PRIMER ON NEPHROLOGY.

Description

Preface Acknowledgments Contents Contributors I: Assessment of the Renal Patient 1: Assessment of the Renal Patient 1.1 Introduction 1.2 Urgent Assessment for Renal Emergencies 1.3 Fluid Assessment 1.3.1 Clinical Assessment 1.3.2 Bedside Tests 1.3.2.1 Investigations 1.4 Assessment of the Patient When the Renal Disorder Has Yet to Be Identified and/or Characterised 1.4.1 Presentation with Renal Impairment 1.4.1.1 Does the Patient Have Acute or Chronic Renal Impairment? 1.4.1.2 Diagnostic Breakdown of Acute or Chronic Renal Dysfunction Pre-renal Causes Post-renal Causes Intrinsic Renal Causes 1.4.2 Presentations Other Than with Biochemical Evidence of Change in Renal Function 1.4.2.1 Haematuria 1.4.2.2 Proteinuria 1.4.2.3 Nephrotic Syndrome 1.4.2.4 Hypertension 1.4.2.5 Loin Pain 1.4.2.6 Electrolyte Disorders 1.4.2.7 Changes in Urinary Volume 1.4.2.8 Renal Manifestation of Multisystem Disorders 1.4.3 Clinical History Relevant to Establishing a Renal Diagnosis 1.4.3.1 Age 1.4.3.2 Gender 1.4.3.3 Ethnicity and Country of Origin 1.4.3.4 Family History 1.4.3.5 Childhood History 1.4.3.6 Obstetric History 1.4.3.7 Occupation 1.4.3.8 Travel and Hobbies Box 1.1 Key Travel Questions 1.4.3.9 Psychosocial History 1.4.3.10 Medication and Allergy Box 1.2 Key Elements of Medication History 1.4.4 Aspects of the Clinical Examination to Help Establish the Cause of a Renal Disorder 1.5 Assessment of the Patient with Known Renal Disease 1.5.1 Patients with ESKD Treated with Dialysis 1.5.2 Patients with ESKD with Functioning Kidney Transplants 1.5.3 Patients with ESKD on Conservative Care Programmes 1.5.4 Patients with CKD and Significantly Reduced GFRs 1.5.5 Patients with Inflammatory Renal Diseases or Requiring Immunosuppression 1.6 Summary and Conclusion Case Study Case 1 Case 2 References 2: Urine Analysis 2.1 Introduction 2.2 Sample Collection Box 2.1 Health Protection Agency Standard Method of MSU Sample Collection in Men and Women 2.3 Urine Dipstick 2.4 Urine Microscopy Box 2.2 Preparation of Urine for Microscopy 2.4.1 Isolated Haematuria 2.4.2 Isolated Proteinuria 2.5 Clinical Significance of Urine Diagnostic Tests 2.5.1 Acute Kidney Injury 2.5.2 Chronic Kidney Disease (CKD) 2.5.3 Is There Any Value in Urine Analysis in Suspected CKD? 2.5.4 Tubular Disorders 2.6 Urine Cytology 2.6.1 Viruses 2.6.2 Malignancy 2.7 Urinary Tract Infection (UTI) Box 2.3 Causes of Sterile Pyuria 2.8 Urinary Electrolytes 2.9 Drug and Poison Screening Case Study Case 1 Case 2 Case 3 Case 4 2.10 Summary References 3: Laboratory Tests in Nephrology 3.1 Introduction 3.2 Kidney Function Assessment 3.2.1 Measurement of GFR 3.2.1.1 Endogenous Markers of GFR 3.2.1.2 Exogenous Markers of GFR 3.2.2 Estimation of GFR 3.2.3 Kidney Function Assessment During Pregnancy 3.2.4 Kidney Function Assessment During Non-steady State: AKI 3.3 Other Laboratory Investigations for Assessing Patients with Kidney Diseases Case Studies Case 1 Case 2 References Further Reading and Guidelines 4: Kidney Biopsy 4.1 Introduction 4.2 Indications and Contraindications for Renal Biopsy 4.3 Indications (See . Table 4.1) 4.4 Contraindications 4.5 Procedure PRB 4.6 Anatomy and Complications and Consent 4.7 Post-Biopsy Monitoring 4.8 Day-Case Vs Inpatient Procedure 4.9 Alternatives to PRB in High-Risk Patients (. Table 4.3) 4.10 Open Renal Biopsy (ORB) 4.11 Laparoscopic Renal Biopsy (LRB) 4.12 Transvenous Renal Biopsy (TVRB) 4.13 Standards for Renal Biopsy Case Study Case 1 Case 2 Case 3 References 5: Imaging in Nephrology 5.1 Introduction 5.2 Diagnostic Imaging Governance and Radiation 5.3 Diagnostic Radiology 5.3.1 Ultrasound 5.3.2 CT Scan 5.3.2.1 Contrast-Associated and Contrast-Induced Acute Kidney Injury (CA-AKI and CI-AKI) 5.3.3 Intravenous Pyelography (IVP) 5.3.4 Magnetic Resonance Imaging (MRI) 5.3.4.1 Nephrogenic Systemic Fibrosis (NSF) 5.3.5 Nuclear Medicine 5.3.5.1 MAG3 Transplant Kidney MAG 3 Indirect Micturating Cystoscintigraphy Captopril Renography 5.3.5.2 DMSA 5.3.5.3 PET-CT 5.4 Interventional Radiology 5.4.1 Fistuloplasty and Venoplasty 5.4.2 Nephrostomy and Antegrade Stent 5.4.3 Tunnelled Dialysis Catheter 5.4.4 Percutaneous Peritoneal Dialysis Catheter 5.4.5 Angiography, Angioplasty and Stent Insertion 5.5 Tips for Requesting Imaging 5.6 Considerations when Requesting Imaging 5.7 Following up Imaging Reports Case Study Case 1 Case 2 Case 3 Case 4 Case 5 5.8 Conclusion References 6: IT and Data in Nephrology 6.1 Introduction 6.2 Big Data 6.3 Big Data in Nephrology 6.3.1 Secondary Care 6.4 Using and Analysing Big Data 6.4.1 Surveillance of Healthcare Delivery and Service Transformation 6.4.1.1 Improving Service Delivery by Using Data 6.5 AKI Alerts 6.5.1 Automated Diagnosis of AKI 6.5.2 Electronic Alerting 6.6 Risk Prediction 6.7 What Are the Weaknesses of Big Data? 6.8 Networks and Communication 6.9 Conclusions References 7: Renal Pathology 7.1 Introduction 7.2 The Pathologist’s Approach to a Medical Renal Biopsy 7.2.1 Clinical Details 7.2.2 Initial Sections 7.2.3 Further Stains 7.2.4 Immunohistochemistry and Immunofluorescence 7.2.5 Electron Microscopy 7.2.6 Reaching a Diagnosis 7.3 What Is Normal? 7.4 Pathologies of each Compartment 7.4.1 Active Versus Chronic 7.4.2 Glomerulus 7.4.3 Tubules (. Figs. 7.15, 7.16, 7.17, 7.18, 7.19, 7.20, and 7.21) 7.4.4 Interstitium 7.4.5 Vascular 7.4.6 Patterns of Injury 7.5 Immunohistology and Immunofluorescence 7.6 Electron Microscopic Findings 7.7 Reaching a Diagnosis 7.8 Classification Systems 7.9 The Banff Classification of Renal Allograft Pathology [4] 7.9.1 The Oxford Classification of IgA nephropathy [6] 7.9.2 The Columbia Classification of Focal Segmental Glomerulosclerosis 7.10 ISN/RPS Classification of Lupus Nephritis 7.10.1 The Modified Karpinski Score for Time Zero Renal Transplant Biopsies [9] Case Studies Case 1 Case 2 Case 3 References II: Acute Kidney Injury 8: Acute Kidney Injury Epidemiology and Causes 8.1 Introduction 8.2 Definitions and Classifications 8.3 Epidemiology: The Incidence and Burden of AKI 8.4 Geographical Location and Natural Environment 8.5 Socio-Economic Factors 8.6 Cultural Factors 8.7 Health Care-Related 8.8 Risk Factors for AKI Box 8.1 Predisposing Risk factors for AKI 8.9 Pathophysiology 8.10 Morphology 8.11 Functional 8.12 Key Causes of AKI 8.13 Pre-Renal Causes of Acute Kidney Injury 8.14 Intrinsic Acute Kidney Injury 8.15 Toxins and AKI 8.16 Rhabdomyolysis 8.17 Intravascular Haemolysis Box 8.2 Causes of Intravascular Haemolysis Causing AKI 8.18 Hyperuricaemia Box 8.3 Risk Factors and Clinical Features of Tumour Lysis Syndrome 8.19 Light Chain and Immunoglobulin-Related Disease 8.20 Hypercalcaemia 8.21 Oxalosis 8.22 Exogenous Toxins 8.23 Contrast-Associated AKI 8.24 Nephrotoxic Drugs 8.25 Recreational Drugs 8.25.1 Opiates 8.25.2 Cocaine and its Levamisole-Adulterated Counterparts 8.25.3 Ecstasy and Other Amphetamines 8.25.4 Anabolic Androgenic Steroids 8.25.5 Solvents 8.26 Ethylene Glycol Poisoning 8.27 Heavy Metal Toxicity 8.28 Natural Toxins 8.29 Envenomation 8.29.1 Plant and Fungal Toxins 8.30 Post-Renal Acute Kidney Injury 8.31 Specific Conditions Associated with AKI 8.32 Special Areas 8.32.1 Children 8.32.2 Pregnancy (See Chapter on Pregnancy and Renal Disease) 8.32.3 The Elderly and CKD 8.33 Cancer 8.34 Summary Case Study References 9: Assessment and Investigation of Acute Kidney Injury (AKI) 9.1 Introduction 9.2 Standardising Classification of Acute Kidney Injury 9.3 Recognition of Biochemical Changes Suggesting Acute Kidney Injury 9.4 Novel Biomarkers in AKI 9.5 Clinical Evaluation in Patients with AKI 9.5.1 AKI Assessment May be Complicated Case Study Case 1 Case 2 9.6 History 9.7 Examination 9.8 Investigation of AKI 9.8.1 Near Patient Testing 9.8.1.1 Urine Dipstick Testing 9.8.1.2 Urine Microscopy 9.8.2 Further Investigation 9.8.2.1 Urine Biochemistry 9.9 Other Blood Tests 9.10 Radiology 9.11 Renal Biopsy 9.12 AKI in Patients with CKD References 10: Prevention and Treatment of Acute Kidney Injury 10.1 Introduction 10.2 Prevention of AKI 10.2.1 Improve Awareness 10.2.2 Identifying Patients at Increased Risk of AKI 10.2.3 Avoidance of Renal Insult 10.2.4 Prophylactic Treatment 10.3 Resuscitate Intravascular Volume and Restore Renal Perfusion 10.3.1 How to Determine the Type of Resuscitation Fluid? 10.3.1.1 Crystalloids 10.3.1.2 Colloids Albumin Hydroxyethyl Starch (HES) Blood 10.3.1.3 Comparing Colloids and Crystalloids 10.3.2 Maintenance Fluids 10.4 Special Consideration Should be Given to Prophylactic Treatments in the Following Situations 10.4.1 Contrast-Induced Acute Kidney Injury 10.4.2 Tumour Lysis Syndrome 10.4.3 Pigment-Induced AKI 10.4.3.1 Volume Resuscitation 10.4.3.2 Urinary Alkalinization 10.4.3.3 Mannitol 10.4.3.4 Loop Diuretics 10.5 Renal Replacement Therapy 10.5.1 Crystal-Induced AKI 10.6 Acyclovir 10.7 Methotrexate 10.8 Indinavir 10.8.1 Aminoglycoside-Induced Nephropathy 10.8.2 Envenomation 10.8.2.1 Snakebite Envenomation 10.9 Hymenoptera Envenomation 10.9.1 AKI in Pregnancy 10.10 Treatment of Established or Incipient AKI 10.11 Pre-Renal AKI 10.12 Intrinsic Renal Disease 10.13 Post-Renal AKI 10.13.1 Maintaining Optimum Blood Pressure 10.13.2 Treat Sepsis 10.13.3 Drugs that Are Not Routinely Used to Prevent or Treat AKI 10.13.3.1 Loop Diuretics 10.14 Dopamine 10.15 Fenoldopam, Natriuretic Peptide, Theophylline and Growth Factor Intervention 10.15.1 Intensive Glycaemic Control 10.15.2 Nutrition and Rehabilitation 10.15.3 Management and Avoidance of AKI Complications 10.16 Indications for Renal Replacement Therapy 10.17 Transfer Criteria 10.18 Treatment Escalation Plans and Ceilings of Care 10.19 Outcome of AKI 10.20 Follow-Up of AKI 10.21 Summary References 11: Establishing an AKI Service 11.1 Introduction 11.2 Service Specifications and Targets for Improvement 11.3 Improving Outcomes in AKI: Domains of Care 11.3.1 Identification of Those at Risk of AKI 11.3.2 Care Bundles 11.4 Service Reconfiguration 11.4.1 Which Clinicians Should Review Patients with AKI? 11.4.2 Follow-Up of AKI Patients 11.5 Patient and Carer Engagement, Education and Sick Day Rules 11.6 AKI in a Primary Care Setting 11.7 Commissioning AKI Services in a High-Income Setting Conclusion 11.8 AKI Services in Low- and Middle-Income Settings Case Study Case 1: Establishing an AKI Service in Blantyre, Southern Malawi References 12: Acute Renal Replacement 12.1 Initiation of Dialysis 12.2 Does the Timing of RRT Influence Outcome in AKI? 12.3 When Should RRT Be Withdrawn in AKI? 12.4 Treatment Options for RRT 12.5 Does Modality of Renal Replacement Therapy Affect Outcomes? 12.5.1 Mortality 12.5.2 Recovery of Residual Renal Function 12.6 Tailoring Intermittent Therapies for Patients with Acute Kidney Injury 12.6.1 Haemodialysis 12.6.2 Haemofiltration 12.6.3 Continuous Renal Replacement Therapies (CRRT) 12.6.4 Hybrid Therapies 12.7 Peritoneal Dialysis 12.8 Choosing Dialysis Modality for Patients 12.9 Convection or Diffusion? 12.10 Choice of Dialyzer/Haemofilter Membrane 12.11 Dose of Renal Replacement Therapy for AKI 12.12 Pulsed High-Volume CRRT or Haemodiafiltration 12.13 Choice of Dialysate and Substitution Replacement Fluid 12.14 Choice of Anticoagulation During IHD/Hybrid and CRRT 12.14.1 Anticoagulation Free Options 12.14.2 Systemic Anticoagulants 12.14.3 Regional Anticoagulants 12.15 Acute Brain Injury 12.16 Cardiorenal Syndrome 12.17 Chronic Cardiorenal Syndromes 12.18 Severe Electrolyte Imbalances 12.18.1 Hyponatraemia in AKI 12.18.2 Hypernatraemia 12.18.3 Hypercalcaemia 12.18.4 Poisoning 12.18.5 Volume of Distribution 12.18.6 Haemodialysis and Haemodiafiltration 12.18.7 Haemoperfusion Case Study Case 1 Case 2 Case 3 Case 4 References Useful Web Sites III: Acid Base and Electrolyte Disorders 13: Common Electrolyte Abnormalities 13.1 Introduction 13.1.1 Approach to Electrolyte Abnormalities 13.1.2 Sodium and Water Disorders 13.1.3 Hyponatraemia 13.1.4 Clinical Features of Hyponatraemia 13.1.5 Causes and Differential Diagnosis of Hyponatraemia 13.1.5.1 Hyponatraemia with Increased ADH (High Urine Osmolarity) 13.1.5.2 Hyponatraemia with Normal or Decreased ADH (Low Urinary Osmolarity) 13.1.6 Assessment and Investigations of Hyponatraemia 13.1.7 Some Specific Causes of Hyponatraemia 13.1.8 Treatment of Hyponatraemia 13.1.9 Outcomes of Hyponatraemia 13.1.10 Hypernatraemia 13.1.11 Clinical Features 13.1.12 Assessment and Investigation of Hypernatraemia 13.1.13 Water Restriction Test 13.1.14 Treatment of Hypernatraemia 13.1.15 Diabetes Insipidus (DI) 13.1.16 Treatment of DI 13.1.17 Potassium Disorders 13.1.18 Hypokalaemia 13.1.19 Some Specific Conditions Causing Hypokalaemia 13.1.20 Treatment of Hypokalaemia 13.1.21 Hyperkalaemia 13.1.22 Causes of Hyperkalaemia 13.1.23 Assessment and Investigation of Hyperkalaemia 13.1.24 Management of Hyperkalaemia 13.1.25 Calcium Disorders 13.1.26 Hypercalcaemia 13.1.27 Causes of Hypercalcaemia 13.1.28 Clinical Features of Hypercalcaemia 13.1.29 Assessment and Investigation of Hypercalcaemia 13.1.30 Treatment of Hypercalcaemia 13.1.31 Hypocalcaemia 13.1.32 Causes of Hypocalcaemia 13.1.33 Clinical Features of Hypocalcaemia 13.1.34 Investigation of Hypocalcaemia 13.1.35 Treatment of Hypocalcaemia 13.1.36 Phosphate Disorders 13.1.37 Hypophosphataemia 13.1.38 Causes of Hypophosphataemia 13.1.39 Clinical Features of Hypophosphataemia 13.1.40 Assessment and Investigation of Hypophosphataemia 13.1.41 Treatment of Hypophosphataemia 13.1.42 Hyperphosphataemia 13.1.43 Clinical Features of Hyperphosphataemia 13.1.44 Treatment of Hyperphosphataemia 13.1.45 Magnesium Disorders 13.1.46 Hypomagnesaemia 13.1.47 Causes of Hypomagnesaemia 13.1.48 Clinical Features of Hypomagnesaemia 13.1.49 Assessment and Investigation of Hypomagnesaemia 13.1.50 Hypermagnesaemia 13.1.51 Clinical Features of Hypermagnesaemia 13.2 Treatment of Hypermagnesaemia Conclusions Case Studies Case 1 Case 2 Case 3 References 14: Acid-Base Disorders 14.1 Introduction 14.2 Determination of Respiratory/Metabolic Acidosis/Alkalosis 14.3 Compensation (Respiratory/Metabolic) 14.4 Respiratory Acid-Base Disorders 14.5 Respiratory Acidosis Box 14.1 Causes of Respiratory Acid-Base ­Disturbances 14.6 Respiratory Alkalosis 14.7 Metabolic Acidosis Box 14.2 Causes of Metabolic Acidosis 14.8 Anion Gap (with Albumin Correction) Box 14.3 Causes of a High Anion Gap Acidosis 14.9 Base Excess 14.10 Stewart Hypothesis/Physiochemical Approach 14.11 Treatment of Metabolic Acidosis 14.12 Metabolic Alkalosis 14.12.1 GI Acid Loss 14.12.2 Renal Acid Loss 14.12.3 Mineralocorticoid Excess 14.12.4 Increased Sodium Delivery 14.12.5 Exogenous Base 14.12.6 Contraction Alkalosis 14.13 Treatment of Metabolic Alkalosis 14.14 Special Cases Box 14.4 Causes of pRTA with Fanconi Syndrome 14.15 Worked Case Example References IV: Hypertension and Renovascular Diseases 15: Approach to Hypertension: Diagnosis and Investigation 15.1 Introduction 15.2 Defining Hypertension and Setting Treatment Thresholds Box 15.1 Initial Investigations in a Patient with Hypertension 15.3 Defining Thresholds in Low-Risk Patients 15.4 Measuring Blood Pressure and Diagnosing Hypertension 15.5 Ambulatory Blood Pressure Measurement (ABPM) in the Diagnosis of Hypertension 15.6 Home Blood Pressure Monitors 15.7 Resistant Hypertension 15.8 White Coat Hypertension 15.9 Masked Hypertension 15.10 Adherence 15.11 Secondary Hypertension Box 15.2 Drugs Which Increase BP 15.12 Renal Causes of Secondary Hypertension 15.12.1 Renal Parenchymal Disease 15.12.2 Renovascular Hypertension (See Chap. 17 on Renal Vasculature) 15.12.3 Coarctation of the Aorta 15.12.4 Distal Tubular Disorders 15.13 Endocrine Causes of Secondary Hypertension 15.13.1 Mineralocorticoid Excess 15.13.2 Cushing’s Syndrome 15.13.3 Pheochromocytoma 15.14 Other Causes of Secondary Hypertension 15.14.1 Obstructive Sleep Apnoea 15.14.2 Obesity 15.14.3 Familial Dysautonomia 15.15 Conclusion Case Study Case 1 Case 2 Case 3 Case 4 References Further Reading 16: Management of High Blood Pressure 16.1 Introduction 16.2 Non-pharmacological Management of Hypertension 16.2.1 Role of Evidenced Natural Therapies as Antihypertensive Agents 16.3 Drugs Used to Lower Blood Pressure 16.4 Controversies in Blood Pressure Management 16.5 Antihypertensive Treatment and Proteinuric Kidney Disease 16.5.1 Antihypertensive Effects of SGLT-2 Inhibitors 16.6 Other Classes of Antihypertensives 16.7 Antihypertensives in Dialysis Population 16.8 Management of Hypertensive Crises 16.9 Pathophysiology 16.10 Determination of Precipitant for Hypertensive Crises Is Crucial to Prevent Recurrence 16.11 Therapeutic Approach to Hypertensive Crisis 16.12 Pharmacological Agents 16.13 Resistant Hypertension and Non-adherence to Antihypertensives 16.14 Delivery of Hypertension Treatment 16.15 Role of RDN (Renal Denervation) in Management of Resistant Hypertension 16.15.1 Overview of Treatments of Major Causes of Secondary Hypertension 16.16 Riley-Day Syndrome: A Complex Scenario Conclusion Case Study Case 1 Case 2 Case 3 References 17: Disease of the Renal Vessels 17.1 Renal Artery Disease 17.1.1 Introduction 17.1.2 Non-atheromatous Renal Artery Stenosis 17.1.2.1 Vasculitis 17.1.2.2 Fibromuscular Disease Clinical Features Epidemiology Aetiopathology Diagnosis Differential Diagnosis Treatment 17.1.3 Atheromatous Renal Artery Disease 17.1.3.1 Clinical Features Subclinical Renovascular and Refractory Hypertension Ischaemic Nephropathy/Progressive Chronic Kidney Disease Acute Kidney Injury Cardiorenal Syndromes Including Flash Pulmonary Oedema 17.1.3.2 Epidemiology 17.1.3.3 Aetiopathology 17.1.3.4 Diagnosis Renal Artery Imaging Cardiac Imaging 17.1.3.5 Differential Diagnosis 17.1.3.6 Treatment Revascularization In Which of the Following Scenarios Is Revascularization to Be Considered? Stable CKD or Incidentally Diagnosed ARVD Acute and Chronic Heart Failure Rapid Loss of Renal Function and Refractory Hypertension 17.1.3.7 Complications of Revascularization 17.1.3.8 Medical Therapy Renin-Angiotensin Blockade Second-Line Treatment of Hypertension Statins Anti-platelet Therapy 17.1.3.9 Future Treatment Options 17.2 Renal Artery Embolic Disease 17.2.1 Cholesterol Emboli 17.2.1.1 Clinical Features 17.2.1.2 Aetiopathology and Epidemiology 17.2.1.3 Diagnosis 17.2.1.4 Treatment 17.2.2 Renal Artery Thromboembolism 17.2.2.1 Clinical Features and Diagnosis 17.2.2.2 Aetiopathology 17.2.2.3 Treatment 17.3 Renal Vein Disease 17.3.1 Renal Vein Thrombosis 17.3.1.1 Clinical Features 17.3.1.2 Aetiopathology 17.3.1.3 Treatment 17.3.2 Renal Vein Stenosis 17.3.3 Left Renal Vein Entrapment Syndrome 17.4 Lymphatic Disease 17.5 Questions and Answers 17.6 Conclusion References Internet Resources V: Glomerular Diseases 18: Management of the Nephrotic Patient: The Overall Approach to the Patient with Nephrotic Syndrome 18.1 Introduction 18.2 The Podocyte 18.3 Causes of Nephrotic Syndrome 18.4 Inherited Causes 18.5 Investigations 18.6 Treatment and General Management 18.7 Steroid Side Effect Prophylaxis 18.8 Personal Treatment Plan (PTP) 18.9 Causes of Relapse or Treatment Resistance 18.10 Complications of Nephrotic Syndrome 18.10.1 Thrombosis and Nephrotic Syndrome 18.10.2 Infection 18.10.3 Acute Kidney Injury 18.11 Progressive Renal Impairment 18.12 Dyslipidaemia 18.13 Nutrition and Endocrine Case Study Case 1 Case 2 Case 3 Case 4 Case 5 References 19: Management of Extracellular Fluid Volume in the Nephrotic Patient 19.1 Introduction 19.1.1 What Are the Clinical Goals of Disease-Specific Management of NS? 19.2 Clinical Features 19.3 Epidemiology 19.4 Aetiopathology 19.4.1 Why Do Nephrotic Patients Become Oedematous? 19.5 Diagnosis 19.6 Treatment 19.6.1 What Are the Clinical Goals of Generic Management of NS? 19.6.2 What Are the Different Classes of Diuretics and How Do They Work? 19.6.3 What Are the Pharmacokinetic Barriers to Achieving Therapeutic Objectives? 19.6.4 What Are the Pharmacodynamic Barriers to Achieving Therapeutic Objectives? Case Study Conclusion References 20: Minimal Change Disease 20.1 Introduction 20.2 Aetiology and Pathogenesis 20.3 Natural History 20.4 Clinical Features and Complications 20.5 Diagnosis and Differential Diagnosis 20.6 Investigations 20.6.1 Routine Investigations 20.7 Renal Biopsy 20.8 Histopathology 20.9 Management 20.10 Childhood Minimal Change Disease 20.11 Diagnosis and Treatment of Initial and Infrequent Relapses 20.12 Frequent Relapsers and Steroid-Dependent MCD 20.13 Adult Minimal Change Disease 20.14 Relapse 20.15 ‘Minimal Change’ Appearance with Non-nephrotic Proteinuria and Normal Albumin Case Study Case 1 Case 2 Case 3 References 21: Focal Segmental Glomerulosclerosis 21.1 Introduction and Epidemiology 21.2 Aetiology and Pathogenesis 21.3 Natural History and Complications 21.4 Clinical Features 21.5 Diagnosis and Differential Diagnosis 21.6 Investigations 21.6.1 Routine Investigations 21.7 Histopathology 21.7.1 Light Microscopy 21.8 Immunofluorescence 21.9 Electron Microscopy 21.10 Histologic Variants of Primary FSGS 21.11 Management 21.12 Focal Segmental Glomerulosclerosis with Non-nephrotic Proteinuria 21.13 Transplant Recurrence Case Study Case 1 Case 2 References 22: Membranous Nephropathy 22.1 Introduction 22.2 Epidemiology 22.3 Pathogenesis 22.4 Clinical Features 22.5 Histopathology 22.6 Remission 22.7 Management 22.7.1 Non-immunosuppressive Treatment 22.7.2 Risk Stratification 22.7.2.1 Low Risk 22.7.2.2 Medium to High Risk 22.7.3 Immunosuppressive Treatment 22.8 Recurrent and De Novo MN Following Transplantation 22.9 AMN and Other Autoimmune Diseases 22.10 Summary Case Study Case 1 Case 2 Case 3 22.11 Seminal Papers References Links 23: Membranoproliferative Glomerulonephritis and C3 Glomerulopathy 23.1 Introduction 23.2 Definition and Classification: MPGN and C3 Glomerulopathy 23.3 Epidemiology 23.4 Aetiology and Pathophysiology 23.5 Antibody-Associated Proliferative GN 23.5.1 Clinical Features 23.5.2 Proliferative GN in Infectious Diseases 23.5.3 Cryoglobulinaemic GN 23.5.4 Autoimmune Disease and Proliferative GN 23.5.5 Treatment of Immune Complex-Associated Glomerulonephritis 23.5.6 Recurrence Post-Transplantation 23.5.7 C3 Glomerulopathies 23.5.8 Dense Deposit Disease 23.5.9 Aetiology and Pathophysiology of DDD Box 23.1 Causes of dense deposit disease (DDD) 23.5.10 Systemic Manifestations of DDD 23.5.11 C3 Glomerulonephritis 23.5.12 CFHR5 Nephropathy 23.5.13 Genetics of MPGN and C3 Glomerulopathy 23.5.14 Investigation of C3 Glomerulopathies 23.5.15 Treatment of C3 Glomerulopathies 23.6 Summary Case Study References Further Reading 24: IgA Nephropathy and IgA Vasculitis 24.1 Introduction 24.2 IgA Nephropathy 24.2.1 Clinical Features 24.2.2 Epidemiology 24.2.3 Aetiopathology 24.2.4 Diagnosis 24.2.4.1 General Investigations 24.2.4.2 Renal Biopsy When to Consider Doing a Renal Biopsy in Suspected IgAN? Renal Biopsy Features The Oxford Classification of IgA Nephropathy 24.2.5 Differential Diagnosis 24.2.5.1 Differentiating Between Causes of Isolated Non-visible Haematuria 24.2.5.2 Other Causes of Recurrent Visible Haematuria 24.2.5.3 Differential Diagnosis of Mesangial IgA Deposition on Renal Biopsy 24.2.5.4 Secondary IgAN 24.2.6 Treatment 24.2.6.1 The Patient with Non-visible Haematuria and 0.5 g/Day Proteinuria and Slowly Progressive IgAN Corticosteroids Fish Oil Experimental and Future Therapies The Patient with Acute Kidney Injury Acute Tubular Necrosis with Intratubular Erythrocyte Casts Crescentic IgAN 24.2.6.4 The Patient with Nephrotic Syndrome 24.2.7 Follow- up 24.2.8 Special Circumstances in IgAN 24.2.8.1 Transplantation 24.2.8.2 Pregnancy 24.3 IgA Vasculitis (Henoch-Schönlein Purpura) 24.3.1 Introduction 24.3.2 Clinical Features 24.3.3 Epidemiology 24.3.4 Aetiopathology 24.3.5 Diagnosis 24.3.5.1 Investigations General Investigations Skin Biopsy Renal Biopsy 24.3.6 Treatment 24.3.7 Follow- up 24.3.8 Special Circumstances in IgAV 24.3.8.1 Transplantation 24.3.8.2 Pregnancy Case Study Case 1 Case 2 Case 3 Conclusion References Resources and Patient Information 25: ANCA-Associated Systemic Small-Vessel Vasculitis 25.1 Introduction 25.2 Clinical Presentation 25.3 Epidemiology 25.4 Diagnosis of ANCA-Associated Vasculitis 25.4.1 Use of ANCA Testing in Diagnosis 25.4.1.1 Indirect Immunofluorescence 25.4.1.2 Enzyme-Linked Immunosorbent Assay (ELISA) 25.4.1.3 Renal Biopsy 25.5 Classification of Disease Severity 25.6 Pathology 25.7 Pathogenesis 25.7.1 Genetic Factors 25.7.2 Environmental Factors 25.7.2.1 Silica Exposure 25.7.2.2 Bacterial Infections 25.7.2.3 Drugs 25.7.3 Role of ANCA in the Pathogenesis of AAV 25.8 Management 25.8.1 Induction Therapy 25.8.1.1 Organ- or Life-Threatening Disease Glucocorticoid AND 25.8.1.2 Rapidly Progressive Renal Failure or Pulmonary Haemorrhage 25.8.1.3 Non-organ-Threatening Disease 25.8.1.4 Standard Prophylaxis 25.8.2 Maintenance Therapy 25.8.3 Refractory Disease 25.8.4 Relapsed Disease 25.8.5 Future Therapy 25.8.6 Monitoring and Follow-up 25.9 Special Considerations 25.9.1 The Elderly or Frail Patient 25.9.2 The Young Woman Wishing to Have a Family 25.9.3 The Septic Patient 25.10 The Vasculitis Unit Case Study Case 1 Case 2 Case 3 References Patient Information and Guidelines 26: Renal Involvement in Large- and Medium-Vessel Vasculitis 26.1 Introduction 26.2 General Approach to Patients with Large- and Medium-Vessel Vasculitis 26.2.1 Clinical Assessment 26.2.2 Laboratory Findings 26.2.3 Imaging 26.2.4 Classification and Diagnostic Criteria 26.3 Giant Cell Arteritis 26.3.1 Epidemiology and Aetiology 26.3.2 Clinical and Laboratory Features 26.3.3 Pathology 26.3.4 Imaging 26.3.5 Treatment 26.3.6 Renal Involvement in GCA 26.4 Takayasu Arteritis 26.4.1 Epidemiology and Aetiology 26.4.2 Clinical and Laboratory Features 26.4.3 Pathology 26.4.4 Imaging 26.4.5 Treatment 26.4.6 Renal Involvement in Takayasu Arteritis 26.5 Polyarteritis Nodosa 26.5.1 Epidemiology and Aetiology 26.5.2 Clinical and Laboratory Features 26.5.3 Pathology 26.5.4 Imaging 26.5.5 Treatment 26.5.6 Renal Involvement in PAN Case Study Case 1 Case 2 Case 3 Conclusion References Resources and Patient Information 27: Goodpasture’s or Anti-glomerular Basement Membrane (GBM) Disease 27.1 Introduction 27.2 Clinical Features 27.3 Epidemiology 27.4 Diagnosis 27.5 Immunology 27.6 Treatment 27.7 Outcomes 27.8 When Not to Treat? 27.9 Transplantation 27.10 Anti-GBM Disease in Alport’s Disease Following Transplantation Case Studies Case 1 Case 2 Case 3 References Patient Information and Guidelines 28: Systemic Lupus Erythematosus, Antiphospholipid Syndrome and the Kidney 28.1 Systemic Lupus Erythematosus 28.1.1 Introduction 28.1.2 Clinical Features 28.1.3 Epidemiology 28.1.4 Aetiopathology 28.1.4.1 Glomerular Disease 28.1.4.2 Vasculopathy 28.1.4.3 Tubulointerstitial Disease 28.1.5 Diagnosis 28.1.5.1 Prognosis of Lupus Nephritis Non-renal Factors Renal Factors 28.1.6 Treatment of Lupus Nephritis 28.1.6.1 Conservative, Non-immunosuppressive Therapy Is Appropriate for ISN/RPS Class I and II Lupus Glomerulonephritis 28.1.6.2 Mycophenolate Mofetil and Corticosteroids for Proliferative Lupus Glomerulonephritis (ISN/RPS Classes III and IV) 28.1.6.3 Hydroxychloroquine for Lupus Nephritis 28.1.6.4 Rituximab for Lupus Nephritis 28.1.6.5 Maintenance Therapy for Proliferative Lupus Nephritis 28.1.6.6 Treatment of Membranous (ISN/RPS Class V) Lupus Glomerulonephritis 28.1.6.7 Newer Agents for the Treatment of Lupus Nephritis 28.1.6.8 Clinical Follow-Up After Initiation of Treatment 28.1.7 Cardiovascular Risk 28.1.8 Pregnancy and Reproductive Health 28.1.9 Case Studies 28.2 Antiphospholipid Syndrome (APLS) 28.2.1 Introduction 28.2.2 Clinical Manifestations 28.2.3 Epidemiology 28.2.4 Diagnosis 28.2.4.1 Clinical Criteria 28.2.4.2 Laboratory Criteria 28.2.5 Treatment 28.3 Resources and Patient Information 28.3.1 For Professionals 28.3.2 For Patients References 29: Practical Immunosuppression Guidelines for Patients with Glomerulonephritis 29.1 Introduction 29.2 Protocol Constituents 29.2.1 Cyclophosphamide 29.2.2 Glucocorticoids 29.2.3 Glucocorticoid Avoidance 29.2.4 Infection, Bone and Gastric Prophylaxis 29.2.5 Plasmapheresis 29.2.6 Fertility Sparing Measures and Pregnancies 29.2.7 Rituximab and Other B Cell-Targeted Therapies 29.2.8 MMF and Azathioprine 29.2.9 Complement Antagonism 29.3 Protocols for Particular Glomerular Diseases 29.3.1 Rapidly Progressive Glomerulonephritis 29.3.1.1 Anti-GBM Disease 29.3.1.2 Immune Complex Glomerulonephritis IgA Nephropathy (IgAN) and IgA Vasculitis (IgAV or Henoch-Schönlein Purpura) Lupus Nephritis Post-Infectious Glomerulonephritis (PIGN) 29.3.1.3 Pauci-Immune Glomerulonephritis Case Study Case 1 Case 2 Case 3 Appendix: Information for Renal Patients Receiving Cyclophosphamide Therapy How Is It Given? How Does Cyclophosphamide Work? What Are the Possible Side Effects? Cyclophosphamide and Pregnancy Contact Details References 30: Infections and the Kidney 30.1 Introduction 30.2 Non-specific Acute Kidney Injury 30.2.1 Covid-19 (SARS-CoV-2) and Other Severe Respiratory Viruses 30.3 Direct Renal Involvement 30.3.1 Hantavirus 30.3.2 Leptospirosis 30.3.3 Brucellosis 30.3.4 Syphilis 30.3.5 Visceral Leishmaniasis 30.4 Direct Involvement: Obstruction 30.4.1 Schistosomiasis (Bilharziasis) 30.5 Indirect (Secondary) Renal Effects of Infection 30.5.1 Post-Infectious Renal Disease 30.5.2 Acute Post-Streptococcal Glomerulonephritis (APSGN) 30.5.3 Aetiopathogenesis 30.5.4 Clinical Features 30.5.5 Parvovirus 30.6 Persistent Infection 30.6.1 Malaria 30.6.2 Filariasis 30.7 Summary References Links 31: Blood-Borne Viruses and the Kidney 31.1 Introduction 31.2 Human Immunodeficiency Virus and the Kidney 31.2.1 Acute Kidney Injury (AKI) 31.2.2 HIV-Associated Thrombotic Microangiopathy 31.2.3 HIV-Associated Nephropathy (HIVAN) 31.2.3.1 Aetiology and Pathogenesis 31.2.3.2 Clinicopathologic Characteristics 31.2.3.3 Treatment and Prognosis 31.2.3.4 Antiretroviral Therapy 31.2.3.5 Corticosteroids 31.2.4 Immune Complex Kidney Disease 31.2.4.1 HIV Immune Complex Kidney Disease (HIVICK) 31.2.4.2 Lupus-Like Nephritis 31.2.4.3 Treatment 31.2.5 Tubulointerstitial Pathology 31.2.6 Diffuse Infiltrative Lymphocytosis Syndrome (DILS) 31.2.7 Immune Reconstitution Inflammatory Syndrome (IRIS) 31.3 Renal Complications of Antiretroviral Therapy 31.3.1 Indinavir 31.3.2 Atazanavir 31.3.3 TDF 31.4 Hepatitis C 31.4.1 Epidemiology 31.4.2 Clinical Presentation 31.4.3 Pathology Box 31.1 Renal Involvement in Hepatitis C 31.4.4 Treatment and Outcome 31.5 Hepatitis B 31.5.1 Epidemiology 31.5.2 Clinical Manifestations Box 31.2 Renal Involvement in Hepatitis B 31.5.3 Pathology 31.5.4 Treatment and Outcome 31.6 HTLV1 and 2 Case Study Case 1 Case 2 Case 3 Case 4 31.7 Conclusion References Patient Information and Guidelines VI: Tubulointerstitial Disease 32: Acute Tubulointerstitial Nephritis 32.1 Introduction 32.2 Acute Interstitial Nephritis 32.2.1 Aetiology and Pathogenesis 32.2.2 Epidemiology 32.2.3 Clinical Manifestations 32.2.4 Diagnosis and Investigation 32.2.4.1 Urinary Analysis 32.2.4.2 Blood Analysis 32.2.4.3 Imaging 32.2.4.4 Renal Biopsy and Histology Findings Diagnostic Challenges 32.2.4.5 Biomarkers Still in Research Phase 32.2.5 Causes of AIN 32.2.6 Infectious Diseases Associated with AIN 32.2.7 Treatment of AIN 32.2.7.1 Management of Allergic AIN or Drug-Induced AIN 32.2.7.2 Prognosis and Long-Term Outcome of Drug-Induced AIN 32.3 Summary Case Study Case 1 Case Study Case 2 Case 3 Case 4 References 33: Acquired Chronic Tubulointerstitial Nephritis 33.1 Introduction 33.2 Clinical Features, Diagnosis and Differential Diagnosis 33.3 Epidemiology 33.4 Aetiopathology, Features and Management 33.4.1 Drugs 33.4.1.1 Lithium 33.4.1.2 Analgesic Nephropathy 33.4.1.3 Other Drugs 33.4.2 Metals 33.4.3 Phytotoxins and Mycotoxins 33.4.3.1 Aristolochic Acid 33.4.3.2 Ochratoxin 33.4.4 Infection 33.4.4.1 Tuberculosis 33.4.4.2 Other Infections 33.4.5 Radiation Nephritis 33.4.6 Eating Disorders and Gastrointestinal Diversion 33.4.7 Other Causes 33.4.8 Chronic Kidney Disease of Undetermined Cause Case Studies 33.5 Conclusion References Further Reading/Guidelines 34: Genetic Tubulointerstitial Disease and Nephronophthisis 34.1 Introduction 34.2 ADTKD 34.3 ADTKD-UMOD 34.3.1 Aetiology and Pathogenesis 34.3.2 Clinical Features 34.3.3 Diagnosis 34.3.4 Treatment 34.4 ADTKD-MUC1 34.4.1 Aetiology and Pathogenesis 34.4.2 Clinical Features 34.4.3 Diagnosis 34.4.4 Treatment 34.5 ADTKD-REN 34.5.1 Aetiology and Pathogenesis 34.5.2 Clinical Features 34.5.3 Diagnosis 34.5.4 Treatment 34.6 ADTKD-HNF1B 34.6.1 Aetiology and Pathophysiology 34.6.2 Clinical Features 34.6.3 Diagnosis 34.6.4 Treatment 34.7 Rarer Forms of ADTKD 34.7.1 Mitochondrial Cytopathy-Related Interstitial Renal Disease 34.7.2 Nephronophthisis 34.7.3 Aetiology and Pathophysiology 34.7.4 Clinical Features 34.7.5 Diagnosis 34.7.6 Treatment 34.7.7 Oral Facial Dactyly Syndrome 34.8 Summary Case Study Case 1 References Patient Information Websites VII: Nephrology Interface 35: Rheumatological Conditions and the Kidney 35.1 Introduction 35.2 Scleroderma and the Kidney 35.3 Definition of SRC Box 35.1 Renal Crisis Classification 35.4 Epidemiology of Scleroderma Renal Crisis 35.5 Clinical Presentation of SRC Box 35.2 Presenting Features of 110 Patients Undergoing SRC in a British Cohort 35.6 Aetiology and Pathogenesis of SRC Box 35.3 Published Risk Factors for Developing SRC 35.7 Diagnosis 35.8 Pathology 35.9 Pathogenesis 35.10 Management Box 35.4 Long-Term Outcome of SRC [15] 35.11 Renal Disease in SSc Other than SRC 35.12 Renal Disease in Mixed Connective Tissue Disease Box 35.5 Types of Renal Disease in MCTD 35.13 Renal Disease in Polymyositis and Dermatomyositis 35.14 Renal Disease in Sjögren’s Syndrome 35.15 Renal Disease in Sarcoidosis 35.15.1 Hypercalcaemia and Hypercalciuria 35.15.2 Renal Tubular Dysfunction 35.15.3 Granulomatous Interstitial Nephritis 35.15.4 Glomerular Disease 35.15.5 Renovascular and Obstructive Uropathy 35.16 Renal Disease in Rheumatoid Arthritis 35.17 Treatment of Renal Disease in RA 35.18 Renal Disease in Ankylosing Spondylitis (AS) 35.19 Renal Disease in Behcet’s Disease 35.20 Rheumatological drugs and kidney disease Case Study Case 1 Case 2 Case 3 35.21 Conclusion References 36: Hepatology and the Kidney 36.1 Definition and Classification of Renal Dysfunction in Cirrhosis 36.2 Definition and Classification of Hepatorenal Syndrome 36.3 Incidence 36.4 Differential Diagnosis for Renal Dysfunction in Those with Liver Disease 36.5 Pathophysiology of HRS 36.5.1 Peripheral Arterial Vasodilation 36.5.2 Haemostatic Compensatory Mechanisms 36.5.3 Cirrhotic Cardiomyopathy 36.6 Clinical Evaluation of Liver Patients with Renal Dysfunction 36.7 Investigations 36.8 Precipitating Factors, Prevention and Initial Therapy 36.9 Treatment of AKI and AKI-HRS 36.9.1 Vasoconstrictors and Albumin 36.9.2 Transjugular Intrahepatic Portosystemic Shunt (TIPS) 36.9.3 Renal Replacement Therapy (RRT) and Artificial Liver Support 36.9.4 Transplantation 36.9.5 Treatment of Hepatitis B and C in Renal Patients 36.10 Patient and Renal Outcomes 36.11 Conclusion References 37: Chronic Kidney Disease: Cardiovascular Complications 37.1 Epidemiology of CVD in CKD 37.2 The Association Between CKD and CVD 37.3 Atherosclerotic and Non-atherosclerotic Disease in the CKD Population 37.3.1 Atherosclerosis 37.3.2 Left Ventricular Disease 37.3.3 Arterial Stiffening 37.3.4 Arterial Calcification 37.4 Approach to Cardiovascular Syndromes in Patients with Kidney Disease 37.4.1 Cardiac Ischaemia 37.4.1.1 Aetiology and Clinical Presentation 37.4.1.2 Diagnostic Imaging 37.4.1.3 Treatment Emergency Reperfusion Delayed/Elective Intervention Medical Therapy 37.4.2 Cardiovascular Causes of Shortness of Breath 37.4.2.1 Aetiology and Clinical Presentation 37.4.2.2 Acute Treatment 37.4.3 Arrhythmia and Sudden Death 37.4.3.1 Aetiology and Clinical Presentation 37.4.3.2 Treatment 37.4.4 Noncardiac Athero-occlusive Disorders 37.4.4.1 Aetiology and Clinical Presentation 37.4.4.2 Treatment Thrombolysis for Stroke Carotid Endarterectomy for Prevention of Stroke 37.4.4.3 Dialysis Around Acute Stroke 37.4.4.4 Outcomes of Interventions for Critical Limb Ischaemia 37.5 Prevention of Cardiovascular Complications in Patients with Kidney Disease 37.5.1 Traditional Vascular Risk Factors and Treatment 37.5.1.1 Blood Pressure 37.5.1.2 Salt Restriction 37.5.1.3 Renin-Angiotensin Blockade 37.5.1.4 Cholesterol 37.5.1.5 Cigarette Smoking 37.5.1.6 Diabetes 37.5.1.7 Antiplatelet Agents 37.6 Prevention of Stroke in Chronic Atrial Fibrillation 37.7 Interventions for Kidney-Related Risk Factors 37.7.1 Albuminuria 37.7.2 Nephrotic Syndrome 37.7.3 Bone Mineral Disorder/Hyperphosphataemia 37.7.4 Medications 37.7.5 Evidence for Other Proposed Kidney-Associated Risk Factors 37.8 Conclusions Case Study Case 1 Case 2 References 38: Management of Diabetic Nephropathy 38.1 Introduction 38.2 Epidemiology 38.3 Aetiology and Pathogenesis 38.3.1 Genetic Factors 38.3.2 Glycaemic Control 38.3.3 Hypertension 38.3.4 Renin-Angiotensin System Activation 38.4 Natural History and Pathogenesis 38.4.1 Pathological Features 38.5 Diagnosis 38.6 Management 38.7 Lifestyle Factors 38.8 Glycaemic Control 38.9 Choice of Blood Glucose-Lowering Drugs in Chronic Kidney Disease 38.9.1 Metformin 38.9.2 Sulphonylureas and Meglitinides 38.9.3 Pioglitazone 38.9.4 Insulin 38.10 Newer Glucose-Lowering Drugs 38.10.1 Glucagon-Like Peptide-1 (GLP-1) Agonists 38.10.2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors 38.10.3 Sodium-Glucose Co-transporters 38.11 Blood Pressure Control 38.11.1 Proteinuria as a Specific Target 38.11.2 Choice of Antihypertensive Agent 38.11.2.1 Renin-Angiotensin System Blockade 38.11.2.2 Other Antihypertensive Agents 38.12 Cardiovascular Risk 38.13 Multifactorial Interventions 38.14 Models of Service 38.15 Management of Patients with Diabetes on Renal Replacement Therapy (RRT) 38.15.1 Dialysis 38.15.2 Transplantation 38.16 Conclusion Case Study Case 1 Case 2 Case 3 References 39: The Endocrine System and the Kidney 39.1 Introduction 39.2 Pharmacotherapy Interactions in Kidney and Endocrine Diseases 39.3 Impact of Renal Disease on the Endocrine System 39.3.1 Nephrotic Syndrome 39.3.1.1 Thyroid 39.3.1.2 Vitamin D and Calcium 39.3.1.3 Glucocorticoid Metabolism 39.3.2 Chronic Kidney Disease 39.3.2.1 Hypothalamic-Pituitary-Gonadal Axis 39.3.3 The Somatotropic Axis 39.3.3.1 Growth Hormone (GH) and Insulin-Like Growth Factor 39.3.3.2 Thyroid Function 39.3.3.3 Primary Hyperthyroidism and Hypothyroidism 39.3.3.4 Insulin and Glucagon 39.3.4 Renin Angiotensin Axis 39.3.5 Hypothalamic-Pituitary-Adrenal Axis (HPA) 39.4 The Effect of CKD on Common Endocrine Medications 39.4.1 Antidiabetics 39.5 Systemic Diseases Affecting the Endocrine System and Kidneys 39.6 Impact of Endocrine Diseases on the Kidney 39.7 Endocrine-Mediated Renal Disease 39.8 Integrated Care in Endocrine and Renal Diseases 39.8.1 Joint Clinics Case Study Case 1 Case 2 Case 3 39.9 Conclusion References 40: Dermatology in Kidney Disease 40.1 Introduction 40.2 Skin Conditions Associated with Chronic Kidney Disease 40.3 Uraemic Pruritus 40.4 Calciphylaxis 40.5 Nephrogenic Systemic Fibrosis 40.6 Acquired Perforating Dermatosis 40.7 Porphyria 40.8 Skin Manifestations of Diseases Associated with Renal Involvement 40.8.1 Lupus Erythematosus 40.8.2 Cutaneous Vasculitis and Renal Disease 40.8.3 Systemic Sclerosis 40.8.4 Amyloidosis 40.8.5 Anderson-Fabry Disease 40.8.6 HIV 40.9 Skin Conditions Associated with Renal Transplantation 40.10 Drug-Specific Dermatoses in Transplantation 40.11 Skin Infections in Solid Organ Transplantation 40.12 Premalignant and Malignant Skin Conditions 40.13 Actinic Keratoses (Solar Keratoses) 40.14 Basal Cell Carcinomas (BCC or Rodent Ulcers) 40.15 Squamous Cell Carcinoma (SCC) 40.16 Melanoma 40.17 Merkel Cell Carcinoma 40.18 Kaposi’s Sarcoma 40.19 Specialist Transplant Skin Clinics 40.20 Conclusions Case Study Case 1 Case 2 Case 3 Case 4 References Patient Information and Guidelines 41: The Nervous System and the Kidney 41.1 Introduction 41.2 Multisystem Diseases Affecting Both the Nervous System and Kidney 41.3 Neurological Diseases and Medications Which Affect the Kidney 41.3.1 Spinal Cord Disorders 41.3.2 Rhabdomyolysis 41.3.3 Medications 41.4 Neurological Manifestations of Kidney Disease 41.4.1 Encephalopathy 41.4.1.1 Uraemic Encephalopathy 41.4.1.2 Hypertensive Encephalopathy 41.4.1.3 Neuropathy 41.4.2 Myopathy 41.5 Stroke 41.5.1 Cognitive Impairment and Dementia 41.6 Common Neurological Presentations in the Renal Patient 41.6.1 Confusion 41.6.2 Seizures 41.6.3 Movement Disorders 41.6.4 Headache 41.7 Renal Treatments and Drugs with Neurological Side Effects 41.7.1 Dialysis 41.7.2 Renal Transplantation and the Immunosuppressed Patient 41.7.3 Medications Commonly Used in Nephrology and Dosing Considerations 41.8 Mental Health in Kidney Disease Case Study Case 1 Case 2 Case 3 References Patient Information and Guidelines 42: Ophthalmology and the Kidney 42.1 Introduction 42.2 Acquired Eye Disease 42.2.1 Hypertensive Retinopathy 42.2.1.1 Pathophysiology 42.2.1.2 Epidemiology 42.2.1.3 Aetiology 42.2.2 Diabetic Retinopathy (DR) 42.2.2.1 Epidemiology 42.2.2.2 Pathogenesis 42.2.2.3 Risk Factors 42.2.3 Inflammatory Diseases of the Eye in Kidney Disease 42.3 Inherited Eye Disease 42.3.1 Developmental Disorders 42.3.2 Disorders of Structure and Function 42.3.3 Metabolic 42.4 Managing the Patient with CKD and Visual Impairment Case Study Case 1 Case 2 Case 3 42.5 Summary References 43: Gastroenterology and the Kidney 43.1 Introduction 43.2 Systemic Diseases Involving the Kidney and GI System 43.2.1 Diabetes Mellitus 43.2.2 Coeliac Disease 43.2.3 Vasculitis 43.3 Renal Pathology Arising from GI Disease 43.3.1 Secondary Hyperoxaluria 43.3.2 High-Output Stoma 43.3.3 AA Amyloidosis 43.3.4 IgA Nephropathy 43.3.5 Drug-Induced Injury 43.3.5.1 5-ASA Compounds 43.3.5.2 Proton Pump Inhibitors 43.3.5.3 Calcineurin Inhibitors 43.4 Use of Laxatives in Chronic Kidney Disease 43.4.1 Bowel Preparation for Colonoscopy Case Study Proton Pump Inhibitor-Induced Tubulointerstitial Nephritis Oxalate Nephropathy Short Bowel Syndrome References 44: Respiratory Medicine and the Kidney 44.1 Introduction 44.2 Respiratory Complications of Chronic Renal Failure 44.2.1 Pulmonary Oedema 44.2.2 Pleural Effusion 44.2.3 Tuberculosis 44.2.4 Respiratory Viruses 44.2.5 Pulmonary Embolism 44.2.6 Dialysis-Associated Hypoxaemia 44.2.7 Sleep-Disordered Breathing 44.2.8 Chronic Obstructive Pulmonary Disease (COPD) 44.2.9 Pulmonary-Renal Syndrome Case Study Case 1 Case 2 Case 3 44.3 Summary References 45: Ageing and the Kidneys 45.1 Introduction 45.2 Ageing and Chronic Kidney Disease (CKD) 45.3 Ageing and the Management of Chronic Kidney Disease (CKD) 45.4 End-Stage Renal Failure (ESRF) and Renal Replacement Therapy Decisions in the Elderly 45.5 Ageing and Transplantation 45.5.1 Patient and Allograft Outcomes 45.5.2 Rejection 45.5.3 Comorbidities and Frailty in the Older KTR 45.5.4 Immunosuppressive Therapy 45.6 Individualisation of Treatment and Palliati ve Care Case Study Case 1 Case 2 References Patient Information and Guidelines 46: The Renal Patient in Critical Care - The ICU: Renal Interface 46.1 Introduction 46.2 Patient-Led Care 46.3 Common Problems in Patients with ESRD on ICU 46.3.1 Access 46.3.2 Renal Replacement Therapy for Critically Ill Patients with ESRF 46.3.3 Nutrition in ICU 46.3.4 Electrolyte Abnormalities 46.3.4.1 Hyperkalaemia 46.3.4.2 Hypocalcaemia 46.4 Medication in the ICU in Patients with ESRD 46.4.1 Drug Dosing 46.4.2 Rationalisation of Medication 46.5 Patient with Renal Transplant in Critical Care 46.5.1 Acute Phase 46.5.2 Chronic Phase 46.6 Critical Illness Recovery 46.7 Skeletal Muscle Mass 46.8 Baseline Muscle Mass and Function 46.9 Altered Protein Homeostasis 46.10 Immobilisation 46.11 Inflammation 46.12 Age 46.13 Acidosis 46.14 Interventions to Increase Anabolism and Recovery 46.15 The Role of Sleep and Delirium in Facilitating and Preventing Rehabilitation 46.16 Anticipation of Deterioration (the ICU Outreach): Renal Interface 46.17 Conclusion References Patient Information and Guidelines 47: Oncology and the Kidney 47.1 Introduction 47.2 Epidemiology 47.3 Renal Disease Impact on Cancer Risk 47.4 Renal Disease Impact on Cancer Prognosis 47.5 Malignancy as a Cause of Renal Disease 47.5.1 Treatment-Related Renal Dysfunction 47.5.1.1 Chemotherapy Agents Causing Predominately Tubular Toxicity Agents Causing Predominately Glomerular Toxicity 47.5.1.2 Radiotherapy 47.5.1.3 Targeted Treatment 47.5.1.4 Supportive Treatment 47.5.1.5 Treatment-Related Complications 47.5.1.6 Treatment Adjustments in Renal Disease 47.5.2 Endogenous Toxins and Paraneoplastic Renal Dysfunction 47.5.2.1 Hypercalcaemia 47.5.2.2 Tumour Lysis Syndrome 47.5.2.3 Paraneoplastic Phenomenon in Lymphoproliferative Disorders Immunoglobulin-Related Renal Disease Glomerulonephritis in Lymphoproliferative Disease Hyperviscosity 47.5.2.4 Glomerulonephritides in Solid Cancers 47.5.2.5 Renal Vein Thrombosis 47.5.2.6 Cancer-Associated Thrombotic Microangiopathy 47.5.3 Renal Impairment Due to Direct Tumour Involvement 47.6 Renal Replacement Therapy in Malignancy 47.7 Renal and Oncology Multidisciplinary Care Conclusion Case Study Case 1 Case 2 Case 3 References 48: Red Cells and the Kidney 48.1 Haemoglobinopathies 48.1.1 Introduction 48.1.2 Sickle Cell Disease 48.1.2.1 Epidemiology 48.1.2.2 Pathogenesis 48.1.2.3 Clinical Features Hyperfiltration Microalbuminuria and Proteinuria Tubular Abnormalities Haematuria 48.1.2.4 Clinical Syndromes of Renal Impairment Acute Kidney Injury Progressive Chronic Kidney Disease Sickle Cell Trait and CKD 48.1.2.5 Investigations Imaging Renal Histology 48.1.2.6 Management of Sickle Cell Nephropathy Therapies for Treating Sickle Cell Disease Therapies for Treating Chronic Kidney Disease Management of Advanced Chronic Kidney Disease Management of the Transplanted Patient Conclusion Case Studies Case 1 Case 2 Case 3 48.2 Other Red Cell Disorders 48.2.1 Thalassaemia 48.3 Haemolytic Anaemias 48.3.1 Paroxysmal Nocturnal Haemoglobinuria 48.3.1.1 Epidemiology and Pathogenesis 48.3.1.2 Clinical Manifestations 48.3.1.3 Renal Disease 48.3.1.4 Investigations 48.3.1.5 Treatment 48.3.2 Malaria 48.3.3 Glucose-6-Phosphate Dehydrogenase Deficiency Patient Information and Guidelines References 49: Multiple Myeloma and the Kidney 49.1 Introduction 49.2 Clinical Features 49.3 Epidemiology 49.4 The Biology of Immunoglobulin Light Chains 49.5 Paraprotein-Related Renal Disease 49.5.1 Monoclonal Gammopathy of Renal Significance-Associated Renal Disease 49.6 Pathogenesis of MM 49.7 Evolution and Development of Myeloma 49.8 Diagnosis Box 49.1 Revised International Myeloma Working Group Diagnostic Criteria for Multiple Myeloma. Reproduced with Permission from Rajkumar et al. (2014) 49.9 Prognostic Factors 49.10 Definition of Renal Failure in MM 49.11 Impact of Kidney Disease on Prognosis 49.12 Pathogenesis of MM and Kidney Disease 49.13 Diagnostic Workup in Patients with Suspected MM 49.14 Management of Patients 49.14.1 MM and AKI 49.14.2 Antimyeloma Therapy 49.14.3 Extracorporeal Removal of Serum Free Light Chains 49.14.4 Supportive Care 49.14.5 Fluid Balance and Acid-Base Status 49.14.6 Drugs 49.14.7 Preventing and Managing Bone Disease 49.14.8 Preventing Infection 49.14.9 Managing Peripheral Neuropathy 49.14.10 Preventing Thrombosis 49.14.11 Managing Fatigue 49.15 Multidisciplinary Working in MM Box 49.2 Multidisciplinary and Medical Specialty Involvement in the Diagnosis and Management of MM Case Study Case 1 Case 2 Case 3 Conclusion 49.16 Resources and Patient Information in MM References 50: Amyloidosis and the Kidney 50.1 Introduction 50.2 Aetiology and Pathogenesis 50.2.1 Amyloid Structure 50.2.2 Common Constituents of Amyloid Deposits 50.2.3 Organ Tropism 50.3 Epidemiology 50.3.1 Systemic Amyloidosis Associated with Monoclonal LCs: AL Amyloidosis 50.3.2 Reactive Systemic AA Amyloidosis 50.3.3 Dialysis-Related Amyloidosis (DRA) 50.3.4 Hereditary Systemic Amyloidosis 50.3.5 Leukocyte Chemotactic Factor 2 (LECT2) Amyloidosis 50.4 Clinical Features 50.4.1 Systemic Amyloidosis Associated with Monoclonal LCs: AL Amyloidosis 50.4.2 Reactive Systemic AA Amyloidosis 50.4.3 Dialysis-Related Amyloidosis (DRA) 50.4.4 LECT2 Amyloidosis 50.4.5 Hereditary Non-neuropathic Systemic Amyloidosis 50.4.5.1 Lysozyme Amyloidosis (ALys) 50.4.5.2 Apolipoprotein A-I Amyloidosis (AApoAI) 50.4.5.3 Fibrinogen a Alpha Chain Amyloidosis (AFib) 50.4.5.4 Apolipoprotein A2 Amyloidosis (AApoA2) 50.4.5.5 Gelsolin Amyloidosis (AGel) 50.4.5.6 Transthyretin Met30 (ATTR) 50.5 Investigations 50.5.1 Histology 50.5.2 Imaging Amyloid Deposits 50.5.2.1 SAP Scintigraphy 50.5.2.2 Imaging the Heart 50.5.2.3 DNA Analysis 50.5.3 Investigation of the Underlying Disease 50.5.3.1 AL Amyloidosis Box 50.1 Inflammatory Conditions Which can be ­Complicated by AA Amyloidosis 50.6 Treatment and Outcome 50.6.1 Principles of Treatment 50.6.2 Systemic AL Amyloidosis 50.6.3 Response to Therapy in Patients with Renal Involvement 50.6.4 Reactive Systemic AA Amyloidosis 50.6.5 Dialysis-Related Amyloidosis (DRA) 50.6.6 Hereditary Non-neuropathic Systemic Amyloidosis 50.6.7 Preservation and Replacement of Organ Function 50.6.8 Renal Dialysis 50.6.9 Renal Transplantation References 51: Thrombotic Microangiopathies 51.1 Introduction 51.2 Clinical Features 51.2.1 Thrombotic Thrombocytopenic Purpura. 51.2.2 Haemolytic Uraemic Syndrome 51.2.3 Shiga Toxin-Associated HUS 51.2.4 Atypical HUS 51.3 Epidemiology 51.4 Aetiopathology of the Thrombotic Microangiopathies 51.4.1 Thrombotic Thrombocytopenic Purpura 51.4.2 Shiga Toxin-Associated HUS 51.4.3 Atypical HUS 51.5 Diagnosis 51.5.1 Thrombotic Thrombocytopenic Purpura 51.5.2 Shiga Toxin-Associated HUS 51.5.3 Atypical HUS 51.6 Treatment 51.6.1 Thrombotic Thrombocytopenic Purpura 51.6.2 Shiga Toxin-Associated HUS 51.6.3 Atypical HUS 51.7 Other Genetic Causes of HUS 51.7.1 HUS Due to Defective Cobalamin (B12) Metabolism 51.7.2 HUS Due to Mutations in Diacylglycerol Kinase ε 51.7.3 HUS Due to Mutations in Other Genes 51.8 HUS Occurring in the Context of Other Infections 51.8.1 HUS Following Streptococcal Infection 51.8.2 HUS Following HIV Infection 51.9 TMAs Occurring in Association with Other Conditions 51.9.1 Pregnancy 51.9.2 Malignancy and its Treatment 51.9.3 Drug-Induced TMA 51.9.4 Malignant Hypertension 51.9.5 Solid Organ Transplantation 51.9.6 Bone Marrow Transplantation 51.9.7 Autoimmune Disease Conclusion Case Study Case 1 Case 2 Case 3 References 52: Pregnancy and the Kidney 52.1 Introduction 52.1.1 Physiological Changes in Pregnancy 52.1.2 Cardiovascular Physiology in Normal Pregnancy [2] 52.1.3 Renal Haemodynamic and Structural Changes [2, 3] 52.1.4 Anatomical Changes in the Urinary Tract 52.2 Tubular Changes 52.2.1 Electrolyte Balance 52.2.2 Acid-Base Balance 52.3 Common Themes in the Care of Pregnant Women with Chronic Kidney Disease 52.3.1 Pre-Conception Counselling 52.4 Hypertension in Pregnancy 52.5 Blood Pressure Targets 52.6 Antihypertensive Drugs 52.7 Angiotensin-Converting Enzyme Inhibitors 52.8 Pre-Eclampsia 52.9 Pre-Eclampsia in Patients with CKD 52.10 Prevention of Pre-eclampsia in Women with CKD and/or Hypertension 52.10.1 Low-Dose Aspirin 52.10.2 Proteinuria 52.10.3 Urinary Tract Infection 52.10.4 Renal Tract Obstruction Versus Physiological Hydronephrosis 52.11 Anaemia in Pregnancy 52.12 Chronic Kidney Disease in Pregnancy 52.12.1 Identification of Women with CKD in Pregnancy 52.13 Role of Renal Biopsy in Pregnancy 52.14 Effect of Pregnancy on Maternal Kidney Function 52.15 Effect of Maternal CKD on Pregnancy Outcomes 52.16 How Should CKD be Managed in Pregnancy? 52.17 Postpartum Care 52.18 Management of Specific Kidney Diseases during Pregnancy 52.18.1 Pregnancy in Women with Systemic Lupus Erythematosus 52.18.2 Diagnosis of Lupus Nephritis for the First Time in Pregnancy Presents Its Own Challenges 52.19 Pregnancy in Women Treated by Dialysis 52.19.1 Diagnosis of Pregnancy 52.19.2 Pre-Pregnancy Counselling 52.20 Pregnancy Outcomes 52.20.1 Peritoneal Dialysis 52.20.2 Haemodialysis 52.21 Guidelines for Management of Pregnancy in Haemodialysis Patients 52.22 Pregnancy Following Renal Transplantation 52.23 The Evidence Base and Sources of Guidance 52.24 The Timing of Pregnancy in Relation to Transplantation 52.25 Transplant Immunosuppression 52.26 Men and Mycophenolate 52.27 Early Pregnancy Outcomes 52.28 Maternal Outcomes of Pregnancies in Renal Transplant Recipients 52.29 Foetal Outcomes 52.30 Long-Term Effect of Pregnancy on Graft and Patient Survival 52.31 Management of Declining Graft Function in Pregnancy 52.32 Factors Affecting Live Birth Rate 52.33 Delivery 52.34 Breastfeeding 52.35 Long-Term Outcome of Children Born to Renal Transplant Recipients 52.36 Pregnancy after Kidney Donation 52.37 Management Guidelines for Renal Transplant Recipients in Pregnancy 52.38 Contraception for Women with Chronic Kidney Disease 52.39 Contraception Counselling 52.40 Overview of Contraceptive Methods 52.41 Oral Contraceptives 52.42 Contraception for Patients with Lupus Nephritis and Renal Transplant Recipients Case Study Case 1: Obstructive Uropathy and AKI in Pregnancy Case 2: Newly Diagnosed Chronic Kidney Disease in Pregnancy Case 3: Pregnancy in a Renal Transplant Recipient References VIII: Urology and Nephrology 53: Urology Renal Interface 53.1 Introduction 53.2 Haematuria 53.3 Renal Stones 53.4 Obstruction 53.5 Congenital Abnormalities of the Kidney and Urinary Tract (CAKUT) (See 7 Chapter 56) 53.6 Recurrent, Persistent, and Complicated Urinary Tract Infection (UTI) 53.7 Renal Tumour Syndromes 53.8 Renal Haemorrhage 53.9 Summary References 54: Urinary Tract Infection 54.1 Introduction 54.2 Diagnosis and Definition 54.3 Balanitis 54.4 Urethritis, Urethral Syndrome, and Vaginitis 54.5 Prostatitis 54.6 Interstitial Cystitis (IC) and Overactive Bladder (OAB) Complex 54.7 Epidemiology of Bacterial Cystitis and Pyelonephritis 54.8 Bacteria Virulence 54.9 Host Defences and the Urinary Microbiome 54.10 Clinical Features of Acute Cystitis and Pyelonephritis 54.11 Treatment of Acute UTI 54.12 Prevention and Treatment of Uncomplicated UTI 54.13 Conservative Measures 54.14 Nonantibiotic Measures 54.15 Antibiotic Prophylaxis 54.16 Antibiotic Treatment 54.17 Special Groups 54.17.1 Pregnancy 54.17.2 Transplantation 54.18 Infections and Complex Uroanatomy (See 7 Chapter 56) 54.19 Infected Renal Cysts 54.20 Renal and Perinephric Abscesses 54.21 Chronic Pyelonephritis 54.22 Xanthogranulomatous Pyelonephritis (XPN) 54.23 Malakoplakia 54.24 Recurrent UTI Service 54.25 Catheter-Associated UTI (CAUTI) 54.26 Tuberculosis of the Urinary Tract 54.27 Epidemiology 54.28 Pathogenesis 54.29 Clinical Features of GUTB 54.30 Investigations 54.31 Management 54.32 Fungal Urinary Tract Infections 54.33 Epidemiology 54.34 Pathophysiology 54.35 Diagnosis of Fungal UTI 54.36 Treatment 54.37 Summary 54.37.1 Additional Resources References 55: Renal Stone Disease 55.1 Introduction 55.1.1 Changes in Epidemiology 55.1.2 Associations with Other Disorders 55.2 Presentations 55.2.1 Common Presentations 55.2.2 Rarer Presentations 55.3 Pathophysiology 55.3.1 Metabolic Risk Factors 55.3.2 Structural Risk Factors 55.3.3 Genetic Causes and Rarer Stone Types 55.3.3.1 Rarer Genetic Causes of Non-calcium Renal Stone Disease 55.3.4 Causes and Pathophysiology of Metabolic Risk Factors 55.3.4.1 Hypercalciuria Treatments 55.3.5 Hyperoxaluria 55.3.6 Mechanisms of Calcium Stone Formation 55.3.7 Stone Types 55.3.7.1 Urinary pH 55.3.7.2 Forming at Low pH (Uric Acid, Cystine) 55.3.7.3 Forming at High pH 55.4 Nephrocalcinosis 55.5 Clinical Assessment 55.5.1 Rationale for Metabolic Screening 55.5.2 Practical Management 55.5.2.1 Acute Setting 55.5.2.2 Initial Investigations in the Urology Clinic 55.5.2.3 Full Metabolic Evaluation History and Examination Dietary Assessment Further Biochemical Investigations Further Radiological Investigations Further Specific Investigations 55.5.3 Running a Medical Stone Clinic 55.5.4 Interpretation of Results and Assessment of Risk 55.5.4.1 Consistently High Urinary pH 55.5.4.2 Consistently Low Urinary pH 24-Hour Urine Collection Results 55.5.5 Should Urinary Metabolites be Measured as Concentrations or Total Daily Amounts? 55.6 Radiological Investigations 55.6.1 Plain Film Kidney/Ureter/Bladder (KUB) Radiograph 55.6.2 Intravenous Urography (IVU) 55.6.3 Ultrasound (US) 55.6.4 Computerised Tomography Kidney-Ureter-Bladder (CT KUB) 55.6.5 Magnetic Resonance Urography 55.7 Treatment 55.7.1 Dietary 55.7.2 Combined Approaches for Particular Stone Types 55.7.3 Surgical Treatment of Ureteric and Renal Stones 55.7.3.1 Stones in the Ureter 55.7.3.2 Stones in the Kidney 55.7.4 Types of Surgical Intervention 55.7.4.1 Shock Wave Lithotripsy (SWL) 55.7.4.2 Rigid Ureteroscopy and Flexible Ureterorenoscopy 55.7.4.3 Percutaneous Nephrolithotomy (PCNL) 55.8 Conclusion Case Study Case 1 Case 2 References 56: Congenital Anomalies of the Kidneys and Urinary Tract 56.1 Introduction Box 56.1 Congenital anomalies of the kidneys and urinary tract 56.2 Epidemiology 56.3 Pathogenesis Box 56.2 Embryology of the kidney 56.4 Genetics Box 56.3 Autosomal dominant monogenic CAKUT gene-phenotype associations 56.5 Clinical Presentation 56.5.1 Renal Parenchymal Malformations 56.5.2 Abnormal Embryonic Migration 56.5.3 Abnormalities of the Collecting System and Ureters 56.5.4 Lower Urinary Tract Malformations 56.6 Diagnosis and Monitoring Box 56.4 Investigations used to monitor clinical status in CAKUT 56.7 Treatment 56.7.1 Ureterosigmoidostomy 56.7.2 Ileal Conduit (Urostomy) 56.7.3 Neobladder (Bladder Reconstruction) 56.8 Complications 56.8.1 Urinary Tract Infections 56.8.2 Stones 56.8.3 Hypertension 56.8.4 Chronic Kidney Disease 56.8.5 Acidosis and Bone Disease 56.8.6 Tubular Dysfunction 56.9 Transplantation Conclusion Case Study 1 Case Study 2 References 57: Acquired Urinary Tract Obstruction/Obstructive Uropathy 57.1 Epidemiology 57.2 Causes 57.3 Pathophysiology of Urinary Tract Obstruction 57.4 Clinical Features of Urinary Tract Obstruction 57.5 Diagnostic Tests 57.5.1 Urodynamics 57.5.2 Bladder Ultrasound and Uroflow Studies 57.5.3 Cystometry and Pressure/Flow Studies 57.5.4 Videourodynamics or VCMGs (Video Cystometrography) 57.6 Upper Tract Imaging 57.6.1 Ultrasonography 57.6.2 Computer-Assisted Tomography 57.6.3 Magnetic Resonance Imaging 57.6.4 Nuclear Medicine Renography 57.6.5 Whitaker Test 57.6.6 Trial of Nephrostomy or Stenting 57.7 Treatment 57.7.1 Lower UTO 57.7.2 Upper UTO 57.8 Post-Obstructive Diuresis 57.9 Post-Obstructive Haemorrhage (Decompression Haematuria) 57.10 Aortitis, Periaortitis, and Retroperitoneal Fibrosis (RPF) 57.11 Malignancy 57.12 Summary Case Study Case 1 Case 2 Case 3 Case 4 Case 5 References 58: Kidney Cancer 58.1 Introduction 58.2 Pathology 58.3 Staging 58.4 Epidemiology 58.5 Hereditary Disease 58.6 Prognosis 58.6.1 Histology 58.6.2 Staging 58.6.3 Metastatic Disease 58.6.4 RCC with ESRF 58.7 Diagnosis and Imaging 58.7.1 Ultrasound 58.7.2 Computerised Tomography(CT) 58.7.3 Magnetic Resonance Imaging (MRI) 58.7.4 Positron Emission Tomography(PET) 58.7.5 Bone Scan 58.7.6 Biopsy 58.8 Treatment 58.8.1 Localised Disease 58.9 Surgical Removal 58.10 Ablative Therapies 58.10.1 Radiofrequency Ablation 58.10.2 Cryotherapy 58.11 Active Surveillance 58.12 Systemic Therapy 58.12.1 Chemotherapy 58.13 Targeted Therapies 58.13.1 Anti-VEGF Antibodies 58.14 Multi-Targeted Receptor Kinase Inhibitors 58.14.1 Tyrosine Kinase Inhibitors (TKIs) 58.14.2 Mammalian Target of Rapamycin Inhibitors (MTORIs) 58.15 Immunotherapy 58.15.1 Cytokines 58.15.2 Immune Checkpoint Inhibition 58.15.3 Nivolumab 58.15.4 Ipilimumab 58.15.5 General Considerations on Systemic Therapy for Advanced/Metastatic RCC 58.16 Management of Patient Presenting with Metastatic Disease 58.16.1 Clinical Staging and Diagnosis 58.16.2 Primary Tumour 58.16.3 Metastatic Sites 58.16.4 Systemic Therapy Case Study Case 1 Case 2 Conclusions References 59: Inherited Renal Tumour Syndromes 59.1 Introduction 59.2 Genetic Diagnosis 59.3 Referral Criteria 59.4 Von Hippel-Lindau Syndrome: VHL Disease 59.4.1 Introduction and Epidemiology 59.4.2 Aetiology and Pathogenesis 59.4.3 Clinical Features 59.4.4 Diagnostic Criteria 59.4.5 Investigations 59.4.6 Management Issues in VHL Disease 59.4.6.1 Clear Cell Renal Cancer 59.4.6.2 Renal Cysts 59.4.6.3 Haemangioblastoma 59.4.6.4 Phaeochromocytoma 59.4.7 Novel Therapies 59.4.8 Follow-Up 59.5 Tuberous Sclerosis Complex 59.5.1 Introduction and Epidemiology 59.5.2 Aetiology and Pathogenesis 59.5.3 Clinical Features 59.5.4 Diagnostic Criteria 59.5.5 Investigations 59.5.6 Management Issues in TSC 59.5.6.1 Renal Angiomyolipomas 59.5.6.2 Fat-Poor Angiomyolipomas 59.5.6.3 Hypertension 59.5.6.4 Nephrolithiasis 59.5.7 Follow-Up 59.6 Birt-Hogg-Dubé Syndrome 59.6.1 Introduction and Aetiology 59.6.2 Clinical Features 59.6.3 Diagnostic Criteria 59.6.4 Management Issues in BHD 59.7 Hereditary Leiomyomatosis and Renal Cancer 59.7.1 Introduction and Aetiology 59.7.2 Clinical Features 59.7.3 Diagnostic Criteria 59.7.4 Management Issues in HLRCC 59.8 Other Causes of Familial RCC 59.8.1 Hereditary Translocation of Chromosome 3 59.8.2 Hereditary Papillary Renal Carcinoma 59.8.3 Succinate Dehydrogenase Case Study References Internet Resources 60: Polycystic Kidney Disease 60.1 Introduction 60.2 Clinical Features 60.2.1 Kidney Involvement 60.2.2 Other Organ Involvement in ADPKD 60.3 Epidemiology 60.4 Genetics 60.4.1 Genetic Testing 60.5 Pathophysiology 60.6 Diagnosis 60.6.1 ADPKD Diagnosis When Genotype Is Unknown 60.7 Differential Diagnosis 60.8 Treatment of Polycystic Kidney Disease 60.8.1 General Principles 60.8.2 Hypertension 60.8.3 Preparing for Renal Replacement Therapy 60.8.4 Practical Implications for Renal Replacement Therapy in Persons with ADPKD 60.8.5 Assessment of a Potential Living-Related Kidney Donor When There Is a Family History of ADPKD 60.9 Novel Therapies for ADPKD 60.10 Resources and Patient Information References 61: Other Cystic Kidney Diseases 61.1 Introduction 61.2 Simple Cysts 61.3 Acquired Cystic Kidney Disease Box 61.1 Diagnostic Criteria for Acquired Cystic Kidney Disease 61.4 Hereditary Cystic Diseases/Ciliopathies 61.4.1 Autosomal Recessive Conditions 61.4.2 Autosomal Dominant Conditions 61.5 Autosomal Recessive Polycystic Kidney Disease 61.6 Medullary Sponge Kidney Conclusion Case Study Case 1 Case 2 References Patient Information and Guidelines 62: Genetic Disorders of the Glomerular Basement Membrane 62.1 The Glomerular Basement Membrane: Components, Structure and Function 62.2 Alport Syndrome 62.2.1 Epidemiology 62.2.2 Aetiology and Pathogenesis 62.2.2.1 X-Linked Alport Syndrome 62.2.2.2 Autosomal Recessive Alport Syndrome 62.2.2.3 Having Both an Abnormal and a Normal Copy of an Autosomal Alport Gene 62.2.2.4 Unsuspected Alport Mutations 62.2.3 Clinical Features 62.2.4 Renal Disease 62.2.5 Carriers and Heterozygotes 62.2.6 Hearing Loss 62.2.7 Ocular 62.2.8 Contiguous Gene Syndromes 62.2.9 Differential Diagnosis 62.2.10 Investigations 62.2.11 Renal Biopsy 62.2.12 Genetic Testing 62.2.13 Skin Biopsy 62.3 Treatment 62.3.1 Drug Therapy 62.3.2 Renal Transplantation 62.3.2.1 Living Donation 62.3.2.2 Post-transplant Anti-GBM Nephritis 62.3.3 Thin Basement Membrane Nephropathy 62.3.4 Epidemiology 62.3.5 Clinical Features 62.3.6 Differential Diagnosis 62.3.7 Investigation 62.3.8 Management 62.3.9 Nail-Patella Syndrome (Hereditary Osteo-onychodysplasia) 62.3.9.1 LMX1B Mutations Without NPS 62.3.10 Laminin Mutations, Pierson Syndrome and Proteinuria 62.3.11 COL4A1 Mutations and HANAC References Online Resources 63: Anderson-Fabry Disease and Other Inherited Lipid Disorders of the Kidney 63.1 Introduction 63.2 Pathophysiology 63.3 Epidemiology 63.4 Clinical Features 63.5 Diagnosis 63.6 Investigations 63.6.1 Urine 63.6.2 Blood 63.6.3 Eyes 63.6.4 Imaging 63.6.5 Histopathology 63.7 Management 63.8 Renal Replacement Therapy 63.8.1 Dialysis 63.8.2 Transplantation 63.9 Enzyme Replacement Therapy (ERT) 63.10 Multidisciplinary Care Team 63.11 Other Inherited Lipid Disorders of the Kidney 63.11.1 Lecithin-Cholesterol Acyltransferase (LCAT) Deficiency 63.11.2 Apoprotein E-Related Glomerular Disorders 63.11.2.1 Lipoprotein Glomerulopathy 63.11.2.2 Apo-E Homozygote Glomerulopathy References Further Resources 64: Inherited Metabolic Disease and the Kidney 64.1 Introduction 64.2 Cystinosis 64.2.1 Presentation and Investigation 64.2.1.1 Diagnosis 64.2.1.2 Genomics 64.2.2 Management 64.2.2.1 General 64.2.2.2 Management of Progression of the Disease 64.2.3 Future Therapies 64.2.3.1 Cysteamine Prodrugs 64.2.3.2 Stem Cell Transplant and Gene Therapy 64.3 Transition 64.4 The Primary Hyperoxalurias 64.4.1 Presentation and Investigation 64.4.2 Genetic Testing 64.4.3 Conservative Management 64.4.4 Dialysis 64.4.5 Transplantation 64.4.6 Management of Urolithiasis 64.4.7 PH2 64.4.8 PH3 64.4.9 New Therapies and Future Strategies 64.5 Additional Information 64.6 Conclusion References Cystinosis The Primary Hyperoxalurias Supplementary Reading Cystinosis The Primary Hyperoxalurias IX: Chronic Kidney Disease 65: Chronic Kidney Disease: Epidemiology and Causes 65.1 Introduction 65.2 Incidence and Prevalence Explained Using Renal Replacement Therapy Data 65.2.1 Limitations of Using RRT Data 65.3 Defining the Incidence and Prevalence of CKD in a Population 65.3.1 Limitations of Using CKD Definition and Staging 65.4 What Influences Prevalence of CKD and Incidence of ESRD? 65.5 Referral of Patients with CKD 65.6 Understanding CKD Progression and the Issue of AKI 65.7 Defining an Underlying Cause of CKD: Considerations and Causes Not to Miss Box 65.1 Some Causes of ESRD to Consider (Beyond the Obvious) with Non-invasive Tests That May Make or Suggest the Diagnosis Box 65.2 Maternal Factors Associated with Low Birth Weight and Pre-term Birth 65.8 Prevention and Screening of CKD 65.9 Summary References 66: Chronic Kidney Disease: Diagnosis and Assessment 66.1 Introduction 66.2 Ascertainment of CKD 66.2.1 Estimating Glomerular Filtration Rate 66.2.2 Measurement of Glomerular Filtration Rate in the Management of CKD 66.2.3 Quantification of Proteinuria 66.3 Finding Patients with CKD 66.3.1 The Role of Automated eGFR Reporting 66.3.2 Screening Programmes 66.4 Predicting Progression 66.4.1 Measuring Progression 66.4.2 Graphing eGFR over Time 66.4.3 Prediction Equations 66.4.4 Risk Factors for Progression 66.4.5 Proteinuria 66.4.6 Hypertension 66.4.7 Others 66.5 How Do You Tell Your Patient That They Have CKD? 66.6 Specialist Referral 66.7 Finding Patients with Treatable Causes 66.8 Radiology 66.9 Renal Biopsy 66.10 Conclusion Case Study Case 1 Case 2 References 67: Clinical Management of CKD: Prevention of Progression 67.1 Non-pharmacological Measures 67.1.1 Patient Activation 67.1.2 Co-operation with Primary Care and Other Secondary Care Disciplines 67.1.3 Salt Intake 67.1.4 Water Intake 67.1.5 Exercise 67.1.6 Weight Loss 67.1.7 Alcohol Intake 67.1.8 ‘Hard’ Drug Use 67.1.9 Avoidance of Acute Kidney Injury Superimposed on CKD 67.2 Pharmacological Measures 67.2.1 Treatment of Anaemia 67.2.2 Antiproteinuric Treatment 67.2.3 Inhibitors of the Renin/Angiotensin/Aldosterone System 67.2.4 Sodium-Glucose Co-transport Inhibition 67.2.5 Non-dihydropyridine Calcium Channel Blockers 67.2.6 Antihypertensive Treatment 67.2.7 Metabolic Acidosis 67.2.8 Hyperkalaemia 67.2.9 Dyslipidaemia 67.2.10 Hyperuricaemia 67.2.11 Other Drug Therapy 67.2.12 Fibrates 67.2.13 Trimethoprim, Cimetidine and Antiretroviral Drugs 67.2.14 Non-steroidal Anti-Inflammatory Drugs (NSAIDs) 67.2.15 Aminoglycosides 67.2.16 Antiviral Drugs 67.3 Clinical Management of CKD: Preparation for End-Stage Kidney Failure 67.3.1 Prediction of Outcome 67.3.2 Multidisciplinary Education Programmes 67.3.2.1 Identification and Workup of Patients Suitable for Transplantation 67.3.2.2 Balancing the Burdens and Benefits of Renal Replacement Therapy: The Option of Active Supportive Care Shared Decision-Making: Patient Decision Aids 67.3.2.3 Late Presentation Conclusion Case Study Case Study 1 Case Study 3 References 68: Thinking About the Future, Symptom Control and Other Aspects of Palliative Care in Advanced CKD 68.1 Introduction 68.2 Thinking About the Future 68.3 Which Patients Need Palliative and Supportive Care? 68.4 Palliative and Supportive Care Assessment 68.5 Symptoms 68.5.1 Symptom Prevalence 68.5.2 Symptom Assessment 68.5.3 Symptom Management 68.5.4 Pain 68.5.4.1 Which Opioids to Use? 68.5.4.2 Specific Types of Pain 68.5.5 Breathlessness 68.5.6 Constipation 68.5.7 Nausea and Vomiting 68.5.8 Pruritus 68.5.9 Restless Legs 68.6 Symptom Management at the End of Life 68.6.1 Care After Death 68.7 Summary References Internet Resources 69: Transition of Adolescents with Nephrological Conditions 69.1 Introduction 69.2 Barriers to Successful Transition Case Study 69.3 Conclusion References/Further Reading/Guidelines Resources and Patient Information 70: Adherence and Kidney Disease 70.1 Introduction 70.1.1 Definition of Adherence 70.1.2 Prevalence of Poor Adherence 70.2 Factors Associated with Non-adherence Box 70.1 Situational Risk Factors for Non-adherence 70.3 Measuring Adherence 70.3.1 Subjective Ratings of Adherence 70.3.2 Objective Measures of Adherence 70.3.2.1 Medication Monitoring 70.3.3 Biochemical Markers of Adherence 70.3.3.1 Interventions to Improve Non-adherence 70.4 Summary Case Study Case 1 Case 2 Case 3 Case 4 Case 5 References Information and Guidelines: Useful Links 71: Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) 71.1 Pathophysiology and Clinical Correlates 71.1.1 Biochemical Features 71.1.1.1 PTH 71.1.1.2 Vitamin D 71.1.1.3 FGF-23 71.1.2 Renal Bone Disease 71.1.2.1 High Turnover (Hyperparathyroid) Bone Disease 71.1.2.2 Adynamic Bone Disease (ABD) 71.1.3 Vascular Calcification (VC) 71.2 General Management Issues 71.2.1 Controlling Hyperphosphataemia 71.2.1.1 Diet 71.2.1.2 Phosphate Binders 71.2.1.3 Dialysis 71.2.2 Controlling Serum Calcium 71.2.3 PTH 71.2.3.1 Parathyroidectomy 71.3 Additional Considerations and Controversies 71.3.1 Native Vitamin D Therapy 71.3.2 Calciphylaxis 71.3.3 Bone Mineral Density and Fracture Prophylaxis 71.3.4 The Transplant Patient 71.3.4.1 Avascular Necrosis Case Study Suggested Further Reading Resources for Patients 72: Anaemia Management in Chronic Kidney Disease 72.1 Introduction 72.2 Practical Stepwise Approach to CKD Anaemia Management 72.3 Excluding Other Causes of Anaemia 72.4 Reticulocyte Count 72.5 Iron Management 72.5.1 Iron Deficiency: Absolute Versus Functional 72.5.2 Detection of Iron Deficiency 72.5.3 Iron Supplementation: Oral Versus Intravenous? 72.6 Reactions to IV Iron 72.7 ESA Therapy 72.8 Epoetins 72.9 Darbepoetin Alfa 72.10 Methoxy Polyethylene Glycol-Epoetin Beta 72.11 Peginesatide 72.12 Trigger Haemoglobin Concentration 72.13 Target Haemoglobin 72.14 Poor Response to ESA Therapy 72.15 Blood Transfusions 72.16 HIF Prolyl Hydroxylase Domain Inhibitors 72.17 Guidelines on Anaemia Management in CKD 72.18 Conclusions Case Study Case 1 Case 2 Case 3 Key Author and Reference Besarab et al.: US Normal Hematocrit Study Drueke et al.: CREATE Study Singh et al.: CHOIR Study Pfeffer et al.: TREAT Study Macdougall et al.: PIVOTAL Study References 73: Nutrition in Kidney Disease 73.1 Introduction 73.1.1 Nutrition in Kidney Disease: The Big Picture 73.2 Undernutrition 73.2.1 Screening and Diagnosis 73.2.2 Evidence-Based Interventions 73.2.3 Nutrition Is a Modifiable Risk Factor in Frailty 73.3 Obesity 73.3.1 When Is Obesity a Problem? 73.3.2 Strategies for the Management of Obesity 73.3.3 Bariatric Surgery Outcomes in CKD 73.4 Diabetes 73.5 Salt and Volume Overload 73.6 Chronic Kidney Disease Mineral Bone Disorder (CKD-MBD) 73.7 Dietary Management of Hyper- and Hypokalaemia 73.7.1 Hyperkalaemia 73.7.2 Hypokalaemia 73.8 Nutrition in Hospitalised CKD Patients 73.8.1 Nutritional Management of AKI 73.8.2 PD Peritonitis and Encapsulating Peritoneal Sclerosis (EPS) 73.8.3 Refeeding Syndrome in CKD 73.8.4 Nutrition Post-transplantation 73.8.5 Nutrition at the End of Life Case Study Case 1 Case 2 73.9 Conclusion References Patient Information and Guidelines 74: Pharmacology and the Kidney 74.1 Absorption 74.2 Distribution 74.3 Metabolism 74.4 Elimination 74.5 Pharmacodynamics 74.6 Drug Metabolism in Normal and Impaired Kidney Function 74.7 Elimination of Drugs by ­Haemodialysis/Filtration and Peritoneal Dialysis 74.8 Electronic Prescribing 74.9 Prescribing in Acute Kidney Injury Case Studies Case 1: Drug Interaction Case 1: Answers and Learning Points Case 2: Dose Change According to RRT Case 2: Dose Change According to RRT: Answers and  Learning Points 74.10 Useful Links 74.11 Summary References 75: Coagulation in Kidney Disease 75.1 Introduction 75.2 Bleeding 75.2.1 Clinical Presentation 75.2.2 Investigation of Platelet Dysfunction 75.3 Therapy for Uraemic Bleeding 75.3.1 Long-Term Prevention of Spontaneous Bleeding 75.3.2 Periprocedural Prophylaxis and Active Bleeding: Non-specific Interventions 75.4 Thrombosis 75.4.1 Venous Thrombosis and VTE Prophylaxis 75.4.2 Nephrotic Syndrome 75.4.3 Vascular Access Thrombosis 75.4.4 Atrial Fibrillation 75.5 Anticoagulants in Renal Disease 75.5.1 Warfarin 75.5.1.1 Monitoring and Dose Adjustments 75.5.1.2 Bleeding and Reversal of Warfarin Anticoagulation 75.5.2 Heparins 75.5.2.1 Unfractionated Heparin 75.5.2.2 Low-Molecular-Weight Heparins and Fondaparinux 75.5.3 Haemodialysis Anticoagulation 75.5.4 Direct Oral Anticoagulants (DOACs) 75.6 Antiplatelet Therapy 75.7 Heparin-Induced Thrombocytopenia (HIT) 75.7.1 Clinical Presentation 75.7.2 Diagnosis 75.7.3 Treatment of HIT Case Study Case 1 Case 2 Case 3 References X: Dialysis 76: Prevention of Infection in Kidney Patients 76.1 Introduction 76.2 Core Principles of Infection Prevention and Control 76.2.1 Hand Hygiene 76.2.2 Personal Protective Equipment (PPE) 76.3 Sharps Disposal 76.3.1 Surveillance 76.3.2 Important Microorganisms Including Multidrug-Resistant Organisms (MDRO) 76.4 Access-Related Infections 76.4.1 Prevention of CVC Infections 76.4.1.1 Peritoneal Dialysis (PD) 76.4.1.2 Insertion of PD Catheter 76.4.1.3 Connection Methods 76.4.1.4 Exit-Site Preparations 76.4.1.5 Invasive Procedures 76.4.1.6 Prevention of Fungal Peritonitis 76.4.1.7 Preventing Fistula and Graft Infections 76.5 Prevention of Other Important Healthcare-Associated Infection 76.6 Preventing the Spread of Blood-Borne Viruses (BBV) 76.6.1 Vaccine Preventable Diseases (Including Travel Health) 76.6.1.1 Tuberculosis 76.7 Persistent Bacterial Infections 76.8 Patient Education 76.8.1 Embedding Infection Control Excellence in the Renal Department 76.9 An Approach to Prevention of Covid-19 Infection 76.9.1 The Haemodialysis Unit 76.9.1.1 Social Distancing 76.9.1.2 Transport 76.9.1.3 Triage 76.9.2 Cohorting 76.9.2.1 Testing and Surveillance 76.9.2.2 Staffing and PPE 76.9.3 Peritoneal Dialysis 76.9.4 Acute Transplantation 76.9.5 Outpatient Services Including Transplant Follow-Up 76.10 Summary Case Study References 77: Setting Up and Running a Haemodialysis Service 77.1 Introduction 77.2 Should Haemodialysis Be Provided? 77.3 Haemodialysis Service Capacity 77.4 Physical Location and Security of Haemodialysis Services 77.5 Functional and Safety Considerations 77.5.1 Utilities 77.6 Treatment Area and Patient Stations 77.7 Occupational Health and Safety 77.8 Functional Areas 77.9 Patient Safety 77.10 Minimum Requirements for Safe and Adequate Delivery of Haemodialysis 77.10.1 Water Treatment Unit 77.11 Maintenance, Documentation and Servicing 77.12 Haemodialysis Machines 77.13 Consumable Equipment 77.14 Dialysis Staff 77.15 Vascular Access 77.16 Basic Medications for Haemodialysis Patients 77.17 Laboratory Tests 77.18 Dialysis Prescription 77.19 Infection Control 77.20 Clinical Protocols 77.21 Additional Considerations for a Haemodialysis Unit 77.21.1 Haemodialysis Schedule 77.21.2 Staffing 77.21.3 Clinical Governance 77.22 Clinical Guidelines Box 77.1 Global Organisations for Nephrology and Haemodialysis Kidney Organisations with Additional Resources 77.22.1 Setting Up a Dialysis Unit in an LLMIC: Developing a New Haemodialysis Unit in Malawi 77.23 Concluding Remarks References 78: Vascular Access: Improving Outcomes for Haemodialysis Patients 78.1 Establishing New Access for HD 78.1.1 Planning Access 78.1.2 Decision-Making and Planning Ahead in Both Modalities 78.1.3 Surgical Considerations 78.1.3.1 Sites 78.1.3.2 Mapping and Terminology Fistula Terminology (. Fig. 78.2) 78.1.3.3 Surgical Techniques, Anaesthesia and Special Considerations Other Surgical Considerations: Patients Presenting at a Late-Stage Requiring RRT 78.1.4 Assisted Patency 78.1.5 First Use 78.2 Maintaining the Current Vascular Access 78.2.1 Needling Technique 78.2.2 Monitoring the Physical Examination 78.2.3 Surveillance 78.2.3.1 Intra-Access Flow (QA) Is Access Surveillance Useful? Patent Yet Stenosed AVG: Is Intervention Useful? Patent Yet Stenosed AVF: Is Intervention Recommended? 78.2.4 If a Subclinical Stenosis Is Suspected: What Next? 78.2.4.1 Percutaneous Fistuloplasty 78.2.4.2 Other Endovascular Techniques to Maintain Access Patency Surgical Techniques to Maintain Patency Juxta-Anastomotic Stenosis Access Monitoring and Surveillance: A Summary 78.2.5 Thrombosed Access 78.2.5.1 Recognition and Patient Safety 78.2.5.2 Contraindications 78.2.5.3 Thrombectomy-Treatment Techniques 78.2.5.4 Thrombolysis 78.3 Reducing Risk 78.3.1 Pharmaceutical Therapies to Reduce Access Thrombosis 78.3.2 Infection 78.3.3 Mechanical Issues 78.3.3.1 True Aneurysms, Pseudoaneurysms, Bleeding and Ruptures 78.3.3.2 Signs of Incipient AVF Bleed/Rupture 78.3.3.3 Central Venous Stenosis 78.3.4 Surgical Solutions to Ischaemic Complications 78.3.4.1 Ischaemic Monomelic Neuropathy 78.3.4.2 Steal Syndrome Management of Steal Surgical Treatments 78.4 Conclusion Case Study References Additional Resources 79: Vascular Access: Haemodialysis Catheters 79.1 Introduction 79.2 Preparation for Line Insertion 79.3 Catheter Selection 79.4 Choosing a Tunnelled CVC Position (KDOQI vascular access guidelines 2006) [1] 79.5 Catheter Insertion Procedure (See Video on Line Insertion) 79.6 Complications of Catheter Insertion 79.7 Catheter Locks 79.8 Catheter Complications 79.9 Catheter Occlusion 79.10 Catheter Infection 79.11 Central Vein Stenosis 79.12 Investigations 79.13 Management of Central Vein Stenosis 79.13.1 HeRO® Graft (Merit Medical) 79.14 Removal of Haemodialysis Catheters 79.15 Dialysis Catheter Repair 79.16 Dialysis Catheter Insertion 79.17 Dialysis Catheter Removal 79.18 Dialysis Catheter Repair Case Study Case 1 Case 2 Case 3 79.19 Conclusion References 80: Complications of Maintenance Haemodialysis and How to Avoid Them 80.1 Introduction 80.2 Blood Pressure and Fluid Management 80.2.1 Aetiology 80.2.2 Measurement of BP 80.2.3 Assessing Volume Status 80.2.4 Target BP 80.2.5 Management 80.2.6 Salt and Fluid Restriction Box 80.1 BP and Volume Control – Salt and Water Restriction and Patient Education (See Text for Further Details) 80.2.7 Identification of Goals 80.2.8 Target Weight Reduction 80.2.9 Use of Antihypertensives 80.2.10 Refractory Hypertension 80.2.11 Intra-dialytic Hypertension 80.3 Intra-dialytic Hypotension 80.3.1 Immediate Management 80.3.2 Prevention 80.3.3 Assessment of Recurrent IDH 80.4 Post-dialysis Fatigue 80.5 Pruritus 80.6 Restless Leg Syndrome 80.7 Cardiovascular Disease in the Haemodialysis Patient (see Wheeler and Caplin) Box 80.2 Possible Presentations of Coronary Artery Disease in the HD Patient (See Text for Further Details) 80.7.1 Prevention 80.7.1.1 Weight Loss 80.7.1.2 Smoking Cessation 80.7.1.3 Exercise 80.7.1.4 Diabetic Management 80.7.1.5 Lipid Lowering Therapy 80.7.1.6 Vitamin Supplements 80.7.1.7 Anaemia Management (7 See Chap. 72) 80.7.1.8 Aspirin (7 See Chaps. 37 and 75) 80.7.1.9 Secondary Prevention in Patients with Established Coronary, Cerebral or Peripheral Arterial Disease 80.7.2 Acute Management of Acute Coronary Syndromes 80.7.3 Management of Cardiac Failure 80.7.4 Sudden Cardiac Death 80.8 Infection Control (7 Chap. 76) 80.8.1 Blood-Borne Virus Protection 80.8.2 Vascular Access 80.8.3 Prevention and Treatment of Infective Episodes 80.9 Intra-dialytic Symptoms 80.9.1 Muscle Cramps 80.9.2 Nausea, Vomiting and Headaches 80.10 Dialysis Disequilibrium Syndrome 80.10.1 Differential Diagnosis 80.10.2 Prevention 80.10.3 Treatment 80.11 Needle Dislodgement 80.12 Air Embolism 80.13 Dialyser Reactions 80.14 Acute Haemolysis 80.15 Differential Diagnosis of Chest Pain Developing During Dialysis 80.16 Differential Diagnosis of Dyspnoea Developing During Dialysis 80.17 Systemic HD Care 80.18 Convective Therapies 80.19 Water Quality 80.19.1 Quality Assurance 80.19.1.1 Communication 80.19.1.2 Technique 80.19.1.3 Hardware 80.19.1.4 Ultrapure Versus Standard Quality Water 80.20 Care of Haemodialysis Inpatients 80.21 Organization of the HD Service Will Be Covered by Roger Greenword 80.21.1 The HD Clinic 80.21.2 The Multidisciplinary Team (MDT) Meeting 80.21.3 The ‘HD Committee’ 80.21.4 Management of Intercurrent Problems Bibliography 81: Hemodialysis Prescription 81.1 Introduction 81.2 Diffusive Dialyzer Clearance 81.3 Convective Dialyzer Clearance 81.4 Sessional Dialyzer Clearance 81.5 Kt/Vurea Model 81.6 Alternate Methods of Estimating Urea Clearance 81.7 Errors in Calculating Kt/V 81.8 Incremental Dialysis for Solute Clearances 81.8.1 Equivalent Renal Urea Clearance (EKRurea, ml/min) 81.9 Augmented Dialysis 81.10 Interpreting Adequacy in Hemodialysis Patients 81.11 Alternative Methods of Assessing Adequacy of Dialyzer Clearance 81.12 Adjusting Kt/V Targets for Individual Patients 81.12.1 Equations 81.13 Summary Case Study References 82: Providing a PD Service 82.1 Introduction Box 82.1 Useful Resources with Guidelines and Training Information 82.2 Survival on PD vs HD 82.3 Patient Selection Case Study 82.1 Questions: Answers: 82.4 Sodium Removal Cases Study 82.2 Answer 82.5 Dialysate Calcium 82.5.1 Obesity 82.5.2 Diabetics 82.5.3 Heart Failure 82.5.4 Cardiac Surgery 82.5.5 Cirrhotic Patients 82.5.6 Lung Disease 82.5.7 Vascular Access 82.5.8 Dementia 82.5.9 Diverticular Disease 82.5.10 Appetite and Constipation 82.5.11 Hernias 82.5.12 Starting PD 82.5.13 Acute PD 82.6 PD Team 82.7 Patient Training Case Study 82.3 Answers: 82.8 Pregnancy and PD Case Study 82.4 Questions: Answers: Case Study 82.5 Questions: Answers: 82.9 Catheter Insertion 82.10 Techniques 82.10.1 Antisepsis 82.10.1.1 LAPD (. Figs. 82.1, 82.2, 82.3, 82.4, and 82.5) (and See Video) 82.10.2 Catheters 82.11 Governance 82.11.1 Key Performance Indicators and Continuous Quality Improvement 82.11.2 Finance 82.11.3 Knowing When to Give Up 82.12 Summary References 83: Peritoneal Dialysis Prescription 83.1 Introduction 83.2 PD Modalities 83.2.1 Continuous Ambulatory Peritoneal Dialysis (CAPD) 83.2.2 Types of Automated Peritoneal Dialysis (APD) 83.2.3 Assisted Peritoneal Dialysis (aAPD) 83.2.4 Hybrid (Combination) Peritoneal and Hemodialysis 83.2.5 Urgent Start Peritoneal Dialysis 83.3 Choice of PD Modality 83.4 Empiric Starting PD Prescription 83.5 How to Adjust PD Prescription 83.5.1 Dialysis Adequacy in Anuric Patients 83.5.2 Treatment for Hyperkalemia and Hypercalcemia 83.6 Sodium Sieving 83.7 Peritoneal Dialysis Fluid 83.7.1 Glucose 83.7.2 Glucose Polymer Icodextrin (Extraneal) 83.7.3 Amino Acids (Nutrineal) 83.8 PD Clearance Targets 83.9 Ultrafiltration Targets 83.10 Summary Case Study 83.1 Case Study 83.2 Case Study 83.3 References 84: Complications of Peritoneal Dialysis 84.1 Introduction Case Study Peritoneal Access Infection Ultrafiltration Box 84.1 Guidelines Published by the International Society of Peritoneal Dialysis (available at 7 www.­ISPD.­org) 84.2 Peritoneal Dialysis-Associated Infection 84.2.1 Prevention of PD-Associated Infection Box 84.2 Methods for Reducing the Risk of PD Peritonitis Box 84.3 Strategies to Prevent Exit Site Infection 84.2.2 PD Peritonitis Box 84.4 Causes of Culture Negative Peritonitis 84.2.3 Treatment of PD Peritonitis Box 84.5 Indications for PD Catheter Removal for Peritoneal Dialysis-Associated Infections 84.3 Exit Site Infection (ESI) 84.4 Audit Standards for PD-Related Infection Box 84.6 Selected Continuous Quality Improvement Measures to Prevent Peritonitis [12] 84.5 Peritoneal Access-Related Problems 84.6 Common Catheter-Related Complications 84.7 Audit Standards for Catheter Placement 84.8 Surgical Complications of PD 84.9 Hemorrhage 84.10 Hematoperitoneum 84.11 Perforation or Laceration 84.12 Wound Infection 84.13 Hernias 84.14 Leaks 84.15 External Cuff Extrusion 84.16 Chylous Effluent 84.17 Indications for Catheter Removal 84.18 Metabolic Complications of Peritoneal Dialysis 84.19 Systemic Metabolic Complications of Peritoneal Dialysis 84.20 Long-Term Changes to the Peritoneal Membrane: Impact on Ultrafiltration Capacity and Patient Outcome 84.21 Encapsulating Peritoneal Sclerosis References XI: Transplantation 85: Setting-Up and Running a Renal Transplant Unit 85.1 Introduction Case Study 85.2 Developing New Transplant Units Box 85.1 Key Stages Toward First Transplant 85.3 The Extended Transplant Team 85.4 Working Toward the First Transplant 85.5 Developing Clinical Governance Conclusion References Further Information 86: Assessment of the Potential Transplant Recipient 86.1 Introduction 86.2 Service Structure 86.2.1 When to Assess and Activate the Patient on the Transplant List? 86.3 Surgical Assessment 86.3.1 Vessels 86.3.2 Space 86.3.3 Bladder Drainage and Pressures 86.3.4 The Hostile Abdomen 86.3.5 Obesity 86.4 Medical Assessment 86.4.1 Cardiovascular Risk Assessment 86.4.1.1 Screening for CAD 86.4.1.2 Valvular Heart Disease Box 86.1 Symptoms Suggestive of Underlying Malignancy that Warrants Directed Investigation 86.4.1.3 Left Ventricular Disease 86.4.2 Cerebrovascular Disease 86.4.3 Recurrent disease 86.4.4 Malignancy 86.4.5 Infection Box 86.2 Principal Infections Screened for in the Pre-transplant Assessment 86.4.5.1 Tuberculosis 86.4.5.2 Atypical Mycobacterial Infection 86.4.5.3 Hepatitis B 86.4.5.4 Hepatitis C 86.4.5.5 HIV Box 86.3 HIV-Specific Assessment for Transplant ­Candidates (See Guidelines for Details) [54] 86.4.5.6 HTLV Infection 86.4.5.7 Herpes Simplex (HSV) 86.4.5.8 Cytomegalovirus (CMV) 86.4.5.9 Varicella Zoster (VZV) 86.4.5.10 Epstein-Barr Virus (EBV) 86.4.5.11 Strongyloides 86.4.5.12 Schistosomiasis 86.4.5.13 Toxoplasma 86.4.5.14 Syphilis 86.4.5.15 Trypanosoma cruzi (Chaga’s disease) 86.4.5.16 Coccidioides 86.4.5.17 Histoplasmosis 86.4.5.18 Human Herpes Virus-8 86.4.6 Frailty 86.4.7 Pulmonary Issues 86.4.8 Gastrointestinal (GI) Issues 86.4.9 Miscellaneous 86.5 Anesthetic Assessment 86.5.1 Preoperative Assessment 86.5.1.1 Cardiovascular Risk 86.5.1.2 Superior Vena Cava Obstruction and Central Vein Access 86.5.1.3 Difficult Airways 86.5.1.4 Chronic Hypotension 86.5.2 Perioperative Management 86.6 Pharmacy Review 86.7 Psychological Assessment 86.8 Patient Education 86.9 Pre-activation Checklist Box 86.4 Pre-activation Checklist Case Study Case 1 Case 2 Case 3 Conclusion References 87: Transplant Donor Selection 87.1 Introduction 87.2 Selection of the Deceased Donor Box 87.1 Contraindications to Solid Organ Donation. Modified from Organ Donation and Transplantation Clinical Guidance 2020 [3] 87.2.1 Donors with Infection 87.3 Hepatitis B Positive Donors 87.3.1 HBsAg +Ve Donors 87.3.2 HBsAg -Ve, HBcAb +Ve Donors 87.4 Hepatitis C Positive Donors 87.5 HIV-Positive Donors 87.6 HTLV Positive Donors 87.7 Donors with Malignancy 87.7.1 Marginal and Expanded Criteria Donors 87.7.1.1 Kidney Donor Profile Index 87.7.1.2 Donor Serum Creatinine 87.7.1.3 DCD Donors 87.7.2 Pediatric Donors 87.7.3 Older Donors 87.7.4 Summary 87.8 Selection of the Live Donor 87.8.1 Choosing the Potential Live Donor 87.8.2 Altruistic Donors 87.8.3 Assessment of the Potential Live Donor Box 87.2 Suggested Minimal Investigations for Donor Assessment 87.8.4 Specific Points in the Workup Process 87.8.5 Kidney Function and the Acceptable Level to Donate 87.8.6 Obesity 87.8.7 Hypertension 87.8.8 Hematuria 87.8.9 Diabetes 87.8.10 Nephrolithiasis in Potential Donors 87.8.11 Genetic Causes of Kidney Failure 87.9 Adult Polycystic Kidney Disease 87.9.1 Cardiovascular Suitability for Donation 87.9.2 Pregnancy Post-Donation 87.9.3 Consent and How Much Should the Donor Know? 87.9.4 Which Kidney to Remove 87.10 Summary 87.11 Conclusion Case Study Case 1 Case 2 Case 3 References 88: Running a Living Donor Programme 88.1 Introduction 88.2 What Makes Living Donor Transplantation Better? 88.2.1 Donor 88.2.2 Recipient 88.3 What Are the Associated Risks of Living Donation? 88.3.1 Short-Term Risks 88.3.2 Medium-Term 88.3.3 Long-Term Risks 88.4 How Should a Potential Living Donor be Assessed? 88.5 Why Is There Variation in Rates of Living Kidney Donation? 88.6 Conclusion References 89: Tissue Typing: Crossmatch, Antibodies, and Risk Analyses of Transplant Rejection 89.1 Introduction 89.2 ABO Blood Groups and ABO Incompatibility 89.3 Human Leukocyte Antigens (HLA) and Tissue Typing 89.3.1 HLA Polymorphism 89.3.2 HLA Nomenclature 89.3.3 HLA Matching 89.3.4 HLA Antibody Screening 89.4 Crossmatching 89.4.1 Virtual Crossmatch Box 89.1 Suggested Criteria for Virtual Crossmatch 89.5 Non-HLA Antibodies 89.6 Sensitization 89.6.1 Risk Factors for Sensitization 89.6.2 Prevention of Sensitization 89.6.2.1 Transfusion Avoidance 89.6.2.2 Avoidance of Allosensitization Following Transplantation 89.6.2.3 Removal of Kidney or Reduction in IS Following Failed Graft 89.7 Improving Graft Numbers and Outcomes in the Context of ABOi or HLAi 89.7.1 National Allocation Schemes for ABOi Transplantation 89.7.2 Paired Exchange/Pooled Donation 89.7.3 Blood Group-Incompatible Transplantation 89.7.4 Strategies for the Management of the HLA and Non-HLA Sensitized Patient 89.7.4.1 Desensitization Strategies 89.7.4.2 Augmented Immunosuppression 89.7.4.3 Reduction in Anti-HLA Antibody Production 89.7.4.4 Intravenous Immunoglobulin (IVIg) 89.7.4.5 Removal of Anti-HLA Antibodies 89.7.4.6 Complement Inhibition 89.7.4.7 Combined Liver-Kidney Transplant (CLK) 89.7.4.8 Stem Cell Transplant 89.8 Summary Case Study Case 1 Case 2 Case 3 89.9 Seminal Papers Conclusion Supplementary Material References Useful Websites 90: Surgical Aspects of Kidney and Pancreas Transplantation 90.1 Deceased Donor Kidney and Pancreas Recovery 90.2 Organ Recovery Techniques 90.3 Organ Assessment 90.4 Organ Preservation and Storage 90.4.1 Scientific Basis of Organ Preservation Techniques 90.4.2 Use of Preservation Fluids for Cold Storage 90.4.3 Machine Perfusion Techniques 90.5 Deceased Donor Kidney Transplantation 90.5.1 Donor Selection Box 90.1 Contraindications to Donation in the UK 90.5.2 Surgical Aspects of Recipient Selection 90.5.3 Implantation Techniques 90.5.3.1 Single Kidney Transplantation 90.5.3.2 Double Adult Kidney Transplantation 90.5.3.3 Robotic-Assisted Kidney Transplantation (RAKT) 90.5.4 Postoperative Surgical Complications 90.6 Pancreas Transplantation 90.6.1 Donor Selection 90.6.2 Surgical Aspects of Recipient Assessment Box 90.2 Recipient Selection for Pancreas Transplantation 90.6.3 Implantation Techniques 90.6.4 Postoperative Surgical Complications 90.7 Live Donor Kidney Transplantation 90.7.1 Donor Selection 90.7.2 Surgical Aspects of Recipient Assessment 90.7.3 Live Donor Nephrectomy Techniques 90.7.4 Implantation Techniques 90.7.5 Patient Safety Systems in Organ Transplantation Case Study References 91: Management of the Acute Transplant 91.1 Introduction 91.2 Preoperative Management 91.2.1 Identification of Potential Recipients 91.2.2 Calling in Potential Recipients 91.2.3 Preoperative Checks 91.2.4 The Cross-Match (See 7 Chap. 67) 91.3 Immunosuppression (See 7 Chap. 70) 91.3.1 Calcineurin Inhibitors (CNIs) 91.3.1.1 Tacrolimus (FK506) 91.3.1.2 Ciclosporin or Cyclosporin (CsA or CyA) 91.3.2 Antiproliferative Agents 91.3.2.1 Mycophenolic Acid (MPA/MMF/Myfortic) 91.3.2.2 Azathioprine 91.3.3 mTOR Inhibitors (Rapamycin: Sirolimus and Everolimus) 91.3.4 Corticosteroids (Prednisolone, Methylprednisolone) 91.3.5 Induction Agents: Monoclonal and Polyclonal Antibodies 91.3.6 Data Collection 91.3.7 In Recovery 91.3.8 The First 24 Hours 91.3.9 The First Week 91.3.10 Early Graft Dysfunction 91.3.11 Delayed Graft Function (DGF) 91.3.12 Thrombosis and Anticoagulation 91.3.13 Acute Cellular Rejection (ACR) 91.3.14 Acute Antibody-Mediated Rejection 91.3.15 Urine Outflow Obstruction 91.4 Other Postoperative Considerations 91.4.1 Hypotension 91.4.2 Hypertension 91.4.3 Accelerated-Phase Hypertension/Thrombotic Microangiopathy (TMA) 91.4.4 Sepsis 91.4.5 Proteinuria 91.4.6 Discharge Planning 91.5 Cases Case History 1: Early Rise in Creatinine Case 2: Urine Leak Case 3: Early Thrombotic Microangiopathy:? Cause 91.6 Quiz Conclusion References Resources and Patient Information 92: Renal Transplant Rejection 92.1 Introduction 92.2 Pathogenesis of Rejection 92.2.1 Hyperacute Rejection 92.2.2 Acute T-Cell-Mediated Rejection (Cellular Rejection) 92.2.3 Acute Antibody-Mediated Rejection 92.2.4 Chronic Antibody-Mediated Rejection 92.3 Epidemiology and Risk Factors for Rejection 92.3.1 Immunological Barriers 92.3.2 Sensitization 92.3.3 Host Factors 92.3.4 Immunosuppression 92.3.5 Non-adherence 92.4 Diagnosis 92.5 Treatment 92.5.1 Acute Rejection 92.5.2 Chronic Antibody-Mediated Rejection 92.6 Summary Case Study References 93: Immunosuppression for Renal Transplantation 93.1 Introduction 93.1.1 Therapeutic Drug Monitoring (TDM) 93.2 Generic Immunosuppression 93.3 Specific Drugs 93.3.1 Induction Agents 93.3.2 Anti-CD25 Antibody 93.3.3 Lytic Induction 93.3.3.1 Polyclonal Anti-T-lymphocyte Antibodies 93.3.3.2 Alemtuzumab 93.3.3.3 Rituximab 93.3.3.4 MuromonabCD3 (OKT-3) 93.4 Small Molecule Drugs (Maintenance Immunosuppression) 93.4.1 Calcineurin Inhibitors 93.5 Tacrolimus 93.6 Ciclosporin 93.7 Choice of Calcineurin Inhibitor 93.8 Intrapatient Variability in CNI Exposure 93.9 Antiproliferative Agents 93.9.1 Mycophenolate 93.9.2 Azathioprine 93.9.3 Leflunomide 93.10 Mammalian Target of Rapamycin (mTOR) Inhibitors 93.10.1 Sirolimus 93.10.2 Everolimus 93.10.3 The Place of mTOR Inhibitors in the Immunosuppressive Regimen 93.11 Corticosteroids 93.12 Belatacept 93.13 Choosing the Optimal Drug Combination 93.14 Treatment of Rejection 93.14.1 Acute T-Lymphocyte-Mediated Rejection 93.14.2 Acute Antibody-Mediated Rejection (AMR) 93.14.3 Chronic Antibody-Mediated Rejection (CAMR) 93.14.4 Increase in Maintenance Immunosuppression 93.15 Compliance 93.16 Avoidance of Inadvertent Drug Interactions 93.17 Immunosuppression in the Elderly 93.18 Immunosuppression and Pregnancy 93.19 Immunosuppressive Drug Interaction with Anti-retrovirals 93.20 Withdrawal of Immunosuppression After Transplant Failure Case Study Case 1 Case 2 93.21 Governance and Education with Transplant Immunosuppression References Links 94: Infectious Complications of Transplantation 94.1 Introduction 94.2 Donor Infections 94.2.1 Recipient Infections Pretransplant: Treatment, Vaccination and Prophylaxis 94.2.2 Time-Line for Posttransplant Infections 94.2.3 Urinary Tract Infection 94.2.4 Specific Infectious Agents 94.2.4.1 Cytomegalovirus (CMV) 94.2.5 Herpes Simplex Virus: HSV 1 and 2 94.2.6 Varicella Zoster Virus (VZV) 94.2.7 Epstein-Barr Virus (EBV) 94.2.8 Human Herpes Virus 6 (HHV-6) 94.2.9 Human Herpes Virus 7 (HHV-7) 94.2.10 Human Herpes Virus 8 (HHV-8) 94.2.11 Polyoma Viruses: Polyomavirus Hominis 1 (BK) and 2 (JC) 94.2.11.1 BKV 94.2.11.2 JCV 94.2.12 Respiratory Viruses 94.2.13 Human Papillomavirus (HPV) 94.2.14 Hepatitis E (HEV) 94.2.15 Bacteria 94.2.15.1 Legionella 94.2.15.2 Listeria 94.2.15.3 Nocardia 94.2.16 Mycobacteria: TM and Non-tuberculous Mycobacterium (NTM) 94.2.17 Fungi 94.2.17.1 Pneumocystis Jirovecii (PJ) 94.2.17.2 Invasive Fungi 94.2.17.3 Candida 94.2.17.4 Aspergillosis 94.2.18 Cryptococcus Neoformans (CN) 94.2.19 Mucormycosis 94.2.20 Histoplasma Capsulatum and Coccidioides Immitis 94.2.21 Cryptosporidiosis 94.2.22 Parasites 94.2.22.1 Toxoplasmosis 94.2.23 Strongyloides Stercoralis 94.2.24 Chagas Disease (Trypanosoma Cruzi) 94.2.24.1 Scabies 94.3 Syndromes 94.4 Summary Case 1 Case 2 Case 3 Case 4 References 95: Long-Term Management of Kidney Transplant Recipients 95.1 Introduction 95.2 Optimizing Graft Function 95.2.1 Definition 95.2.2 Epidemiology and Differential Diagnosis of Chronic Graft Failure 95.2.2.1 Nonimmunological Causes of Graft Failure Donor-Derived Damage and Hyperfiltration Poor Graft Function Hypertension Body Mass Index Proteinuria Viral Infection CNI Toxicity Hyperlipidemia Recurrent Disease Poor Adherence 95.2.2.2 Immunological Graft Loss Episodes of Rejection HLA Matching Allosensitization 95.2.3 Monitoring in the Clinic Box 95.1 Methods for Monitoring Transplant ­Function 95.2.4 Management of Late Graft Dysfunction 95.3 Optimizing Kidney Transplant Recipient 95.3.1 Definition 95.3.2 Cardiovascular Risk 95.3.2.1 Hypertension 95.3.2.2 Posttransplant Diabetes Mellitus (PTDM) or New-Onset Diabetes after Transplantation (NODAT) 95.3.2.3 Lipids 95.3.2.4 Lifestyle 95.3.3 Cancer 95.3.3.1 Skin Cancer 95.3.3.2 Posttransplant Lymphoproliferative Disease (PTLD) 95.3.3.3 Other Solid Tumors 95.3.4 Infection 95.3.5 Other Morbidities 95.3.5.1 Mineral and Bone Disorders after Transplantation Osteoporosis Avascular Necrosis Vitamin D Deficiency Persistent Hyperparathyroidism Gout and Urate Calcineurin Inhibitor-Induced Bone Pain 95.3.5.2 Hematological 95.3.5.3 Reproductive Function 95.3.6 Annual Review Clinics 95.4 Management of the Failing Allograft 95.4.1 Definition 95.4.2 Epidemiology 95.4.3 Management Aspects 95.4.3.1 Starting Renal Replacement Therapy (RRT) 95.4.3.2 Graft Nephrectomy 95.4.3.3 Managing Immunosuppression Medications 95.4.3.4 Managing Immunological Aspects of Listing Case Study 95.5 Conclusions References XII: Teaching, Training and Collaboration 96: International Health Partnerships: Developing Nephrology in Low- and Middle-Income Countries 96.1 Introduction – Health Care Challenges in Low-and Middle-Income Countries 96.2 Kidney Disease a Low Priority in LMIC 96.3 Global Health 96.4 Varying Resources and Opportunities in LMIC 96.5 Opportunities for Health Care Improvement in LMIC: The Role of International Health Partnerships 96.5.1 Partnerships with HIC Governments 96.5.2 Partnerships with Higher Education Institutions 96.5.3 Partnership Through Professional Organizations and Through Individuals 96.5.4 International Society of Nephology (ISN) Capacity Building Programs for LMIC 96.6 Opportunities for Young HIC Physicians to Be Involved in LMIC Nephrology 96.6.1 NOT a One-Way Experience 96.6.2 Personal Commitment – Not ‘Physician Tourism’ 96.7 Other Health Care Resources 96.8 Nephrology on the Move Worldwide References Further Reading 97: Education and Training in Nephrology 97.1 Introduction 97.2 Specialty Training: The International Picture 97.3 Educational Theory 97.4 Workplace-Based Learning 97.5 Supervision 97.6 Simulation and Technology in Training 97.7 Training the Teacher 97.8 Instructional Design and Program Development Conclusion Case Studies and Resources Case Study 1 – Communities of Practice: The Renal SpR Club Case Study 2 – Simulation Case Study 3 – The Online Environment Resource 1 – Simulation and Interprofessional Education Resource 2 – Reflection on Action Resource 3 – Training the Teacher References 98: Climate Change, Sustainability, and Nephrology 98.1 Introduction: The Scale and Gravity of the Global Environmental Crisis 98.2 First Do No Harm? Kidney Care Is Part of the Problem 98.3 Embedding Environmental Impact in Management and Procurement of Kidney Services Box 98.1 Sustainable Value in Healthcare [11] 98.4 Improving Resource Efficiency in Dialysis 98.4.1 Reduction in Dialysis Consumables Case Study 1 – Infrastructure: Central Acid Delivery – St Luke’s Hospital, Bradford, UK [12, 13] Case Study 2 – Procurement: Concentrated Acid Solution – East Kent Hospitals University NHS Foundation Trust, UK [13, 14] 98.4.1.1 Process Innovations 98.4.2 Saving Water 98.4.3 Minimizing Energy Use 98.4.4 Renewable Energy Generation [20] Case Study 3: Photovoltaic Energy Generation 98.4.5 Travel 98.4.6 Responsible Waste Disposal 98.5 Clinical Transformation to Sustainable Models of Care 98.5.1 Low-Carbon Alternatives: Prioritizing High-Value, Resource-Efficient Interventions 98.5.2 Lean Service Design Case Study 4: Electronic Consultation as an Alternative to Hospital Referral for Patients with Chronic Kidney Disease – Bradford, UK [28] 98.5.3 Supporting Patient Empowerment and Self-Care 98.5.4 Reducing Demand 98.6 Summary References Index