Medical management of kidney and electrolyte disorders

630 Pages·2001·29.563 MB·English

by  F John Gennari

Medical
Management
of
Kidney and
Electrolyte
Disorders
Clinical Guides to Medical Management
Consulting Editor
BURTONE . SOBELM, .D.
Medical Center Hospitalo f Vermont
University of Vermont
Burlington, Vermont
Medical Managemento f Heart Disease, edited by BurtonE . Sobel
MedicalM anagement of RheumaticM usculoskeletala ndC onnective
TissueD iseases, editedb yJ anD equeker,G abriel Panayi, Theodore
Pincus, and Rodney Grahame
Medical Managemento f Atherosclerosis, edited by John LaRosa
Medical Managemento f Liver Disease, edited by EdwardL . Krawitt
Medical Management of Pulmonary Diseases, edited by Gerald S. Davis;
Associate Editors: TheodoreW . Marcy and ElizabethA . Seward
MedicalM anagement of DiabetesM ellitus, editedb yJ ack L.L eahy,
Nathaniel G. Clark, and WilliamT . Cefalu
Medical Management of Kidney and Electrolyte Disorders, edited by F.
John Gennari
ADDITIONATLIT LEISN PREPARATION
Medical
Management
of
Kidney and
Electrolyte
Disorders
edited by
F. John Gennari
University of Vermont
Burlington, Vermont
m
MARCEL
MARCELD EKKERIN, C NEWY ORK RASEL
UEKKER
To rny parents, rvho tuught me front the start to think outside
the erlvelope and gave me the gifts of love, discipline, energv, und
intellectual curiosity tltut have ertriched III~li fe und rvork.
ISBN: 0-8247-8869-9
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Foreword
The Medical Management series was developetdo provide practitioners, whether
they be generalists or specialists, with current and comprehensive information
pertinent to the care of their patients. The material is presented in a format consis-
tent with the nature of clinical experience and epistemology. Thus, cardinal signs
and symptoms rather than diagnostic labels are points of departure.
This component of the series. edited by Dr. F. John Gennari. addresses
kidney and electrolyte disorders. It does so elegantly, thoroughly, thoughtfully,
and practically.
Renal disease knows no definitive specialty borders. Whether it presents
as eclampsia requiring an obstetrician’s wisdom, glomerulonephritis challenging
the pediatrician, drug-induced interstitial nephritis challenging the internist’s acu-
men, or hypertensive or diabetic nephropathyid entified and treatedb y a conscien-
tious cardiologist, renal disease must be recognized and aggressively managed
by each patient’s personal physician. Generally, in internal medicine and family
practice as well as in emergency medicine, all too often the first recognition of
kidney disease is end-stage renal disease following an indolent, subtle course
concealed as a result of patient denial or inadequately aggressive diagnostic eval-
uation.
Medical Manngernent of Kiduey and Electrolyte Disorders identifies and
highlights symptoms of renal and electrolyte disordersi n Part I with four chapters
written by internationally respected authorities. Clinical presentation and labora-
tory evaluation are the subjects of Part I1 comprising ten chapters by authorities
who cover a broad spectrum ranging from the nephrotic syndrome and hematuria
to derangements in tonicity,p otassium,c alcium,p hosphorus,a ndm agnesium
iii
iv Foreword
balance and metabolism. The bulk of the book, Part 111, comprises 18 chapters.
They address management of renal disease and electrolyte disorders. The presen-
tations cover acute and chronic renal failure; hypertensive and diabetic nephropa-
thy; glomerular, tubular, and interstitial disorders; drug- and toxin-induced ne-
phropathy; kidney stones and infections; obstructive nephropathy and inherited
renal diseases; kidney diseasei n special settings such as pregnancy and hyperten-
sion; management of recipients of kidney transplants; treatment of acid-base,
tonicity, and electrolyte disorders; and modification of drug dosage in patients
with renal insufficiency.
As is the case for the preceding components of the Medical Management
series, the focuso f this book is on authoritative guidance rather than encyclopedic
review. Each chapter is designed to serve as a clinician’s “consultant” to aid
in the interpretation and development of inferences derived from recognition of
cardinal signs and symptoms of disease. The material should facilitate the con-
cerned clinician’s consideration of pathophysiological mechanisms underlying
disease and their diagnostic and therapeutic implications instead of reinforcing
reliance on algorithms and recipes.
Dr. Gennari has assembled a truly outstanding group of authorities from
his own institution and throughout the United States. Their contributions provide
definitive delineation of kidney and electrolyte disorders and their management
that should serve the reader well. Because of its breadth and scope, the book
should be useful to generalists and specialists; students, house staff, and fellows;
attendings in academic medical centers; practitioners in rural and urban settings;
and hospital-, office-, and emergency room-based physicians. It is hoped that
this contribution to the Medical Management series will complement its well-
received previous publications addressing medical management of atherosclero-
sis, heart disease, diabetes mellitus, pulmonary disease, liver disease, and dra-
matic musculoskeletal and connective tissue diseases.
Burtotz E. Sobel, M.D.
Preface
Kidney diseases, and disorders of fluid and electrolyte balance, can sometimes
be a sourceo f confusion for physicians who interact with these important clinical
problems only intermittently. This book was conceivedto remove that confusion,
by providing a comprehensive and concise source of information for the prac-
titioner. To accomplish this goal, experts in specific areas of nephrology have
contributedt h eirk nowledgeT. heirc ontributionsi n cludei n formationa bout
pathophysiology, clinical presentation, diagnosis, and treatment, presented in a
succinct and readable manner. Although many authors contributed, the book has
been carefully edited for consistency of style and approach, and the information
has been filtered by a single editor to ensure its accessibility for the reader. It
was written with the primary care physician in mind, but should also be a useful
reference text for emergency room physicians, hospitalists, intensive care physi-
cians, and all physicians with an interest in this area.
The book is organizedi ntot hreep arts to allowp hysicianst oe ntert he
subject from a varietyo f perspectives. The first four chapters approach the subject
from the viewpointo f patients’ symptoms, allowing readerst o determine whether
their patient’s complaint can be accounted for by renal or electrolyte disorders.
The subsequent ten chapters approach the topic from the perspective of physical
and laboratory findings, defining the characteristic syndromes with which patients
‘
present and taking the reader through the key laboratory findings that are the
hallmarks of these disorders. The third and largest portion of the book covers
the subject from the perspective of specific diseases, and focuses on diagnosis
and management. These chapters enable the physician with a question about a
specific disease to obtain information about its presentation, diagnosis, and man-
V
vi Preface
agement. A centerpiece of this section of the book is a comprehensive chapter
that covers the diagnosis and management of glomerular diseases in a concise
and readily accessible manner. In addition, the key topics of the management of
chronic renal insufficiency and diabetic nephropathy are reviewed in this section
of the book, with particular attention to strategies designed to slow progression
to end-stage renal disease.T he last chapter of the book covers the important topic
of drug dosage modification in patients with renal disease.
This book is intended to provide comprehensive information about all the
disorders that comprise the subspecialty of nephrology, but a special highlight
is its coverage of electrolyte disorders, an area of particular interestt o the editor.
The chapters covering these disorders, four of which were written by the editor,
arei ntersperseda mong all threep arts of theb ook. The first part containsa
chapter that covers the symptoms of electrolyte disorders, a unique contribution.
In the second part, the pathophysiology, clinical presentation, and tools for diag-
nosis of these disorders are covered.T he specific treatments for electrolyte disor-
ders are presented separately in the third part of the book, allowing the clinician
with specific questions about treatment to find the answers quickly.
This book will benefit practitioners of medicine who must manage the in-
creasing population of patients with renal and electrolyte disorderass our popula-
tion ages. By providing pragmatic and accessible information, it should help to
dissolve confusion and provide a rational approach to these disorders.
F. John Gennuri, M.D.
Contents
...
ForewoBrd u rton E. Sobel 111
Preface V
Contributors xi
Part I: Symptoms of Renal and Electrolyte Disorders
1. Oliguria and Polyuria 1
Gertrude S. Lefavour
2. Edema 19
Rainer Lnng
3. Uremia 39
Jeffrey A. Kraut
4. Symptoms of Electrolyte Disorders 57
Deborah B. Adey
vii