Medical Management of Kidney and Electrolyte Disorders Clinical Guides to Medical Management Consulting Editor BURTONE . SOBELM, .D. Medical Center Hospitalo f Vermont University of Vermont Burlington, Vermont Medical Managemento f Heart Disease, edited by BurtonE . Sobel MedicalM anagement of RheumaticM usculoskeletala ndC onnective TissueD iseases, editedb yJ anD equeker,G abriel Panayi, Theodore Pincus, and Rodney Grahame Medical Managemento f Atherosclerosis, edited by John LaRosa Medical Managemento f Liver Disease, edited by EdwardL . Krawitt Medical Management of Pulmonary Diseases, edited by Gerald S. Davis; Associate Editors: TheodoreW . Marcy and ElizabethA . Seward MedicalM anagement of DiabetesM ellitus, editedb yJ ack L.L eahy, Nathaniel G. Clark, and WilliamT . Cefalu Medical Management of Kidney and Electrolyte Disorders, edited by F. John Gennari ADDITIONATLIT LEISN PREPARATION Medical Management of Kidney and Electrolyte Disorders edited by F. John Gennari University of Vermont Burlington, Vermont m MARCEL MARCELD EKKERIN, C NEWY ORK RASEL UEKKER To rny parents, rvho tuught me front the start to think outside the erlvelope and gave me the gifts of love, discipline, energv, und intellectual curiosity tltut have ertriched III~li fe und rvork. ISBN: 0-8247-8869-9 This book is printed on acid-free paper. Headquarters Marcel Dekker, Inc. 270 Madison Avenue. New York, NY 10016 tel: 2 12-696-9OOO; fax: 2 12-6854540 Eastern Hemisphere Distribution Marcel Dekker AG Hutgasse 4, Postfxh 812, CH-4001 Basel. Switzerland tel: 4 1-6 1-26 1-8482f:a x: 4 1-6 1-26 1-8896 World Wide Web http:llwww.dekker.com The publisher offers discounts on this book when ordered in bulk quantities. For Inore information, write to Special SaleslProfessional Marketinga tt he headquarters address above. Copyright 0 2001 by Marcel Dekker, Inc. All Rights Reserved. Neither this book nor any part may be reproduced or transmitted in any form or by any means, elcctronic or mechanical. including photocopying, microfilming, and recording. or by any information storage and retrieval system, without permission in writing from the publisher. Current printing (last digit): 1 0 9 8 7 6 5 4 3 2 1 PRINTED IN THE UNITED STATES OF AMERICA Foreword The Medical Management series was developetdo provide practitioners, whether they be generalists or specialists, with current and comprehensive information pertinent to the care of their patients. The material is presented in a format consis- tent with the nature of clinical experience and epistemology. Thus, cardinal signs and symptoms rather than diagnostic labels are points of departure. This component of the series. edited by Dr. F. John Gennari. addresses kidney and electrolyte disorders. It does so elegantly, thoroughly, thoughtfully, and practically. Renal disease knows no definitive specialty borders. Whether it presents as eclampsia requiring an obstetrician’s wisdom, glomerulonephritis challenging the pediatrician, drug-induced interstitial nephritis challenging the internist’s acu- men, or hypertensive or diabetic nephropathyid entified and treatedb y a conscien- tious cardiologist, renal disease must be recognized and aggressively managed by each patient’s personal physician. Generally, in internal medicine and family practice as well as in emergency medicine, all too often the first recognition of kidney disease is end-stage renal disease following an indolent, subtle course concealed as a result of patient denial or inadequately aggressive diagnostic eval- uation. Medical Manngernent of Kiduey and Electrolyte Disorders identifies and highlights symptoms of renal and electrolyte disordersi n Part I with four chapters written by internationally respected authorities. Clinical presentation and labora- tory evaluation are the subjects of Part I1 comprising ten chapters by authorities who cover a broad spectrum ranging from the nephrotic syndrome and hematuria to derangements in tonicity,p otassium,c alcium,p hosphorus,a ndm agnesium iii iv Foreword balance and metabolism. The bulk of the book, Part 111, comprises 18 chapters. They address management of renal disease and electrolyte disorders. The presen- tations cover acute and chronic renal failure; hypertensive and diabetic nephropa- thy; glomerular, tubular, and interstitial disorders; drug- and toxin-induced ne- phropathy; kidney stones and infections; obstructive nephropathy and inherited renal diseases; kidney diseasei n special settings such as pregnancy and hyperten- sion; management of recipients of kidney transplants; treatment of acid-base, tonicity, and electrolyte disorders; and modification of drug dosage in patients with renal insufficiency. As is the case for the preceding components of the Medical Management series, the focuso f this book is on authoritative guidance rather than encyclopedic review. Each chapter is designed to serve as a clinician’s “consultant” to aid in the interpretation and development of inferences derived from recognition of cardinal signs and symptoms of disease. The material should facilitate the con- cerned clinician’s consideration of pathophysiological mechanisms underlying disease and their diagnostic and therapeutic implications instead of reinforcing reliance on algorithms and recipes. Dr. Gennari has assembled a truly outstanding group of authorities from his own institution and throughout the United States. Their contributions provide definitive delineation of kidney and electrolyte disorders and their management that should serve the reader well. Because of its breadth and scope, the book should be useful to generalists and specialists; students, house staff, and fellows; attendings in academic medical centers; practitioners in rural and urban settings; and hospital-, office-, and emergency room-based physicians. It is hoped that this contribution to the Medical Management series will complement its well- received previous publications addressing medical management of atherosclero- sis, heart disease, diabetes mellitus, pulmonary disease, liver disease, and dra- matic musculoskeletal and connective tissue diseases. Burtotz E. Sobel, M.D. Preface Kidney diseases, and disorders of fluid and electrolyte balance, can sometimes be a sourceo f confusion for physicians who interact with these important clinical problems only intermittently. This book was conceivedto remove that confusion, by providing a comprehensive and concise source of information for the prac- titioner. To accomplish this goal, experts in specific areas of nephrology have contributedt h eirk nowledgeT. heirc ontributionsi n cludei n formationa bout pathophysiology, clinical presentation, diagnosis, and treatment, presented in a succinct and readable manner. Although many authors contributed, the book has been carefully edited for consistency of style and approach, and the information has been filtered by a single editor to ensure its accessibility for the reader. It was written with the primary care physician in mind, but should also be a useful reference text for emergency room physicians, hospitalists, intensive care physi- cians, and all physicians with an interest in this area. The book is organizedi ntot hreep arts to allowp hysicianst oe ntert he subject from a varietyo f perspectives. The first four chapters approach the subject from the viewpointo f patients’ symptoms, allowing readerst o determine whether their patient’s complaint can be accounted for by renal or electrolyte disorders. The subsequent ten chapters approach the topic from the perspective of physical and laboratory findings, defining the characteristic syndromes with which patients ‘ present and taking the reader through the key laboratory findings that are the hallmarks of these disorders. The third and largest portion of the book covers the subject from the perspective of specific diseases, and focuses on diagnosis and management. These chapters enable the physician with a question about a specific disease to obtain information about its presentation, diagnosis, and man- V vi Preface agement. A centerpiece of this section of the book is a comprehensive chapter that covers the diagnosis and management of glomerular diseases in a concise and readily accessible manner. In addition, the key topics of the management of chronic renal insufficiency and diabetic nephropathy are reviewed in this section of the book, with particular attention to strategies designed to slow progression to end-stage renal disease.T he last chapter of the book covers the important topic of drug dosage modification in patients with renal disease. This book is intended to provide comprehensive information about all the disorders that comprise the subspecialty of nephrology, but a special highlight is its coverage of electrolyte disorders, an area of particular interestt o the editor. The chapters covering these disorders, four of which were written by the editor, arei ntersperseda mong all threep arts of theb ook. The first part containsa chapter that covers the symptoms of electrolyte disorders, a unique contribution. In the second part, the pathophysiology, clinical presentation, and tools for diag- nosis of these disorders are covered.T he specific treatments for electrolyte disor- ders are presented separately in the third part of the book, allowing the clinician with specific questions about treatment to find the answers quickly. This book will benefit practitioners of medicine who must manage the in- creasing population of patients with renal and electrolyte disorderass our popula- tion ages. By providing pragmatic and accessible information, it should help to dissolve confusion and provide a rational approach to these disorders. F. John Gennuri, M.D. Contents ... ForewoBrd u rton E. Sobel 111 Preface V Contributors xi Part I: Symptoms of Renal and Electrolyte Disorders 1. Oliguria and Polyuria 1 Gertrude S. Lefavour 2. Edema 19 Rainer Lnng 3. Uremia 39 Jeffrey A. Kraut 4. Symptoms of Electrolyte Disorders 57 Deborah B. Adey vii