Chronic Renal Disease

Paul L. Kimmel,Mark E. Rosenberg

• Publisher: Academic Press
• Year: 2014
• ISBN:
  9780124116160
• Topic: Medicine
• Subtopic: Toxicology

Chronic Renal Disease comprehensively investigates the physiology, pathophysiology, treatment, and management of chronic kidney disease (CKD). This translational reference takes an in-depth look at CKD while excluding coverage of dialysis or transplantation, which are both well detailed in other textbooks and references. Chapters in the basic science sections are devoted to the scientific underpinnings of the development and progression of CKD, including consideration of different etiologic factors. Chapters in the treatment and management sections are geared towards the most common problems faced by nephrologists in the management of CKD. Each chapter relates specific illnesses to the CKD framework instead of covering only the specific illness. Readers will learn, for example, how the management of CKD in a patient with diabetic nephropathy differs from that of other CKD patients. Chapters indicate which unique complications the reader needs to be aware of when treating a specific patient or disease.

Chronic Renal Disease includes a companion web-based question and answer supplement to each chapter. This is a valuable resource to reinforce the content of the chapters. The questions are multiple-choice, clinically focused and include referenced discussions of answers. The questions can be used for medical student, resident and fellow teaching, preparation for board or maintenance of certification examinations, and clinician teaching or conference preparation.

• Provides a useful resource to professors who need to create lectures for residents and fellows, and to identify and summarize relevant literature as it relates to various research projects
• Includes multiple choice questions and answers, which can be used as a teaching tool for conferences and continuing medical education activities
• Includes coverage of classification and measurement, epidemiology, pathophysiology, complications of CKD, fluid / electrolyte disorders in CKD, CKD and systemic illnesses, clinical considerations, therapeutic considerations, and special considerations

Part I

Introduction

Outline

Chapter 1 Introduction: Chronic Renal Disease

Chapter 1

Introduction

Chronic Renal Disease

Paul L. Kimmel^a and Mark E. Rosenberg^b,    ^aDivision of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, DC, USA,    ^bDivision of Renal Diseases and Hypertension, University of Minnesota Medical School, Minneapolis, MN, USA

In our discussions as we planned this work, we were struck that no major textbook had considered the relatively new field of chronic kidney disease – CKD – as a coherent whole. It must be acknowledged that the CKD revolution has transformed the clinical and scientific landscapes of nephrology, by systematizing the classification of the protean aspects of the discipline, and setting boundaries that have allowed clinical epidemiology and clinical research to advance, perhaps exponentially. CKD classifications have led to new nomenclature for acute renal disease as well, which has proved useful. In addition, the approach has led to advances in considering acute kidney injury and CKD interrelated syndromes. Nevertheless, the classification approach must not narrow the richness of clinical observation and etiologic clarity that has characterized our field over the last century or so. This book covers broadly, but comprehensively, the history, pathophysiology, and practical approaches to diagnosis, patient care and treatment issues in CKD. The scope of the book is limited to CKD – up to the initiation of ESRD care. This delineated population, however, entails the vast majority of CKD patients.

We have specifically solicited pre-eminent authors who are experts in the scientific underpinnings as well as the clinical implications of their chosen topics to contribute to the book. Basic biologic knowledge of course is the foundation of pathophysiologic approaches and clinical therapeutics. Over the past decade, enormous advances have been made in our understanding of the genetics of kidney disease. Our appreciation of an important cause of CKD as a common disorder associated with at least one gene that plays a major role, in some populations, similar to Mendelian disease has made us reassess approaches to screening and treatment, and may revolutionize patient care, bringing personalized medicine to the CKD clinic. We understand CKD as a disease that varies across the globe, as a result of complex interactions of genetics and the environment, including poverty. Great strides have been made in our understanding of the breadth and natural history of pediatric CKD, in part because of the establishment of well-designed observational studies more than a decade ago. The role of common comorbidities such as diabetes mellitus and hypertension has been studied, but as with nutrition and its improvement in this population, much work remains to be done. Over the past two decades, the role of inflammation in CKD has been increasingly determined, but the implementation of effective treatments using this knowledge has been elusive. Treatment of organ system complications of diminution in glomerular filtration rate and uremia are at widely varying stages of development and maturity, and our evidence base in a few of these domains and in specific patient subpopulations is woefully inadequate. Although several pathways culminating in kidney disease have been identified, with diverse treatment opportunities and implications, we have learned to our chagrin that more treatment is not necessarily better treatment. We must develop and test novel therapies and interventions to prevent the initiation and ameliorate the progression of CKD. If and when the time comes, we must help our patients prepare for end-stage renal disease care. Advances in the clinical trials and basic sciences associated with CKD may help us achieve our goals – improving the quantity and quality of life of our patients with CKD.

This book, we hope, will be a reference for all who want to know about or increase their knowledge regarding any or all aspects of CKD. As befits a twenty-first-century publication, it is available in paper and electronic versions. There are specific chapters regarding considerations of certain patient scenarios or syndromes. Each chapter is grounded in the experience of a specific patient – whom we have seen, and that you have seen or will encounter over your career. Perusing the Table of Contents, a few chapters may at first blush seem duplicative, but they in fact approach problems from very different angles, with different expertise. The problems in CKD are necessarily interdigitated and overlapping. We did not want the authors to be artificially limited by chapter titles. It is hoped that each chapter is comprehensive and can stand on its own as a reference. We owe a great debt to the individual authors and thank them sincerely for their exemplary work. This book is after all just paper and bytes without them.

We set a high bar for this text. We intended the book to be patient-oriented, to deal with common clinical problems, but at the same time to be synoptic in scope, broadly inclusive, scientific and useful as a reference for therapy. We believe that the authors have achieved this goal!

This book is knowingly and specifically titled Chronic Renal Disease to highlight its embedding in the scientific literature. “Kidney” is the Middle English term for the organ we love. “Renal” and “nephrology” (from the French and Greek respectively) are scientific terms for use by professionals. As we grappled with “hypertension” compared with “high blood pressure” in our educational youth, we had to learn a nomenclature as we developed medical expertise. As “hypertension” and “high blood pressure” mean the same thing, “kidney” and “renal” are equivalent, while at the same time having different, important connotations. The intellectual mansion built by our predecessors, Bright, Addis, Peters, Richards and Smith, to name a few, has many rooms. In keeping with the scientific focus of Chronic Renal Disease, all the book chapters are grounded in basic and clinical scientific principles, so the clinical characteristics and therapy of the individual topic under consideration in each chapter can be appreciated as a logical development from previous knowledge. Controversial issues are highlighted and dealt with clearly, directly and emphatically. When there are gaps or deficiencies in the literature, or in our therapeutic knowledge – and there are – these are clearly acknowledged. This is a book for clinicians and scientists, not necessarily the lay public.

We hope this book will serve people interested in clinical chronic kidney disease from many communities – ranging from medical students, to residents, internists and pediatricians, to renal fellows, and nephrology faculty including researchers and practitioners. Educational principles have advanced as well over the last decades. We know that different readers, including those who tackle a subject from varying levels and perspectives, learn in different ways. Each chapter is accompanied by multiple choice questions. We conceived the questions as an integral part of the book – complementing the chapters, and functioning as both self-study tools and the point of departure for discussion in clinical conferences. The electronic version of the text and questions will help mobile users keep current on the go. In accord with current notions of CKD, a set of abbreviations has been used consistently throughout the text.

We are interested in your feedback and constructive and other criticisms. Please let us know what you think of the book – including overall perceptions and comments regarding individual chapters. You are encouraged to contact us – with your kudos and concerns – by contacting our publisher. We hope you enjoy the book and find it useful simultaneously.

Paul L. Kimmel

Mark E. Rosenberg

Part II

Classification and Measurement

Outline

Chapter 2 From Bright’s Disease to Chronic Kidney Disease

Chapter 3 Classification of Chronic Kidney Disease – Historic Perspective: From Insufficiency and Failure to Chronic Kidney Disease

Chapter 4 Assessing Kidney Function

Chapter 5 Clinical Assessment and Management of Chronic Kidney Disease Across its Stages

Chapter 2

From Bright’s Disease to Chronic Kidney Disease

Steven J. Peitzman, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA

In the 1820s and 1830s, Richard Bright of Guy’s Hospital in London showed that dropsy (edema) when associated with heat-coagulable urine (albuminuria) predicted one or another form of pathologically altered kidneys at autopsy. His first cases were of hospitalized patients, but he later recognized and described indolent cases, what we would call chronic disease. Subsequent pathologists created classification schemes for chronic renal disease. In the late 19th century, a movement called “functional diagnosis” turned attention to the kidney’s “power” in health and disease, using tests of excretion and concentration. Here arose terms such as “chronic renal failure” which persisted into the 1990s. The notion of renal “work” led to attempts to “rest” the presumably overworking nephrons of impaired kidneys with the low-protein diet. Key figures were Thomas Addis in the period 1920s–1940s, and Barry Brenner in the later decades of the 20th century. Meanwhile, clinicians identified various causes of chronic kidney disease, only in recent decades including diabetes. Treatment from Bright’s time onward aimed at reducing symptoms, such as edema, until concepts of hyper-filtration and injurious effects of proteinuria prompted therapies (beyond diet) aimed at slowing progression. With a sense that the course of chronic renal disease if identified early might be favorably influenced (particularly by inhibition of the renal-angiotensin-aldosterone axis), nephrologists in the United States and elsewhere through their organizations effected changes in nomenclature (e.g. “kidney” not “renal”) and other measures to de-mystify and raise awareness of kidney disease. The hope was that earlier detection might allow interventions to slow progression and thus avoid or delay the need for renal replacement therapy.

Keywords

Richard Bright; Thomas Addis; Barry Brenner; Robert Platt; History; Functional diagnosis; Classification; Nomenclature; Progression; Low-protein diets

Bright’s Disease

In 1840, Richard Bright (1789–1858), the first authority on proteinuric kidney disease, who unintentionally provided the disorder’s earliest name, described what we would call a chronic case.¹ The patient, presumably from Bright’s private practice, was a “man, aged about 25, pale and scrofulous in appearance, and deeply pitted with the small-pox,” who, in early March of 1835, “came to me, labouring under anasarca, and having albuminous urine.” His illness began with a bout of diarrhea. As he recovered, the young man was able to spend a month in the country, but there “his legs began to swell, and anasarca proceeded up his thighs and abdomen.” Bright found the urine “exceedingly coagulable” and “frothy on agitation.” The patient tended to pass large, not small, quantities of urine. “I ordered him to adopt most strictly a milk diet, and to put on warm clothing, with flannel next to the skin.” Because the stomach “sympathized” with the skin and kidneys, its irritability had to be quieted with an easy diet and gentle medicines such as bicarbonate of soda.

The patient improved briefly, with less coagulability of the urine, but in April developed some cough, and his “skin inclined to be dry.” Bright prescribed again some ipecac, as a diaphoretic and “expectorant.” By June the patient had improved greatly, his swelling was almost gone, though the urine still “froths much.” Then a painful “periosteal enlargement” appeared on his left shin, which the patient feared was the reappearance of “some venereal symptoms,” presumably syphilis. Bright prescribed a concoction for this. By July 9 the patient was again “greatly improved” and the reader now learns that he was able to return to his work as a bookbinder. Bright d...