Front Cover 1
Chronic Renal Disease 4
Copyright Page 5
Contents 6
List of Contributors 10
Abbreviations 14
I. Introduction 16
1 Introduction 18
II. Classification and Measurement 20
2 From Bright’s Disease to Chronic Kidney Disease 22
Bright’s Disease 22
Pathologies 24
Physiologies 24
Causes 27
Treatments and Progression 29
CKD 31
References 33
3 Classification of Chronic Kidney Disease – Historic Perspective: From Insufficiency and Failure to Chronic Kidney ... 35
Introduction 35
Definition and Classification OF CKD 36
Awareness of CKD 37
Limitations of the CKD Definition and Classification 37
General Population CKD Screening 39
Targeted Screening 39
Targeted Screening: Diabetes, Hypertension and Old Age 39
Targeted Screening: CVD 40
Targeted Screening: Family history of CKD 40
Targeted Studies: Ethnic and Racial Minorities 40
Identity of CKD in Primary Care 40
Blood Pressure Control in CKD 40
Patient Safety in CKD 41
Clinical Research 42
Estimated GFR Reporting 42
Detection of CKD 43
Drug Prescription Practice and Patient Safety 43
Nephrology Consultation 43
Conclusion 44
Acknowledgment 44
References 44
4 Assessing Kidney Function 46
What is Kidney Function? 46
What is Glomerular Filtration Rate? 46
Physiological variation in GFR 46
Age-Related Decline in GFR 47
Direct Measurement of GFR 48
Exogenous Filtration Markers 48
Urinary and Plasma Clearance 48
Clinical Indications for Measured GFR 49
Endogenous Filtration Markers 50
Serum Creatinine 50
Urinary Creatinine Clearance 50
Cystatin C 50
Other Markers 50
Estimation of Measured GFR 51
The “Estimated GFR Construct” 51
Specific Equations Used in Clinical Practice 52
Ethnicity 53
Elderly 53
Limitations of Estimated GFR 53
Conclusions 53
References 54
5 Clinical Assessment and Management of Chronic Kidney Disease Across its Stages 58
Introduction 58
Overview of CKD 58
Estimating GFR 59
Diagnostic Considerations 61
Treatment of CKD 61
Specific Treatment Recommendations 63
Adjustment of Drug Dosages 63
Management of Hypertension 63
Cardiovascular Disease 64
Other Treatments 65
Delivery OF CKD Care 66
Conclusion 66
References 66
III. Epidemiology 70
6 Epidemiology of Chronic Kidney Disease: Scope of the Problem 72
Introduction 72
Background 72
Definition of CKD 72
Assessment of GFR and Urine Albumin Excretion 73
Prevalence of CKD 74
CKD and Outcomes 75
CKD and All-Cause Mortality 75
CKD and CVD 76
Global Burden OF CKD 77
Defining the Global Burden of Disease 77
CKD as a Contributor to the GBD 77
CKD in Population Sub-Groups 77
Major Risk Factors for CKD 79
Hypertension 79
Diabetes 79
Obesity 79
Metabolic Syndrome 80
Limitations and Caveats 80
Conclusion: Scope of the Problem of CKD 80
References 80
7 Gender Issues in Chronic Kidney Disease 84
Introduction 84
Gender and Non-Diabetic CKD 84
Gender and Diabetic CKD 86
Factors Contributing to Gender Differences in Renal Disease Progression 87
Direct Effects of Sex Hormones on Cellular Biology 87
Therapeutic Implications 91
Conclusion and Future Directions 92
Acknowledgments 92
References 92
IV. Pathophysiology 96
8 The Uremic Syndrome 98
Introduction 98
Signs and Symptoms of Uremia 98
Well-Being and Physical Function 99
Neurologic Function 100
Appetite, Taste and Smell 100
Cellular Functions 100
Causes of Persistent Uremia with Current ESRD Therapy 101
Properties of Poorly Dialyzed Solutes 101
Large Molecule Solutes 101
Protein-Bound Solutes 102
Sequestered Solutes 102
Other Solutes with Very High Clearance by Native Kidneys 103
Sources of Retained Solutes 103
Removal of Useful Vitamins and Minerals with Dialysis 103
Prospects for Advances in Uremia Therapy 104
Conclusions 104
References 104
9 The Pathophysiology of Proteinuria 107
Introduction 107
Pathogenesis of Albuminuria 108
The Endothelium 108
Mesangium 110
The Glomerular Basement Membrane 110
The Podocyte 111
Tubular Albumin Transport 113
Tubular Handling of Non-Albumin Proteins 115
Renal Consequences of Albuminuria 116
Conclusion 116
References 117
10 Protein Energy Metabolism in Chronic Kidney Disease 121
Scope of the Problem 121
Pathophysiology of PEW 121
Anorexia and Nutrient Insufficiency 121
Energy Balance 123
Hormonal Dysfunction 124
Insulin Resistance 125
Growth Hormone Resistance 125
Testosterone 126
Metabolic Acidosis 126
Inflammation 126
Muscle Biology Dysfunction 127
Oxidative Stress 128
Comorbidities 128
Diagnosis of PEW in CKD 128
Treatment of PEW in CKD 130
Ghrelin 131
Insulin Resistance and Sensitivity 131
Testosterone 131
Recombinant Human Growth Hormone 131
Exercise and Resistance Training 132
Inflammation 132
Metabolic Acidosis 132
Diet and Nutritional Supplements 133
Recommendations and Guidelines 134
Conclusions 135
References 136
11 Aging and the Kidney: Clinical and Pathophysiological Issues 141
Introduction 141
Pathophysiology 142
Structural and Morphologic Changes 142
Clinical and Functional Changes 143
Pathogenesis 145
Diagnosis 147
Treatment 147
Summary 148
References 148
12 Pathophysiology of Progression: Organ and Cellular Considerations 151
Introduction 151
Compartmental Processes 151
Glomerular Processes 151
Tubular Processes 152
Tubular Trafficking of Reabsorbed Proteins 152
Tubular Injury as the Basis for CKD 153
Maladaptive Tubular Responses in Surviving Nephrons 153
Hematuria-Induced Tubular Injury 154
Interstitial Processes 154
Interstitial Inflammation 154
Interstitial Fibrosis 154
Capillary Rarefraction 155
Specific Mediators and Inhibitors of Chronic Kidney Disease 155
Transforming Growth Factor-ß 155
The Renin–Angiotensin–Aldosterone System 157
Oxidative Stress 157
Endothelin 158
Micro RNAs 159
Wnt Signaling 159
Heme Oxygenase 160
Acid–Base Status 160
Conclusions 161
Acknowledgments 161
References 161
13 Pathophysiology of Diabetic Nephropathy 166
Introduction 166
Pathology 166
Clinical Course 167
Stage I 167
Stage II 168
Stage III 168
Stages IV and V 169
Metabolic Mechanisms of Diabetic Nephropathy 169
Glucose Metabolism Pathways 169
Advanced Glycation Reactions 170
Protein Kinase C Signaling 171
Oxidative Stress 171
Glomerular Hemodynamics and the Renin-Angiotensin-Aldosterone System 171
Tgf-ß is the Downstream Mediator of ECM Accumulation in Dn 172
Genetic Risk Factors 172
Conclusion 173
References 173
14 Pathophysiology of Hypertension in Chronic Kidney Disease 178
Scope of the Problem and Public Health Implications 178
Pathophysiology of Hypertension in CKD 179
Sodium Retention and Fluid Retention 179
Raas Hyperactivation 180
Sympathetic Nervous System Hyperactivation 180
Vascular Endothelial Dysfunction 181
Drugs and Other Exposures 182
Conclusion 182
References 183
15 Chronic Kidney Disease and Vascular Endothelium 185
Development and Lifespan of Vascular Endothelium 185
Structural Components of Renal Microvasculature 186
Primary Endothelial Dysfunction Leading to Kidney Disease 186
Angiogenic Incompetence in CKD 187
Endothelial Cell Dysfunction in CKD – Genetic Screen 188
Metabolic Abnormalities in Endothelial Cell Dysfunction 189
Premature Endothelial Cell Senescence in CKD 189
Endothelial–Mesenchymal Transition and the Role of TGF-ß and Endostatin Signaling 190
Lymphatic Endothelium 191
Microvascular and Tissue Regeneration: Role of Stem and Progenitor Cells 191
Endothelium, First Heal Thyself – Therapeutic Strategies 192
Inhibitors of Angiotensin II Action 192
Summary 192
References 193
16 Cardiovascular Disease and Chronic Kidney Disease 196
Introduction 196
Burden of Disease 196
Risk Factor 196
Prognostic Factor 197
Structural Cardiovascular Abnormalities 198
Pathophysiology 198
Coronary Artery Disease 198
Microvascular Disease 199
Dysregulation of Energy Metabolism 199
Arteriosclerosis 199
Vascular Calcification 200
Left Ventricular Hypertrophy 200
Valvular Disease 202
Congestive Heart Failure 202
Atrial Arrhythmias 202
Sudden Death 202
Diagnosis 203
Coronary Artery Disease 203
Biomarkers for Ischemic Heart Disease 203
Non-Invasive Testing for CAD 203
Computed Tomography 204
Coronary Angiography 204
Arteriosclerosis 204
Cardiomyopathy 205
Therapy 205
Treatments Aimed at Precursor Risk Factors 205
Treatment for Clinically Evident Cardiovascular Disease 207
Atrial Fibrillation 208
Coronary Atherosclerosis 208
Carotid and Peripheral Vascular Atherosclerosis 208
Sudden Cardiac Death Prevention 209
Conclusions 209
References 209
17 Inflammation in Chronic Kidney Disease 214
Introduction 214
Scope of the Problem 214
Prevalence of Inflammation in CKD 214
Determinants of Inflammation 214
Genetics of Inflammation 214
Pathophysiology of Inflammation in CKD 216
Mediators of Inflammation 216
Etiology of Inflammation 218
Damage/Danger-Associated Molecular Patterns and Pathogen-Associated Molecular Patterns 218
Diagnosis of Inflammation 218
Utility of Inflammatory Biomarkers 218
Is CRP an Ideal Biomarker of Inflammation in CKD? 219
Consequences of Inflammation 219
Progression of CKD 219
Progression of Cardiovascular Disease 220
Protein Energy Wasting 220
Insulin Resistance 221
Anemia of CKD 221
Infection and Inflammation in CKD 221
Inflammation and Depression 221
Treatment of Inflammation in CKD 221
Targeting Inflammation through Pharmacological Manipulation of Inflammatory Cell Responses 221
Targeting Inflammation through Reduction of Source of Ligands 222
Direct Anti-Inflammatory Therapies 222
Conclusion 223
References 223
18 Genetics and Chronic Kidney Disease 228
Introduction 228
Non-Diabetic Glomerular Diseases Leading to CKD 228
Diabetes-Associated Chronic Kidney Disease 230
Kidney Disease Genes in Immunoglobulin A Nephropathy and Lupus Nephritis 231
FSGS and Diffuse Mesangial Sclerosis 232
GWAS for Estimated GFR and Albuminuria in General Populations 233
Inherited Interstitial Nephropathies 234
Autosomal Dominant Interstitial Renal Disease 234
Autosomal Recessive Nephronophthisis 236
Inherited Conditions of Renal Failure with Nephrocalcinosis 236
Approach to Diagnosis and Therapy 237
Summary 237
References 237
V. Complications of Chronic Kidney Disease 242
19 Psychosocial Issues in Chronic Kidney Disease Patients 244
Introduction 244
Psychopathology 244
Depression 244
Other Psychopathology 245
Quality of Life 246
Quality of Life Definitions 246
Threats to Quality of Life 246
Adherence 247
Medical Prescription 247
Evidence of Non-Adherence 247
Barriers to Adherence 248
Effects of Non-Adherence 248
Mental Health Disparities 249
Conclusions 249
References 249
20 Ophthalmic Issues in Chronic Kidney Disease 252
Introduction 252
Ophthalmic Findings in Hypertensive Nephropathy 252
Ophthalmic Complications in CKD Patients 252
Retinopathy and Other Fundus Pathology 252
Ocular Calcification 253
Intraocular Pressure 254
Cataracts 254
Optic Neuropathy 254
Macular Degeneration 254
Ophthalmic Findings in Diabetes 255
Epidemiology of Diabetic Retinopathy 255
Risk Factors for Progression of Retinopathy 255
Non-Proliferative Diabetic Retinopathy 255
Proliferative Diabetic Retinopathy (PDR) 256
Macular Edema 256
Management 257
Oculorenal Systemic Diseases 257
Autoimmune Diseases 257
Genetic Conditions 259
Conclusion 261
References 261
21 Neurologic Complications of Chronic Kidney Disease 264
Introduction 264
Cognitive Impairment in CKD 264
Definitions of Cognitive Impairment (in the Non-CKD and CKD Populations) 264
Epidemiology of Cognitive Impairment in CKD 265
Pathophysiology of Cognitive Impairment in CKD: The Brain–Kidney Connection 266
Uremic Encephalopathy 267
Model of Pathways Leading to Cognitive Impairment in CKD 267
Risk Factors for Cognitive Impairment in CKD 267
Importance of Making the Diagnosis of Cognitive Impairment: Avoiding Adverse Outcomes of a Missed Diagnosis 268
Cognitive Impairment Screening Instruments 268
Diagnosis of Cognitive Impairment 268
Treatment of Cognitive Impairment in CKD Patients 269
Health Policy Implications 270
Conclusion 270
The Epidemiology of Stroke in Chronic Kidney Disease 270
Stroke Risk in CKD 270
Risk Factors and Mediators of Stroke 271
Erythropoiesis-Stimulating Agents and Stroke Risk 272
Primary and Secondary Stroke Prevention 273
Conclusion 274
Neurological and Muscular Disease 275
Uremic Somatic Polyneuropathy 275
Uremic Autonomic Neuropathy 275
Uremic Mononeuropathies 276
Uremic Pruritus 276
Uremic Myopathy 276
Conclusion 277
Summary 277
References 277
22 Hematologic Complications of Chronic Kidney Disease: Erythrocytes and Platelets 281
Anemia of CKD 281
Erythropoiesis and Erythropoietin 282
Iron and Anemia of CKD 283
Erythrocytosis in Patients with CKD 284
Disorders of Platelets and Coagulation 285
Treatment of Uremic Bleeding 285
Conclusions 287
References 287
23 Hematologic Complications of Chronic Kidney Disease: Leukocyte and Monocyte Function 292
Introduction 292
The Immune System 292
Responses 293
CKD-Related Immune and Leukocytic Dysfunction 295
Effects of CKD on Innate Immunity 295
Effects of CKD on Adaptive Immunity 296
Specific Uremic Toxins Related to the Immune Dysfunction 297
Conclusion 297
References 298
24 Immune Function in Chronic Kidney Disease 300
Epidemiology and Background 300
Structure and Function of the Immune System 300
CKD-Associated Immune Deficiency 302
CKD-Associated Inflammation 303
Effects of CKD on Components of Innate Immunity 303
Monocytes and Macrophages and Their Abnormalities in CKD 303
Polymorphonuclear Leukocytes and Their Abnormalities in CKD 304
Dendritic Cells and Their Abnormalities in CKD 304
Natural Killer Cells and Their Abnormalities in CKD 305
Role of Intestinal Epithelium and Other Non-Immune Cells 305
Components of Adaptive Immunity and Their Abnormalities in CKD 306
T Lymphocytes 306
Helper T Cells 306
Cytotoxic T Lymphocytes 306
Memory T Cells 306
Regulatory T Cells 306
CKD-Associated T Cell Abnormalities 306
B Lymphocytes 307
CKD-Associated B Cell Abnormalities 307
Clinical Considerations 308
The Role of Vitamin D and CKD-Mineral Bone Disorders 308
Role of Iron Deficiency and Iron Overload on CKD-Associated Immunological Disorders 309
Conclusions 309
References 309
25 Chronic Kidney Disease and Gastrointestinal Disorders 313
Introduction 313
Gastrointestinal Symptoms in CKD Patients 313
Dysgeusia 313
Anorexia 313
Hiccups 315
Stomatitis and Salivary Gland Inflammation 315
Nausea and Vomiting 315
Gastroesophageal Reflux Disease and Dyspepsia 316
Gastritis, Duodenitis, Upper Gastrointestinal Hemorrhage 316
GI Hemorrhage Presentation and Diagnosis 316
Pathogenesis of GI Hemorrhage in CKD 316
Diseases of the Colon 318
Diverticulosis 318
Constipation 318
Diarrhea 319
Gastroparesis 320
Disorders of the Pancreas 320
Disorders of the Gall Bladder 321
Gastrointestinal Tract Disorders Associated with Renal Injury and CKD 321
Inflammatory Bowel Disease 321
Gastric Bypass and Renal Injury 321
Amyloidosis 321
Medications 321
Summary 322
References 322
26 Endocrine Complications of Chronic Kidney Disease 325
Introduction 325
Sexual Function in CKD 325
Male Sexual Dysfunction in CKD 325
Female Sexual Dysfunction 327
Growth Hormone in CKD 328
GH/IGF-I Axis 328
Effect of Growth Failure in Children and Adults with CKD 328
Recombinant Growth Hormone Therapy in CKD 329
Thyroid Dysfunction in CKD 329
Effects of Thyroid Hormones on Renal Development and Physiology 329
Effects of Thyroid Dysfunction on the Kidney 329
Hypothyroidism 329
Hyperthyroidism 331
CKD and Thyroid Dysfunction 331
Other Kidney Diseases Associated with Thyroid Dysfunction 331
Conclusion 332
References 332
27 Disorders of Mineral and Bone Metabolism in Chronic Kidney Disease 335
Introduction 335
Pathobiology 335
Pathogenesis 336
Pathogenic Factors in the CKD-MBD 337
Pathology of Renal Osteodystrophy 339
Predominant Hyperparathyroid Bone Disease, High Turnover ROD, Osteitis Fibrosa 340
Low-Turnover Bone Disease, Adynamic Bone Disorder 340
Mixed Uremic Osteodystrophy, High Turnover ROD Plus a Mineralization Defect 340
Associated Features 340
Osteoporosis and Osteosclerosis 340
Bone Aluminum, Iron, Lanthanum, and Bisphosphonate Accumulation 341
Heterotopic Mineralization, Calciphylaxis, and Tumoral Calcinosis 342
Bone Pain, Fractures and Skeletal Deformities 342
Summary and Conclusion 342
Acknowledgments 342
References 343
28 Sleep and Sleep Disorders in Chronic Kidney Disease 347
Introduction 347
Insomnia 347
Pathogenesis 348
Impact 349
Diagnosis and Treatment 350
Sleep Disordered Breathing 351
Prevalence 351
Pathogenesis 351
Significance of OSA and CKD 355
Diagnosis and Treatment 356
Restless Legs Syndrome (Willis–Ekbom Disease) 357
Prevalence 357
Pathogenesis 357
Significance of RLS in CKD 358
Treatment 358
Conclusion 359
Acknowledgments 359
References 359
29 Sexual Dysfunction in Chronic Kidney Disease 365
Sexual Dysfunction Among Men with CKD 365
Scope of the Problem 365
Pathophysiology 365
Diagnosis 367
Treatment 368
CKD-Related Factors 370
Conclusions 371
Sexual Dysfunction Among Women with CKD 371
Scope of the Problem 371
Pathophysiology 371
Diagnosis 373
Treatment 373
Conclusions 375
References 375
VI. Fluid/Electrolyte Disorders in Chronic Kidney Disease 380
30 Water Metabolism in Chronic Kidney Disease 382
Epidemiology of Impaired Water Homeostasis in CKD 382
Pathophysiology of Impaired Concentrating and Diluting Abilities in CKD 384
The Renal Concentrating Mechanism in CKD 384
Proposed Mechanisms for the Impaired Urinary Concentration in CKD 384
Urinary Dilution in CKD 386
Clinical Implications of Impaired Water Homeostasis in CKD Patients 387
Treatment of Dysnatremias in Patients with CKD 388
Normal Saline for Volume Repletion 388
Pharmacologic Agents that Inhibit Antidiuretic Hormone Action 388
Water Restriction 388
Loop Diuretics 388
Summary 388
References 389
31 Sodium Metabolism in Chronic Kidney Disease 390
Sodium Homeostasis and Sodium Metabolism 390
Alterations and Adaptations in CKD 390
Body Fluid Spaces 390
Control Systems 391
Role of Mineralocorticoids 391
Natriuretic Peptides 391
Magnification Phenomenon 391
Adaptation to Changes in Sodium Intake 392
Clinical Implications 392
Rate of Altering Sodium Intake or Excretion 392
Sodium and Hypertension in CKD 393
Progression of CKD 393
Clinical Guidelines 393
Use of Diuretics 394
Effects of Other Drugs 394
Summary 394
References 394
32 Potassium Metabolism in Chronic Kidney Disease 396
Introduction 396
Scope of the Problem 396
Normal Potassium Homeostasis 397
Normal Renal Potassium Handling 397
Potassium Homeostasis in Acute Kidney Injury 398
Potassium Homeostasis in CKD 398
Extrarenal K+ Homeostasis in CKD 399
Gastrointestinal Excretion of K+ in CKD 400
Approach to the Hyperkalemic Patient with CKD 400
A. Impaired Renal Excretion 401
B. Decreased Distal Delivery of Sodium 401
C. Primary Decrease in Mineralocorticoid Activity 401
Distal Tubular Defects 402
Treatment of Hyperkalemia in the CKD Patient 403
Conclusion 403
References 403
33 Pathophysiology of Calcium, Phosphorus, and Magnesium in Chronic Kidney Disease 406
Calcium 406
Phosphorus 411
Intestinal Phosphate Absorption in CKD 412
Renal Handling of Phosphate in CKD 413
Consequences of Disruption of Phosphate Homeostasis in CKD 413
Magnesium 415
Summary 416
References 417
34 Acid–Base Metabolism in Chronic Kidney Disease 421
Classes of Biologically Important Acids 421
Metabolic Acidosis Due to Metabolizable Acids 422
Metabolic Acidosis Due to Non-Volatile Inorganic Acids and/or Non-Metabolizable, or Poorly Metabolizable, Organic Acids 422
Normal Renal Acid Excretion 422
Bicarbonate Reclamation (Reabsorption) 423
HCO3 Regeneration and Generation/NH4 and Titratable Acid Excretion 424
Chronic Kidney Dysfunction and Metabolic Acidosis 425
Renal Acidosis – Hyperchloremic vs. Anion Gap 425
Effect of Generalized Renal Dysfunction on Renal Tubule Proton Secretion 427
Acid Balance in Chronic Renal Disease States 428
Harmful Effects of Chronic Metabolic Acidosis 428
Skeleton 428
Muscle and Albumin 429
Endocrine Effects 429
Impact on Progression of Renal Dysfunction 429
Treatment of Metabolic Acidosis of Chronic Renal Dysfunction 430
Conclusion 430
References 431
35 Uric Acid Metabolism and the Kidney 433
Introduction 433
Uric Acid Metabolism 433
Generation of Uric Acid 433
Excretion of Uric Acid 433
Causes of Hyperuricemia and Hypouricemia 434
Hyperuricemia 434
Hypouricemia 435
Uric Acid and Renal Disease 436
Hyperuricemia as a Primary Cause of CKD 436
New Insights Regarding the Entity of Primary Hyperuricemic Nephropathy 436
Clinical Manifestations of Hyperuricemic Nephropathy 438
Role of Hyperuricemia in Progression of CKD 438
Role of Uric Acid-Lowering Therapy in CKD 439
Uric Acid and ESRD 439
Hyperuricemia, Hypertension, and Metabolic Syndrome 439
Challenges to the Uric Acid Hypothesis 439
Should People with CKD and Hyperuricemia be Treated? 440
Conclusions 440
References 440
36 Trace Elements in Patients with Chronic Kidney Disease 444
Introduction 444
Trace Metals and CKD 444
Renal Transport of Cationic Metals 444
Renal Toxicity of Cationic Metals 447
Individual Trace Metals and CKD 447
Zinc 447
Copper 447
Manganese 448
Cadmium 448
Cobalt 448
Gadolinium 448
Strontium 449
Platinum 449
Uranium 449
Nickel 449
Thallium 449
Lanthanum 449
Bismuth 450
Toxicity Due to Metals in Patients With CKD 450
Lead 450
Mercury 450
Aluminum 451
Metalloids in Chronic Kidney Disease 451
Arsenic 451
Polonium 451
Other Trace Elements in CKD 451
Fluoride 451
Selenium 452
Summary 452
References 452
VII. Chronic Kidney Disease and Systemic Illnesses – Clinical Considerations 456
37 Approach to the Patient with Chronic Glomerular Disease 458
Introduction 458
Nephrotic Syndromes and Chronic Kidney Disease 459
Minimal Change Disease 459
Membranous Nephropathy 459
Focal Segmental Glomerulosclerosis 460
Nephritic Syndrome and Chronic Kidney Disease 461
Post-Infectious Glomerulonephritis 461
IgA Nephropathy 461
Lupus Nephritis 463
Pauci-Immune Glomerulonephritis 463
Antiglomerular Basement Membrane Disease 464
Membranoproliferative Glomerulonephritis 464
Other Glomerular Diseases 465
Thrombotic Microangiopathies 465
Inherited Glomerulopathies 465
Conclusion 465
References 466
38 Approach to the Patient with Hypertensive Nephrosclerosis 470
Introduction 470
Scope of the Problem and Public Health Implications 470
Pathophysiology 471
Mechanisms of Renal Injury in Hypertension 471
Genetic Susceptibility 473
Morphological Features of Hypertensive Nephrosclerosis 474
Diagnosis 475
Establishing the Diagnosis of HN 475
Evaluation of Hypertension 476
Treatment 477
Blood Pressure Goals 478
Overall Management Approach and Drug Choices 478
Summary 481
References 481
39 Approach to the Patient with Chronic Kidney Disease and Renovascular Disease 485
Scope of the Problem 485
Definition and Prevalence 485
Pathophysiology of CKD with Renovascular Disease 487
Hemodynamic Features Specific to the Kidney 487
Mechanisms of Kidney Injury Beyond Arterial Occlusive Disease 487
Large Vessel Pathology 487
Small Vessel Changes 488
Transition to Inflammatory Injury 488
Fibrogenesis 490
Clinical Syndromes With RVD and CKD 490
Diagnostic Considerations in CKD Associated with RVD 492
The State of the Kidney 492
Treatment of Ckd Associated with RVD 493
Medical Therapy for CKD Associated with RVD 493
Renal Revascularization for CKD Associated with RVD 493
Adjunctive Therapy: The Role of Cell-Based Therapy and Other Protective Measures 495
Conclusion 495
References 496
40 Polycystic Kidney Disease 499
Scope of the Problem 499
Pathophysiology 499
ADPKD 499
ARPKD 504
Diagnosis 505
ADPKD 505
Differential Diagnosis of ADPKD 506
Genetic Testing in ADPKD 507
Diagnostic Screening in Individuals at Risk for ADPKD 508
ARPKD 509
Management and Treatment 510
Slowing Disease Progression 510
Symptomatic Care – ADPKD 511
Counseling 512
Symptomatic Care – ARPKD 512
Conclusions 513
Acknowledgments 513
References 513
41 Lupus Nephritis 516
Introduction 516
Pathogenesis of Kidney Injury in Lupus Nephritis 516
Clinical Manifestations of Lupus Nephritis 517
Clinical Presentation 517
Laboratory Findings 518
Kidney Biopsy Findings 518
Treatment 520
General Treatment Concepts 520
Proliferative Lupus Nephritis: Induction Therapy 520
Proliferative Lupus Nephritis: Maintenance Therapy 522
Membranous Lupus Nephritis 523
Conclusions 524
References 524
42 Chronic Kidney Disease and Sickle Cell Disease 528
Introduction 528
Renal Syndromes Associated With Sickle Cell Disease 528
Hematuria 528
Defective Concentrating Ability 529
Renal Tubular Acidosis 530
Proximal Tubular Function Disorders 530
Glomerular Hyperfiltration, Microalbuminuria and Proteinuria 530
Acute and Chronic Kidney Injury 531
Renal Medullary Carcinoma 531
Renal Anatomic and Pathologic Findings Associated With Sickle Cell Disease 531
Renal Pathophysiologic Mechanisms 532
Hematuria 532
Glomerular Hyperfiltration 532
Viscosity-Vaso-Occlusion Phenotype 533
Hemolysis-Endothelial Dysfunction Phenotype 533
The Kinin-Kallikrein System and Hyperfiltration 534
Progressive CKD 534
Ischemic Model of Chronic SCN 534
Genetic Factors 534
Genetic Modifiers 535
Treatment 535
Summary 536
References 536
43 Approach to Chronic Kidney Disease in the Diabetic Patient 538
Introduction 538
Natural History and Diagnosis of Diabetic Nephropathy 538
Management of Diabetic Nephropathy 540
Glycemic Control 540
Blood Pressure Control and ACEI and ARB Therapy in DKD 541
Lipid Control 543
Dietary Protein Restriction 544
Other Lifestyle Modifications 544
Diabetes in ESRD 544
Summary 544
References 545
44 Human Immunodeficiency Virus Infection and Chronic Kidney Disease 549
Introduction 549
History 549
Renal Syndromes that Cause CKD in HIV Patients 550
Acute Kidney Injury 550
HIV-Associated Nephropathy 550
HIV Associated Immune Complex Renal Disease 551
Thrombotic Microangiopathy and HIV Infection 553
Tubulointerstitial Renal Diseases and HIV Infection 553
cART Nephropathy 553
Epidemiology of CKD in Patients with HIV Infection 554
Screening for CKD in HIV Patients 554
Treatment of Chronic Kidney Disease in HIV-Infected Patients 555
Kidney Transplantation for HIV Patients 555
Conclusion 556
Acknowledgments 556
References 556
45 Chronic Kidney Disease and Liver Disease 559
Kidney Disease Associated with Liver Disease 559
Overview 559
Hepatitis B Virus and CKD 561
Hepatitis C Virus and CKD 562
HCV and Glomerular Disease 562
Kidney Disease Associated with Cirrhosis 563
Pathophysiology 563
Diagnosis 565
Defining Kidney Disease in Cirrhosis 566
Differential Diagnosis of Kidney Disease in Cirrhosis: HRS and Beyond 566
Treatment 567
Prevention 568
General Measures 569
Pharmacologic Treatment 569
TIPS 570
Liver versus Simultaneous Liver–Kidney Transplantation 571
Conclusion 571
References 572
46 Chronic Kidney Disease and Heart Failure – A Nephrologic Approach 575
Background 575
Epidemiology 576
Pathophysiology of Heart Failure in CKD 578
Prevention and Treatment of Heart Failure in CKD 579
Summary 583
References 584
47 Cancer and Chronic Kidney Disease 586
Introduction 586
Lymphomatous Infiltration of the Kidney and CKD 587
Chemotherapy-Induced CKD 587
Paraneoplastic Glomerular Diseases and CKD 588
CKD Associated with Hematopoietic Stem Cell Transplantation 590
CKD Associated with Renal Cell Carcinoma 591
Kidney Disease Associated with Plasma Cell Dyscrasias and Paraproteins 591
Detection of Monoclonal Ig 592
Monoclonal Ig Deposition Disease 592
AL Amyloidosis 592
Monoclonal Gammopathy of Undetermined Significance and CKD 593
Treatment Issues in the Patient with CKD 593
Management of Anemia in the Patient with CKD and Cancer 594
Chemotherapy Dosing in CKD 595
Conclusion 596
Onconephrology, a New Focus in Nephrology 596
References 596
VIII. Therapeutic Considerations 600
48 The Interdisciplinary Chronic Kidney Disease Clinic 602
Scope of the Problem 602
Definition of CKD Clinic: Models of Interdisciplinary Care 603
Who Will Benefit from Interdisciplinary Care 604
Proteinuria 604
Rate of Change in GFR 604
Age 604
Goals of Treatment for a CKD Clinic 604
Patient Education 605
Cardiovascular Risk Management 605
Progression of CKD 606
Preparation for ESRD 606
Hemodialysis 606
Peritoneal Dialysis 607
Transplantation 607
Advanced Care Planning 607
Anemia of CKD 607
Metabolic Bone Disease 607
Underlying Disorders 607
CKD Clinics Improve Outcomes 608
Economics of CKD Clinics 608
Conclusion 609
Acknowledgments 609
References 609
49 Slowing Progression of Chronic Kidney Disease 613
Introduction 613
Epidemiologic Issues 613
Rates of Progression 613
Competing Risk of Cardiovascular Disease 613
Pathophysiologic Mechanisms of Progression 614
Glomerular Hyperfiltration 614
Renal Fibrosis 615
Loss of Podocytes 615
Renin-Angiotensin-Aldosterone System 615
Proteinuria 615
Therapy to Slow Progression of CKD 616
Blood Pressure Control 616
Inhibition of the Renin-Angiotensin-Aldosterone System 618
Other Therapeutic Considerations 619
Emerging Therapies 621
Conclusion 623
Acknowledgments 623
References 623
50 Nutritional Management of Patients with Chronic Kidney Disease 628
Introduction 628
Dietary Factors and CKD-Induced Metabolic Abnormalities 629
Nutritional Considerations for Inorganic Ions in CKD 630
Requirements for Dietary Constituents in CKD 631
Energy Intake of CKD Patients 631
Protein Intake of CKD Patients 632
Mechanisms that Regulate Body Protein Stores 633
Vitamins and Trace Elements in Renal Disease 633
Assessment of Dietary Compliance 634
Non-Urea Nitrogen 635
Nutritional Safety of Low-Protein Diets for Patients with CKD 636
Conclusions 636
References 637
51 Management of Anemia in Chronic Kidney Disease 639
Introduction 639
Diagnosis and Evaluation of Anemia in CKD Patients 639
General Approach to Treatment of CKD Anemia 640
Guidelines for ESA Use in the Treatment of CKD Anemia 641
Types of ESA Therapy 641
Short-Acting ESA 641
Long-Acting ESA 643
Continuous Erythropoietin Receptor Activator 643
Frequency of Administration and Route of Administration 643
Evaluation and Correcting Persistent Failure to Reach or Maintain Target Hb 643
Iron Supplementation to Treat CKD Anemia 644
Iron Agents Dosing and Frequency in CKD 645
Safety of Iron Agents in the Treatment of CKD Anemia 645
Adjuvant Therapies for CKD Anemia 646
Conclusion 646
References 646
52 Management of Hypertension in Chronic Kidney Disease 649
Introduction 649
Causes and Pathophysiology of Hypertension in CKD 649
Excess Total Body Sodium and Fluid Volume 650
Renin-Angiotensin-Aldosterone System Activation 651
Increased Sympathetic Nervous System Activity 651
Endothelial Dysfunction and Nitric Oxide 651
Oxidative Stress 652
Antihypertensive Therapy 652
Goal BP Level 652
Urinary Protein or Albumin Level 653
Non-Pharmcologic Therapy 653
Dietary Sodium Restriction 653
Weight Reduction 653
Other Dietary and Lifestyle Modifications 653
Renal Denervation – a Novel Non-Pharmacologic Approach to Treating Hypertension in CKD 653
Pharmacologic Therapy 654
Diuretics 654
Aldosterone Blockers 654
Renin-Angiotensin-Aldosterone System Inhibitors 655
Combined ACEI and ARB Therapy 655
Other Combination Therapies 655
Direct Renin Inhibitors 656
Vasodilators 656
Calcium-Channel Blockers 656
Adverse Effects of Antihypertensive Therapies in CKD 656
Conclusion 656
References 657
53 Management of Mineral and Bone Disorders in Chronic Kidney Disease Patients 661
Scope of the Problem and Public Health Implications 661
Pathophysiology 661
Calcium 661
Phosphorus 662
Vitamin D 663
Parathyroid Hormone 663
FGF-23 664
Bone 664
Vascular Calcification 664
Diagnosis 664
Calcium 665
Phosphorus 665
Vitamin D 665
PTH 665
FGF-23 665
Bone 666
Vascular Calcification 667
Treatment 667
Calcium 667
Phosphorus 667
Vitamin D 671
Parathyroid Hormone 672
FGF-23 673
Bone 673
Vascular Calcification 674
Conclusion 674
References 674
54 Albuminuria: A Target for Treatment in Diabetic and Non-Diabetic Nephropathy 678
Introduction 678
Criteria for Acceptance of Albuminuria as a Target for Renal Protection Treatment 679
Level of Albuminuria Predicts Renal Outcome 679
Changes in Albuminuria Predict Changes in Renal Outcome 680
A Short-Term Treatment-Induced Change in Albuminuria Indicates a Treatment-Induced Change in Renal Outcome 680
Is Albuminuria an Independent Target? 682
Optimize Conditions in Albuminuria Response 683
Conclusions 685
Note 685
References 685
55 Drug Metabolism and Chronic Kidney Disease 689
Introduction 689
Drug Absorption 689
Drug Distribution 690
Volume of Distribution 690
Plasma Protein Binding 691
Drug Elimination 692
Hepatic Clearance 692
Mechanisms of Drug Transport and Metabolism 692
InVitro and Animal Studies of Metabolism 693
Endogenous Metabolism 694
Clinical Studies 694
Conclusion 695
References 695
56 Use of Diuretics in Chronic Kidney Disease Patients 697
Introduction 697
Site and Mechanism of Action of Diuretics 697
Pharmacokinetics 697
Pharmacodynamics 699
Diuretic Braking, Tolerance, and Resistance 700
Strategies to Address Inadequate Diuretic Responsiveness due to Braking, Tolerance, or Resistance 701
Use of Agents Other Than Loop Diuretics in CKD 703
Carbonic Anhydrase Inhibitors 703
Thiazides 703
Aldosterone Receptor Antagonists 704
Diuretics for Treatment of Hypertension in CKD 705
Diuretic Complications 705
References 705
57 Non-Steroidal Anti-Inflammatory Drugs and Chronic Kidney Disease 708
Introduction 708
Pharmacology of NSAIDs 708
Prostaglandins and the Kidney: an Overview 709
NSAIDs as a Cause of CKD 710
Mechanism 710
Importance of NSAID Use as a Causative Factor in CKD 710
Relationship between NSAID-Induced CKD and Analgesic Nephropathy 711
Conclusions 712
Adverse Consequences of NSAID Therapy in Patients with CKD 712
Acute and Acute-on-Chronic Kidney Injury Due to NSAIDs 712
Non-Hemodynamically-Mediated AKI Due to NSAIDs 714
Effect of NSAIDs on the Progression of Established CKD 714
Hyperkalemia 715
Hyponatremia 715
Sodium Retention 715
Exacerbation of Hypertension 716
Non-Renal Side-Effects of NSAID Use in Patients with CKD 716
Conclusions 717
References 718
58 Dyslipidemia and Chronic Kidney Disease: Trials and Guidelines 721
The Typical Lipid Profile in CKD Patients 721
Pathophysiology of Dyslipidemia in CKD and End-Stage Renal Disease 721
Impact of Proteinuria on Dyslipidemia 721
Impact of Dialysis on Dyslipidemia 722
Why Should Patients With CKD Stages 3–5 Be Treated With a Statin? 722
Why Not Perform Frequent Follow-Up Measurements of Serum Lipids? 722
KDIGO Does Not Recommend Initiation of Statin Treatment in Dialysis Patients 723
The 4D Study (Die Deutsche Diabetes Dialyse Studie) 723
Aurora Study 723
Sharp (Study of Heart and Renal Protection) 723
Results from Trials in the General Population 724
Conclusion 724
References 724
59 Nephrolithiasis and Chronic Kidney Disease 726
Introduction 726
Types of Stones 726
Pathogenesis of Kidney Stone Formation 726
Risk Factors for Stone Formation 727
Clinical Presentation 727
Pain 727
Hematuria 727
Rarer Presentations 728
Differential Diagnosis 728
Pyelonephritis 728
Ectopic Pregnancy, Rupture or Torsion of Ovarian Cysts, Dysmenorrhea 728
Acute Appendicitis, Diverticulitis, Intestinal Obstruction, Mesenteric Ischemia and Biliary Colic 728
Loin Pain Hematuria Syndrome 728
Clot-Colic, Debris-Colic 728
Diagnosis 728
Abdominal X-Ray/Kidney Ureter Bladder Radiograph 729
Intravenous Pyelography 729
Ultrasonography 729
Non-Contrast Helical CT 729
MRI 729
Nephrolithiasis and CKD 729
Management 730
Management of Acute Renal Colic 730
Metabolic Evaluation of Kidney Stone Formers 730
General Measures to Prevent Stone Recurrence 731
Fluid Intake 731
Dietary Salt Intake 731
Dietary Protein Intake 731
Dietary Calcium Intake 731
Treatment of Specific Stone Types 732
Calcium Stones and Hypercalciuria 732
Hyperoxaluria 732
Hypocitraturia 733
Distal Renal Tubular Acidosis 733
Hyperuricosuria 733
Oxalobacter Formingenes 733
Uric Acid Stones and Hyperuricosuria 733
Calcium Phosphate Stones and Nephrocalcinosis 734
Struvite Stones 734
Cystine Stones 735
Conclusion 735
References 736
60 Treatment of Psychiatric Disorders in Chronic Kidney Disease Patients 740
Scope of the Problem 740
Diagnosis 740
Substance Abuse 741
Eating Disorders 741
Cognitive Disorders 741
Bipolar Affective Disorder 741
Treatment 741
Non-Pharmacologic Interventions 741
Pharmacologic Management 742
Pharmacokinetics 742
Prescribing Medications to the Elderly 744
Prescribing Medications to Adults 744
Prescribing Medications to Children with CKD 745
Summary 751
Acknowledgments 751
References 751
61 Evaluation of Patients’ Chronic Kidney Disease for Kidney Transplantation 753
Introduction 753
Cardiovascular Disease 754
Cardiac Disease 754
Cerebral Vascular Disease 755
Peripheral Arterial Disease 755
Malignancy 755
Infections 757
Recurrent Kidney Disease 758
Renal-Limited Disease Recurrence 759
Systemic Disease Recurrences 759
Primary Oxalosis 760
Hemolytic Uremic Syndrome/Thrombotic Thrombocytopenic Purpura 760
Genitourinary Disease 760
Gastrointestinal Disease 760
Pulmonary Disease 761
Psychosocial Evaluation 761
Immunological Evaluation 761
Obesity 762
Conclusion 763
References 763
62 Planning for Hemodialysis 766
Patient Education 769
Cardiovascular Risk Factor Management 770
Anemia Management 772
Vascular Access Management 773
Timing of the Initiation of Hemodialysis 775
Conclusion 777
References 777
63 Preparing for Peritoneal Dialysis 780
Introduction 780
Characteristics of Dialysis Program 780
Required Elements of a Home Dialysis Program 780
How Patients Make Decisions 781
Dialysis Informational Interview 781
Characteristics of the Dialysis Patient 781
Influence of Age 781
Co-morbidities 782
Quality of Life 782
Body Size and Residual Renal Function 783
Nutritional Aspects of Peritoneal Dialysis 783
Anticipated Lifespan of Patients and the Choice of Peritoneal Dialysis 783
Timing of Catheter Placement and Patient Follow-Up 784
Conclusion 785
References 785
64 Emerging Therapies for Chronic Kidney Disease 786
Scope of the Problem 786
Preventing the Progression of CKD 786
Pentoxifylline 786
Statins 786
Mammalian Target of Rapamycin (mTOR) Inhibitors 787
V2 Receptor Antagonists 787
Anti-Uric Acid Agents 787
Prolyl Hydroxylase Domain Inhibitors as Oral Erythropoiesis-Stimulating Agents and Potential Inhibitors of Renal Fibrosis 787
Mechanism of Action of PHD Inhibitors 787
Clinical Experience with PHD Inhibitors for the Treatment of Anemia 787
Links Between Oxygen Biology, Inflammation and Fibrosis 788
Vascular Calcification in CKD 788
Mechanisms of Vascular Calcification 788
RANK/RANKL/OPG Pathways 788
Vitamin D Receptor Agonists 788
Vitamin K 789
Calcimimetics 789
Renal Denervation Therapies for Hypertension 789
Biologic Rationale for Renal Denervation Therapy 789
Interventional Technique 789
Early Human Studies of Current Renal Denervation Approaches 789
Randomized Clinical Trials 789
Novel Paradigms for Dialysis Vascular Access 791
Biology of AVF Maturation Failure 791
Novel Therapies for AVF Maturation 791
PRT 201 Elastase 791
Sirolimus COL-R Wraps 791
Vascugel Endothelial Cell Loaded Wraps 792
Combining Biology, Technology and Process of Care 792
Acknowledgments 793
Disclosures 793
References 793
IX. Special Considerations 796
65 Prenatal Origins of Chronic Kidney Disease 798
Introduction 798
Developmental Origins of Health and Disease: General Overview 798
Maternal–Fetal Undernutrition and Risk of CKD 800
Brief History and Typical Outcomes 800
Altered Organ Structure in MFUN: Reduction in Functional Units 801
Redistribution of Fetal Blood Flow Selectively Impairs Organ Growth 801
MFUN May Permanently Reduce Nephron Number 802
Maternal–Fetal Energy Excess and Risk of CKD 807
Brief History and Typical Outcomes of MFEE 807
Organ Development During MFEE: Tissue Inflammation and Oxidative Stress 808
Postnatal Consequences of MFEE for the Kidney: Yet Another Pathway to Kidney: Body Mismatch? 808
Maternal–Fetal Psychosocial Stress and risk of CKD 809
The Kidney as Secondary Downstream Target of Concurrently Programmed Cardiometabolic Diseases 809
Clinical Implications, Challenges, and Opportunities for Nephrologists 810
Early Identification of At-Risk Individuals 810
Mitigation of Renal Hemodynamic Stress in At-Risk Individuals 811
Conclusions 811
References 811
66 Pregnancy and Chronic Kidney Disease 815
Physiologic Changes of Pregnancy 815
Renal and Pregnancy Outcomes in CKD 815
Pre-Pregnancy Counseling 815
Impact of Kidney Disease on Pregnancy, Fetus, and Neonate 815
Impact of Pregnancy on Renal Disease 816
Fertility and Pregnancy Strategies in CKD 817
Evaluation of Renal Function and Proteinuria in Pregnancy 817
Estimating GFR in Pregnancy 817
Quantification of Proteinuria in Pregnancy 817
Clinical Approach to Proteinuria in Pregnancy 818
Management of CKD Complications in Pregnancy 818
Hypertension 818
Edema 820
Anemia 820
Secondary Hyperparathyroidism 820
Venous Thromboembolism 820
Superimposed Pre-Eclampsia 820
Specific Renal Diseases 821
Diabetic Nephropathy 821
Lupus Nephritis 822
IgA Nephropathy 823
Membranous Nephropathy 823
Polycystic Kidney Disease 823
Alport Syndrome 824
Drugs and Lactation 824
Conclusion 824
References 824
67 Chronic Kidney Disease in Children 828
CKD in Children 828
History of CKD in Children 829
Epidemiology of CKD in Children 829
Diagnosis of CKD in Children 829
Genetic Testing 831
Oncology and Hematopoietic Stem Cell Transplantation 832
Non-Renal Solid Organ Transplantation 832
Sickle Cell Disease 832
Progression of pediatric CKD and Treatment Strategies to Slow Progression 832
Treatment of CKD Co-Morbidities 834
Cardiovascular Disease 834
Growth and Nutrition 834
Neurocognitive Function 834
Timing and Indications for Renal Replacement Therapy 835
Conclusion 835
References 835
68 Reflux Nephropathy 840
Introduction 840
Incidence and Prevalence 840
Pathogenesis 841
RISK Factors for Reflux Nephropathy 841
Complications 842
Hypertension 842
Proteinuria 843
CKD 843
RN in Adult Patients 843
Prevention of Reflux Nephropathy 843
Antimicrobial Prophylaxis 843
Surgical Intervention 844
Other Management 844
Summary 845
References 845
69 Ethnicity and Chronic Kidney Disease in Disadvantaged Populations – An International Perspective 848
Background 848
Pre-Dialysis CKD 849
The Americas: Canada 849
The Americas: Latin America 849
Asia 850
Africa 850
Australia, New Zealand, and South Pacific Islands 850
ESRD 851
The Americas: Canada 852
The Americas: Latin America 852
Asia 852
Africa 852
Australia, New Zealand, and Pacific Islands 852
Access to Renal Care 853
Relation Between Ethnicity and CKD Risk 854
Conclusions 854
References 855
70 Chronic Kidney Disease in the Elderly – Who Has it? Who Does One Treat and How are They to be Treated? 858
Introduction 858
Epidemiology and Public Health Implications 858
Kidney Senescence 859
Diagnosis 860
Renal Replacement Therapy vs. Conservative Management 861
Functional Status and Frailty 862
Palliative or Conservative Care and Symptom Burden 862
Advance Care Planning and Illness Trajectory 863
Hospice and CKD 864
Issues in Modality in Elderly Patients Choosing Renal Replacement Therapy 864
Hemodialysis 864
Peritoneal Dialysis 864
Kidney Transplantation 864
End-of-Life Care in CKD 865
Summary and Conclusions 865
References 865
71 Pain and Chronic Kidney Disease 869
Introduction 869
Epidemiology 869
Screening for and Diagnosis of Pain in CKD 869
Management of Pain in CKD Patients 870
WHO Ladder Step 1 871
WHO Ladder Step 2 873
Adjuvant Therapy 873
WHO Ladder Step 3 873
Conclusion 874
References 874
72 Acute Kidney Injury and Chronic Kidney Disease: A Janus-faced Syndrome 876
Introduction 876
AKI Leads to CKD 877
AKI as a Synergistic Complication of Progression of CKD 879
Mechanisms Associated with Progressive Renal Injury 880
Clinical Considerations 881
Future Directions 881
Conclusions 882
References 882
73 The Perioperative Management of the Chronic Kidney Disease Patient 885
Introduction 885
Epidemiology and Risk Assessment 885
Preoperative Assessment 886
Medications in the Perioperative Period 886
Perioperative Laboratory Evaluation and Tests 888
Intraoperative Volume and Blood Pressure Management 890
Anesthesia, Analgesia and Neuromuscular Blocking Agents 891
Induction Agents 891
Volatile Anesthetics 891
Neuromuscular Blocking Agents 891
Analgesics 892
Postoperative Management 892
Conclusion 892
References 892
74 Ethical Issues in Chronic Kidney Disease 897
Illustrative Case 897
Informed Consent for Treatment of CKD 898
Shared Decision-Making in the Process of Advance Care Planning 899
Completion of Advance Directives and Medical Order Forms to Implement Advance Care Planning Decisions 899
THE “Biomedicalization” of Aging and Consequences for Dialysis Decision-Making in Elderly Stage 5 CKD Patients 901
Conflicts of Interest in the Treatment of CKD 902
The Ethical Imperative for Careful Management of CKD Patients 903
References 904
75 Imaging the Chronic Kidney Disease Patient: Clinical Approaches, Utility and Complications 905
Introduction 905
Utility of ImaGing Modalities 905
Modality Selection 905
Ultrasound 905
Nuclear Medicine 906
Computed Tomography 907
Magnetic Resonance Imaging 907
Imaging to Diagnose Disease States 908
Imaging CKD Complications 909
Contrast Use in CKD 910
Conclusion 911
References 911
Index 912