Understanding Kidney Diseases

Dr Hugh Rayner gained a first class degree in physiology at Cambridge University before qualifying with honours at the London Hospital Medical College in 1981. He was awarded an MD from the University of Leicester for studies on experimental models of kidney disease. After a number of training posts, including a year as clinical fellow in Melbourne Australia, he was appointed as a consultant in renal and general medicine in Birmingham in 1993. As part of his studies for the Diploma in Medical Education from Dundee University in 1996, he presented a dissertation on the interpretation of serum creatinine and published a consensus curriculum for undergraduate renal medicine [1]. He is a full time nephrologist, clinical lead for the West Midlands Renal Network, and continues to teach renal medicine to undergraduates and trainee doctors.

Introduction.- The purpose of the book – understanding the natural history of kidney disease.- how displaying a GFR history is a fundamental part of the clinical assessment of kidney diseases.- how the eGFR graph is used to inform patients and plan treatment.-principles but not details of treatment.- The basics of creatinine measurement and eGFR equations in adults.- Simple guide to the classification of AKI, AKD and CKD.- Stages of CKD – including proteinuria.- The meaning of ‘stability’ in an eGFR graph – variation over time.- Cases.- Section 1: Acute kidney injury – changes over 50% drop, assuming no asymmetry).- Recurrent AKI leading to CKD.- Section 2: AKD – changes >48 hours 3months.- Patterns of progression – Linear and Non-linear.- Monitoring response to treatment – e.g. immunosuppression for GN, BP control in malignant hypertension.- Section 4: CKD – changes over years.- non-progressive (stable) CKD  - e.g. obstructive uropathy.- progressive CKD – e.g. transplant nephropathy, lithium nephrotoxicity, role of proteinuria as risk marker.- Use of graphs to plan future renal replacement therapy – e.g. linear progression in ADPKD.- Section 5: Acute-on-chronic kidney disease.- Chronic slowly progressive diabetic nephropathy with superimposed acute pathology, e.g. response to ACEI/ARB, contrast nephropathy, glomerulonephritis, interstitial nephritis.- Transplant rejection.- Pregnancy in women with CKD.- Section 6: Nephrotic syndrome.- GFR, serum albumin and urinary PCR graphs – use to monitor treatment and relapses, and to plan treatment.- Section 7: Other graphs.- 24 hour BP measurement – importance of nocturnal dip and timing of antihypertensives in CKD care.- Diabetes mellitus - HbA1c – colour coding as patient education tool; role of glucose control in preventing diabetic nephropathy (but no impact once CKD established).- Serum free light chains and myeloma kidney/light chain nephropathy/immune GN.- Conclusions.- eGFR graphs – an essential tool in patient assessment which tells the story of kidney disease.- The role of graphs (eGFR, 24 hour BP, and HbA1c) in patient education and support of self-management.- Role of eGFR graphs in systematic CKD surveillance by renal units and pathology labs – evidence of benefit.