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Posttransplantation Monitoring and Outcomes

Introduction Kidney transplantation is the kidney replacement modality of choice for most patients with end-stage kidney disease (ESKD). Evidence shows that most kidney transplant recipients (KTRs) experience a higher quality of life and improved long-term survival compared to wait-listed patients receiving dialysis. However, the risk of death in KTRs compared to wait-listed dialysis patients is actually higher during the early posttransplant period due to the operative…

Selection of Prospective Kidney Transplant Recipients and Donors

Kidney transplantation is the treatment of choice for most patients with end-stage kidney disease (ESKD) because it prolongs survival, improves quality of life, and is less costly than the alternative therapy of dialysis. However, less than 20% of ESKD patients will be wait-listed or receive a transplant. Many patients are not suitable candidates because of coexisting illness that may affect perioperative risk and survival after transplantation,…

Conservative Kidney Management

Introduction Dialysis extends and improves the lives of many patients with advanced kidney disease. It frequently serves as an effective bridge to kidney transplantation. However, for some patients, dialysis does not add meaningful time and negatively impacts quality of life. Conservative kidney management (CKM) is a holistic, team-based approach to treating end-stage kidney disease (ESKD) without dialysis. CKM includes medical management of chronic kidney disease (CKD),…

Peritoneal Dialysis

Introduction In peritoneal dialysis (PD), a chronically indwelling catheter is placed into the peritoneal space. A peritoneum enriched in a vascular capillary network is the dialysis membrane. Introduction of dialysis fluid into the peritoneum (glucose [or dextrose monohydrate] based) creates an osmotic pressure gradient across the membrane promoting fluid removal, and movement of uremic solutes across the membrane occurs by both diffusion and convection. Unique to…

Hemodialysis and Hemofiltration

## Hemodialysis (HD) is an extracorporeal therapy that is prescribed to reduce the signs and symptoms of uremia and to partially replace a number of the key functions of the kidneys when kidney function is no longer sufficient to maintain an individual’s well-being or life. Although HD is one of several kidney replacement therapies (along with peritoneal dialysis, hemofiltration [HF]/hemodiafiltration [HDF], and transplantation) that can be…

Anemia and Other Hematologic Complications of Chronic Kidney Disease

Anemia Epidemiology and Pathogenesis Anemia is defined by the World Health Organization as a hemoglobin (Hb) concentration less than 13.0 g/dL in adult men and nonmenstruating women and less than 12.0 g/dL in menstruating women. The incidence of anemia in patients with chronic kidney disease (CKD) increases as the glomerular filtration rate (GFR) declines. Population studies, including the United States National Health and Nutrition Examination Survey (NHANES) and…

Cardiac Function and Cardiovascular Disease in Chronic Kidney Disease

## Cardiovascular disease is the leading cause of death across the spectrum of chronic kidney disease (CKD), with increased risk seen in individuals with reduced glomerular filtration rate (GFR) and in those with even minimally elevated urine albumin excretion. There is a high incidence and prevalence of atherosclerotic disease and nonatherosclerotic disease, ischemic heart disease, heart failure and left ventricular hypertrophy (LVH), valvular diseases, and arrhythmia…

Bone and Mineral Disorders in Chronic Kidney Disease

Chronic kidney disease (CKD) alters the regulation of calcium, phosphate, and vitamin D homeostasis, leading to secondary hyperparathyroidism, elevations in serum fibroblast growth factor 23 (FGF23), metabolic bone disease, soft tissue calcifications, and other metabolic derangements that have a significant impact on morbidity and mortality. Mineral and bone disorders (MBD) are important targets of therapy in CKD. Earlier interventions and stringent management guidelines to control serum…

Nutrition and Kidney Disease

Nutrient Metabolism in Kidney Disease As chronic kidney disease (CKD) progresses, the requirements and utilization of different nutrients change significantly. Protein energy wasting (PEW), defined as a state of decreased body stores of protein and energy fuels, is common in individuals with CKD and has many causes. Protein Metabolism and Requirements Amino Acid Metabolism CKD patients have well-defined abnormalities in their plasma and, to a lesser…

Staging and Management of Chronic Kidney Disease

## Chronic kidney disease (CKD) is a growing worldwide public health problem, characterized by increasing prevalence, high cost, and poor outcomes. The poor outcomes include progression of kidney disease leading to kidney failure, increased risk for acute kidney injury (AKI), cardiovascular disease (CVD), and mortality, as well as a wide variety of other complications. In 2002, the Kidney Disease Outcomes Quality Initiative (KDOQI) of the National…

Development and Progression of Chronic Kidney Disease

Chronic kidney disease (CKD) is defined as abnormal measurements of the actual or estimated glomerular filtration rate (GFR) for a minimum of 3 months ( Box 50.1 ), or situations where the GFR is normal but pathology in the kidney is still present, such as radiographically imaged cysts in polycystic kidney disease or isolated proteinuria in early glomerular disease (see Chapter 51). The most commonly reported…

Global Kidney Disease

Introduction Risk factors for kidney disease span the social determinants of health (poverty, illiteracy, unemployment, pollution, discrimination), infections (HIV/AIDS, tuberculosis, malaria, hepatitis, diarrheal illnesses, pneumonia), and non-communicable diseases (hypertension, diabetes mellitus, cardiovascular disease, chronic liver disease, cancers). It is, therefore, not surprising that as many as 850 million people worldwide may be living with chronic kidney disease (CKD), acute kidney injury (AKI), or kidney failure. Mortality…

Management of Kidney Disease in the Elderly

Epidemiology of CKD in the Elderly The prevalence of chronic kidney disease (CKD) increases markedly with age, and the number of older adults with advanced kidney disease will continue to increase as longevity improves due to medical advances and improved access to healthcare around the world. The prevalence of CKD increases from fewer than 6% in individuals less than 40 years old, to 44% among those…

The Kidney in Pregnancy

Kidney Anatomy and Physiology During Normal Pregnancy Pregnancy produces dramatic changes in systemic hemodynamics, leading to alterations in total circulating blood volume, cardiac output, and systemic vascular resistance. The kidney itself undergoes marked changes during gestation, including alterations in kidney size, glomerular hemodynamics, and tubular function. These adaptations are critical for favorable pregnancy outcomes. Although much of our knowledge of kidney anatomic and physiologic changes in…

Kidney Diseases in Infants and Children

Kidney Development and Maturation Nephrogenesis begins in utero at approximately 5 to 6 weeks’ gestation and continues until nephron formation is complete at approximately 35 weeks’ gestation, although significant functional changes continue in the postnatal period. Fetal urine production commences prior to the end of the first trimester, and by the third trimester becomes the primary component of the amniotic fluid, which is essential for normal…

Nephrolithiasis

Epidemiology The prevalence of nephrolithiasis in the US population rose from 3.8% in the late 1970s to 8.8% in the late 2000s, and it is estimated that more than 5 billion US dollars are spent on stone disease annually. Nephrolithiasis appears to be more common in non-Hispanic white populations than in black populations, and it is positively correlated with male sex, age, and obesity. School-aged children…

Obstructive Uropathy

Obstruction of the urinary tract can occur anywhere between the collecting duct and the urethral meatus. Microcrystals in the collecting duct, urinary calculi, tumors, and luminal strictures all may block the normal flow of urine. Regardless of the cause, the ultimate effect is the same: an increase in the hydrostatic pressure of the collecting system, which is transmitted into Bowman space. This reduces the glomerular filtration…

Chronic Tubulointerstitial Disease

Primary interstitial kidney disease comprises a diverse group of disorders that elicit interstitial inflammation associated with tubular damage. Traditionally, interstitial nephritis has been classified morphologically and clinically into acute and chronic forms. Acute interstitial nephritis (AIN) generally induces rapid deterioration in kidney function with a marked interstitial inflammatory response characterized by mononuclear cell infiltration with or without eosinophils, interstitial edema, and varying degrees of tubular cell…

Fabry Disease

Fabry disease (OMIM 301500) is an X-linked lysosomal storage disorder that results from absent or deficient activity of the enzyme α-galactosidase A (αGAL; EC 3.2.1.22). This enzyme is encoded by the GLA gene on Xq22 ( Fig. 42.1 ), with more than 1000 different variants so far described. Importantly, many of these genetic variants are seemingly benign, and carriers are not candidates for specific enzyme replacement…

Alport Syndrome and Related Disorders

Alport syndrome is a disease of type IV collagen that always affects the kidneys, usually the ears, and often the eyes. Cecil Alport described the association of hereditary hematuric nephritis with hearing loss in a family whose affected male members died in adolescence. Genetic advances have broadened the scope of the condition to include optical defects, late-onset kidney failure, and normal hearing in some families. Approximately…