Table Of ContentMark Harber
Editor
Primer
on Nephrology
Second Edition
123
Primer on Nephrology
Mark Harber
Editor
Primer on
Nephrology
Second Edition
Editor
Mark Harber
Department of Renal Medicine
UCL
London, UK
ISBN 978-3-030-76418-0 ISBN 978-3-030-76419-7 (eBook)
https://doi.org/10.1007/978-3-030-76419-7
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V
Preface
The forerunner to Primer in Nephrology, Practical Nephrology, was published in 2014
and aimed to provide a clear, modern account of nephrology with a practical spin. The
motivation for the book came from teaching and the acknowledgment that practical
experience, examples of real-world nephrology (good and bad), and case discussions
are an essential aspect of training. This edition of Primer in Nephrology is an update
with the same ethos, but hopefully yet more experience imparted. In addition, much
has happened both within and outside nephrology since 2014 that has transformed the
practice, and this edition addresses major ongoing challenges for our patients and staff
as well as key questions for us as nephrologists.
Our knowledge and understanding of acute kidney injury (AKI) have grown sub-
stantially, particularly the appreciation of the long-term impacts of moderate to severe
AKI on renal function and frailty, with significant implications for patients who survive
episodes of AKI. AKI is not only emerging as an important cause of chronic kidney
disease (CKD) but CKD is also an important risk factor for AKI. In the context of a
massive increase in the global prevalence of CKD, secondary to an aging population
with multiple comorbidities, this represents a major test for nephrologists specifically
and healthcare providers in general. By way of a medical counterattack, there have
been many exciting new treatments in nephrology over the last few years. In particular,
the development of GLA-1 receptor agonists and SGLT-2 inhibitors that significantly
slow the progression of diabetic nephropathy and markedly mitigate the risk of cardio-
vascular comorbidities is particularly welcome. The observation that SGLT-2 inhibitors
are equally effective in protecting non-diabetic patients with heavy proteinuria from
renal progression and cardiovascular disease offers huge potential in combating pro-
gressive renal disease. The real challenge for us, however, is implementation of all the
measures we know to prevent the development and severe consequences of CKD and
cardiovascular co-morbidity. How do we as a specialty tackle major healthcare inequal-
ities and ensure that patients from all backgrounds and in all communities are identified
early, supported, and treated to deliver the best outcome?
The COVID-19 pandemic has shaken the world and pummeled health services. It
has demonstrated the susceptibility of patients with end-stage renal disease, particu-
larly those with no choice but to attend hospital dialysis as well as those who are immu-
nosuppressed. It has highlighted the critical importance for our patients of prevention
of infectious disease in the form of good infection control and vaccination. The early
pandemic revealed nephropathies associations with this virus but most strikingly it has
reminded us of the importance of appropriate fluid replacement in sepsis; when anxi-
ety about wet lungs, and relative fluid restriction, contributed to a huge surge in hospi-
tal AKI. This unintended consequence, in turn, demonstrated the vulnerability of
supply chains for acute renal replacement therapy and engendered an unprecedented
cooperation between nephrologists and intensivists, working in a less rigid and more
dynamic way across regions supporting colleagues outside usual arrangements. We
have rapidly learned to assess patients in virtual clinics, been forced to become more
fluent with setting ceilings of treatment and guiding patients and families through end-
of-life care in profoundly stressful circumstances, as well as adapting to deliver back-
ground renal medicine including transplantation, and treatment of autoimmune
diseases with the minimum possible risk. It has also reminded us of the selfless dedica-
tion, value, and, at times, vulnerability of frontline workers in the healthcare sector. We
have learned a great deal over the last 2 years and adapted rapidly in our patient’s
interests. A key question is how many of the positive aspects of practice will we pre-
serve post pandemic, and will we retain our capacity to innovate imaginatively when
things normalize?
The above questions are germane to another, greater global crisis, that of the cli-
mate emergency. It is still very difficult to discuss the scientifically backed implications
V I Preface
of global warming without seeming to resort to hyperbole. But the bottom line from
the 6th International Panel on Climate Change was that “climate change is real, man
made, rapid and unprecedented. That temperatures will continue to rise in all scenar-
ios. Species extinction, widespread disease, unlivable heat, ecosystem collapse and cities
menaced by rising seas will become painfully obvious before a child born today turns
30.” Or put it another way, approximately 1 billion, nearly half the world’s population
of children, currently live in regions at extreme risk of environmental stresses from
flooding to drought, extreme heat, ecosystem collapse, and famine. Low-income coun-
tries will bear the brunt initially, but high-income countries are already seeing extreme
weather events and a dawning of the disorder this will cause. The multitude of ways
climate change will affect patients with kidney conditions are not difficult to imagine,
but supply-chain disruption including energy, food, and water will occur. In 2019, there
were estimated to be approximately 80 million refugees or internally displace individu-
als. Extremes of heat, flooding, and famine will inevitably contribute to a huge increase
in this number. Optimizing the care of patients with lifelong CKD or those receiving
renal replacement therapy as the consequences of climate change or war, will become
increasingly demanding, especially for those who are displaced or in high-risk regions.
We face the most serious practical, ethical, and financial issues, many of which are not
difficult to predict, and yet our collective response has thus far been grossly inadequate.
The healthcare sector is responsible for roughly 5% of CO emissions, and nephrol-
2
ogy has a disproportionately large carbon footprint, so we have a particular obligation
to address this and start thinking sustainably. The good news is that, as recently dem-
onstrated, we are at our best when free to innovate and invent. In this context, there are
huge changes afoot in healthcare with rapidly developing alliances of like-minded peo-
ple and green nephrology networks aimed at sustainable change and using the financial
clout of the healthcare sector to catalyze change in providers. And then there is us,
healthcare professionals who have had a crash course in supporting each other and
remodeling, who like science, evidence, and facts, the wealth of which mean it is not
difficult to predict the challenges ahead. As a profession, we are well regarded and have
a responsibility to influence change and change the ethos of the institutions we work in
with vigor and urgency.
I hope that this edition not only serves as a useful and engaging text on nephrology
but also invites us all to ambitiously reassess practice with the aim of achieving the best
possible experience and outcomes for our patients.
Mark Harber
Hampstead
London, UK
VII
Acknowledgments
As with the previous edition, Practical Nephrology, I would like to thank again the
generosity of the numerous authors who have contributed to this book. For most, clin-
ical practice over the last 2 years has been particularly punishing and all consuming, so
I remain especially indebted to all those authors have over the years taught me much of
the nephrology I know and who contributed so generously and with such tolerance.
I am also particularly grateful to those who have very generously contributed to the
additional material used in the book, especially Sue Car and Peter Topham, Steve Holt
and Michael Ci, Mr. Peter Veitch, Arundi Mahendran, Justin Harris, Dominic Yu,
Shella Sandoval, Ramesh Batra, Hannah Deltrey-King, Amanda Rea, and David
Bishop who have produced videos that demonstrate procedures with much greater clar-
ity than I could have achieved in prose and that I hope will assist doctors in carrying
out these procedures with safety and confidence. I would particularly like to thank Paul
Sweny for his mentorship and for the gift of his collection of clinical images accumu-
lated over the years of frontline service. Histological images were generously provided
by Lauren Heptinstall, Paul Bass, Alec Howie, Catherine Horsfield, and Mared Casey-
Owen.
Once again, my heartfelt thanks to our patients who have contributed to this book
in so many ways and who remain the key motivation behind this book.
IX
Contents
I Assessment of the Renal Patient
1 Assessment of the Renal Patient ............................................................................................. 3
Maryam Khosravi, Omid Sadeghi-Alavijeh, Phil Masson, and Ben Caplin
2 U rine Analysis ....................................................................................................................................... 29
Scott R. Henderson and Mark Harber
3 Laboratory Tests in Nephrology ............................................................................................... 45
Ali M. Shendi
4 K idney Biopsy ....................................................................................................................................... 67
Lakshman Weerasekara, Nick Woodward, and Mark Harber
5 Imaging in Nephrology .................................................................................................................. 81
Ciara N. Magee, Arum Parthipun, Antony Goode, and Asmat Abro
6 IT and Data in Nephrology ........................................................................................................... 103
Thomas Oates
7 R enal Pathology .................................................................................................................................. 111
Lauren Heptinstall and Paul Bass
II Acute Kidney Injury
8 Acute Kidney Injury Epidemiology and Causes ............................................................. 153
Dilushi Wijayaratne, Chathurika Beligaswatta, and Mark Harber
9 Assessment and Investigation of Acute Kidney Injury (AKI) ................................. 181
Maria Prendecki and Ed Kingdon
10 Prevention and Treatment of Acute Kidney Injury ...................................................... 197
Dinesha Himali Sudusinghe, Yogita Aggarwal, Chris Laing, and Mark Harber
11 Establishing an AKI Service ......................................................................................................... 227
Sarah Hildebrand, Rhys Evans, and Ed Kingdon
12 Acute Renal Replacement ............................................................................................................. 239
Andrew Davenport
III Acid Base and Electrolyte Disorders
13 Common Electrolyte Abnormalities ...................................................................................... 263
Alfredo Petrosino, Domenico Bagordo, Antje Fürstenberg-Schaette, and Chris Laing
14 A cid-Base Disorders ......................................................................................................................... 299
Elizabeth R. Wan and Stephen B. Walsh
X Contents
IV Hypertension and Renovascular Diseases
15 Approach to Hypertension: Diagnosis and Investigation ...................................... 317
Roohi Chhabra, Reecha Sofat, Aroon Hingorani, and Jennifer Cross
16 Management of High Blood Pressure. .................................................................................. 335
M. Umaid Rauf and Jennifer Cross
17 Disease of the Renal Vessels ....................................................................................................... 353
Diana Vassallo, James Ritchie, Darren Green, and Philip A. Kalra
V Glomerular Diseases
18 Management of the Nephrotic Patient: The Overall Approach
to the Patient with Nephrotic Syndrome ........................................................................... 379
Gabrielle Goldet and Ruth J. Pepper
19 Management of Extracellular Fluid Volume in the Nephrotic Patient ............ 393
Liam Plant
20 Minimal Change Disease ............................................................................................................... 401
Philip David Mason
21 Focal Segmental Glomerulosclerosis. ................................................................................... 413
Philip David Mason
22 M embranous Nephropathy ......................................................................................................... 423
Sanjana Gupta and Alan D. Salama
23 Membranoproliferative Glomerulonephritis and C3 Glomerulopathy ......... 433
Daniel Gale and Mared Owen-Casey
24 IgA Nephropathy and IgA Vasculitis. ..................................................................................... 451
Haresh Selvaskandan, Chee Kay Cheung, and Jonathan Barratt
25 ANCA-Associated Systemic Small-Vessel Vasculitis .................................................... 467
Jennifer Scott and Mark A. Little
26 Renal Involvement in Large- and Medium-Vessel Vasculitis ................................. 489
Stephen P. McAdoo
27 Goodpasture’s or Anti- glomerular Basement Membrane (GBM) Disease .... 505
Alan D. Salama
28 Systemic Lupus Erythematosus, Antiphospholipid Syndrome
and the Kidney ..................................................................................................................................... 515
Eve Miller-Hodges, Christopher O. C. Bellamy, David C. Kluth,
and Neeraj Dhaun
29 Practical Immunosuppression Guidelines for Patients
with Glomerulonephritis .............................................................................................................. 531
Ruth J. Pepper and Alan D. Salama
XI
Contents
30 Infections and the Kidney ............................................................................................................ 543
Elizabeth Williams, Padmasayee Papineni, Sanjay Bhagani, and Mark Harber
31 Blood-Borne Viruses and the Kidney .................................................................................... 565
Rachel K. Y. Hung, Douglas Macdonald, Sanjay Bhagani, Mark Harber,
and John Booth
VI Tubulointerstitial Disease
32 A cute Tubulointerstitial Nephritis .......................................................................................... 585
Vasantha Muthu Muthuppalaniappan and Simon Ball
33 Acquired Chronic Tubulointerstitial Nephritis ............................................................... 599
Heidy Hendra, Mark Harber, and Ben Caplin
34 Genetic Tubulointerstitial Disease and Nephronophthisis .................................... 611
Alice Gage, Buddhika Illeperuma, and Mark Harber
VII Nephrology Interface
35 Rheumatological Conditions and the Kidney ................................................................. 623
Conall Mac Gearailt, Áine Burns, and Bernadette Lynch
36 Hepatology and the Kidney ........................................................................................................ 641
Aisling O’Riordan and Thuvaraka Ware
37 Chronic Kidney Disease: Cardiovascular Complications ......................................... 655
Katharine Pates, Ben Caplin, and David C. Wheeler
38 Management of Diabetic Nephropathy .............................................................................. 671
Bryan Conway, Jane Goddard, Alan Jaap, and Alan Patrick
39 The Endocrine System and the Kidney ................................................................................ 691
Rachel K. Y. Hung, Stephanie M. Y. Chong, and Mark Harber
40 Dermatology in Kidney Disease ............................................................................................... 711
Ferina Ismail and Rakesh Anand
41 The Nervous System and the Kidney .................................................................................... 733
Anna Nagy, Geraint Dingley, and Rebecca Liu
42 Ophthalmology and the Kidney ............................................................................................... 751
Marilina Antonelou, Zoya Hameed, Ali Abdall-Razak, Cathy Egan,
and Detlef Bockenhauer
43 Gastroenterology and the Kidney .......................................................................................... 765
Sarah Blakey and Richard W. Corbett
44 Respiratory Medicine and the Kidney .................................................................................. 775
Marilina Antonelou, James Brown, and Sally Hamour
