s current access for dialysis (e.g an arteriovenous

fi stula, a PTFE graft, or a tunnelled dialysis catheter)?

• What is their usual fl uid gain between treatments?

• Do they know their blood pressure at the end of a dialysis session?

The patient on peritoneal dialysis

• When was their last episode of peritonitis?

All dialysis patients

• How are they coping with dialysis?

The transplant patient

Dry Scratch marks Bruising (uraemic bleeding tendency) Vasculitic rash Subcutaneous nodules (soft tissue calcification) Uraemic frost (severe uraemia) Transplant patient: cutaneous malignancies

Hands

Metabolic flap (severe uraemia) Shortening of distal phalanges + pseudoclubbing (severe hyperparathyroidism) Raynaud’s

Sclerodactyly Calcinosis

Systemic sclerosis

SVC obstruction

Evidence of past or present

haemodialysis access

(e.g tunnelled lines,

scars from previous

dialysis lines, AV fistula)

’s lines) au

Fig 1.1 Examination by area