THERAPY OF RENAL DISEASES AND RELATED DISORDERS

THERAPY OF RENAL DISEASES AND

RELATED DISORDERS

Edited by WADI N. SUKl and SHAUL G. MASSRY

1984 MARTINUS NUHOFF PUBLISHING a member of the KLUWER ACADEMIC PUBLISHERS GROUP

DORDRECHTI BOSTON I LANCASTER

Distributors

for the United States and Canada: Kluwer Boston, Inc., 190 Old Derby Street, Hingham, MA 02043, USA for all other countries: Kluwer Academic Publishers Group, Distribution Center, P.O. Box 322, 300 AH Dordrecht, The Netherlands

Library of Congress Cataloging in Publication Data

Main entry under title:

Therapy of renal diseases and related disorders.

Includes index. 1. Kidneys-Diseases--Treatment. I. Sllki, Walii N.,

1934- • II. Massry, Shaul G. (DNIM: 1. Kidney Diseases--therapy. WJ 300 T398J RC903.T47 1984 616.6'106 84-6130 ISBN·13: 978·1-4613·3809-3 e-ISBN-13: 978-1-4613-3807-9

DOl: 10.1007/978-1-4613-3807-9

Copyright

© 1984 by Martinus Nijhoff Publishing, Boston.

Softcover reprint of the hardcover 1 st edition 1984

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, with­out the prior written permission of the publishers, Martinus Nijhoff Publishing, 190 Old Derby Street, Hingham, MA 02043, USA.

FOREWORD

'Where are all these kidney patients coming from? A few years ago we never heard of kidney disease and now you are speaking of patients in the hundreds of thou­sands and indeed potentially millions'. My reply, not meant to be grim, was 'From the cemetery, Sir'. This is a summary of some Congressional testimony I once gave on behalf of extending kidney disease under Medi­care. Where indeed were all the patients with kidney disease in the United States before World War II? They were certainly not under the care of Nephrologists! Nephrology was not listed in the questionnaires for any State or the American Medical Association as a subspe­cialty or even as a special interest. Indeed, even in the late 1960's, when I wrote the American Medical Asso­ciation editor and asked why Nephrology had not been included on a questionnaire to American physicians about their specialty interests, I received a 'tongue in cheek' answer, 'What's Nephrology?' Indeed, for those of us who bridge back, it is often hard to realize the rapid evolution of our specialty. For uremia, we gave low protein diets, adequate hydration, attention to fluid and electrolytes, comfort and prayer. In my first two years at Georgetown where every death in the hospital was reviewed, my Nephrology Division made death conference all but a few weeks out of the first two years. In a 1961 book on uremia * I wrote:

'The reversibility of uremic coma has received some attention but could use more. In a further effort to discourage pessimism we have therefore placed a capi­tal 'R' following each of the potentially reversible types of renal disease. It is our sincere hope that the number of' R's' will provide a pleasant surprise for the many physicians and medical students who are want to think of the uremia syndrome as a terminal state during which little treatment can be instituted, except that designed for the comfort of the patient'.

This is not to say that the science underlying nephro-logy was inactive. Quite to the contrary, many cases of fruitful science relating to the kidney area not only existed but flourished and had a profound impact on many young clinicians. Thomas Addis raised to a state of applied perfection the study of the urinary sediment, clinically practical kidney function tests and the natural history of a number of kidney diseases including glome­rulonephritis. William Goldring, Herbert Chasis, Dana

* Schreiner GE, Maher JF: Uremia, Chemistry and Pathogen­esis & Treatment. Charles C Thomas Publisher, Springfield, IL, 1961, p. 24.

v

Atchley and others studied the effects of hypertension, endocarditis, and circulatory diseases on the kidney and spawned successive generations of alert clinical investi­gators who began to chronicle the natural histories of a wide variety of kidney diseases. Quantitative studies of renal function flourished under a school headed by Homer Smith, and surprisingly precise techniques were developed for studying a whole range of explicit nephron functions. Imagine the joy with the advent of catheteri­zation to be able to apply extraction ratios and the Fick principle in a precise way to an organ such as the kidney by sampling arterial blood, venous blood and the output of the urine! One had a quantitative handle on the entire function of a vital organ-perhaps for the first time in biologic history. One no longer looked only at the street side of the revolving door; one could find out, for exam­ple, that if ammonia didn't go into the acid trap of the urine it indeed might go back into the circulation via the renal vein.

The same story unfolded for a broad range of physio­logical substances. In the metabolic school of Nephrolo­gy represented perhaps most billiantly by Professor John Peters at Yale, a host of pioneer investigators applied the methods of quantitative clinical biochemistry to the elements of the blood whose homeostasis was so careful­ly regulated by the kidney. His deep interest in endocri­nology and metabolism pointed our way to appreciate the endocrine role of the kidney in making or releasing a whole array of potent hormones affecting bodily func­tion (e.g. erythroproietin, renin, aldosterone, etc.), and indeed the very survival of the human organism. Post­war technology rushed to the fore and supplied nephro­logists with such wonderful tools as the flamephotome­ter, electrophoresis, microchemistry, immunoassay, son­ography, renal biopsy, immunofluorescence, electronmi­croscopy, nuclear magnetic resonance and permitted a total integration of form, histological structure and func­tion. Clinical nephrology became indeed the real fusion of biochemistry, physiology, immunology, renal endo­crinology, and the focus of newer imaging techniques.

With this precision in diagnosis one could rationally hope for rational therapy, and one could be optimistic that some day the correct therapy would be correctly applied to the correct patient with the appropriately diagnosed disease.

With the evolution of such developments an expert observer could indeed realistically hope that out of the myriad and mushrooming books of nephrology would come one with a message of constructive hope focusing on the treatment of renal disease. Indeed, with the book

VI Foreword

to follow, Dr. Suki and Dr. Massry have fulfilled that hope with a book appropriately entitled The Therapy of Renal Disease and Related Disorders. They have syste­matically taken the available scientific information and fused it into a practical text of therapy for the patient. The first section, entitled 'The disorders of fluid electro­lyte and acid-base balance', covers some of the more challenging general conditions, such as hyperosmolar and hypoosmolar states, polyuria, edema and acute ren­al failure. The book then proceeds systematically to dis­orders of the ions, potassium, calcium, magnesium, phosphate and the major quartet of acid-base balance embracing alkalosis and acidosis in its clinically present­able forms. The book proceeds to the intrinsic parenchy­mal diseases covering the major areas of glomerular and tubular interstitial disorders and what can be done about them. From there it launches into the vast sea of rela­tionships with systemic diseases such as SLE, vasculitis, hyperuricemia, dysproteinemia, liver disease, pregnancy and diabetes, among others. Adequate attention is paid to genetic and congenital disorders including the genetic counselling of families beset by genetically determined disorders. Neoplasia, chemical and physical injuries, and a number of other unusual events are considered with practical insights. Then the book tackles the vast prob­lem of uremia.

Uremia is to the nephrologist what the baby is to the pediatrician, for it is the final common pathway of liter­ally hundreds of disease processes that lead to scarring and destruction of nephrons.

We estimate that today there are in excess of 200,000 patients in the world living on the varied methodologies represented by the three basic forms of substituted kid­ney function: hemodialysis, peritoneal dialysis and renal

transplantation. These 200,000 plus persons and their families, who have intimate, repetitive personal experi­ences with uremia, serve as living witnesses of the medi­cal progress of nephrology in the past three decades. They are witnesses of the fact that many of today's kid­ney patients have indeed, and literally, 'come from the cemetery'.

But it is not enough to consider only the techniques of substitution therapy. For with living patients come not only the facets of uremia that are not yet handled by therapy, such as cardiovascular complications, renal os­teodystrophy, anemia, disorders of immune surveil­lance, nutritional problems, etc., but there is also a necessity to know which particular patients fit which particular therapy best, and to choose the optimum time for applying one particular therapy to one particular patient. Indeed, the management of the uremic patient becomes essentially a life plan for that person and the ills that kidney patients have, live on with them instead of going prematurely with them to the grave.

This is a book which is unique among many books available today. This is a book which thinks positively. This is a book which blends the analytical aspects of diagnosis with the hard realities of scientific and appro­priate therapy. This is a book that will be enjoyed by young nephrologists and by physicians with a wide di­versity of interests. Most of all,it is a book that will be deeply appreciated by their patients.

George E. Schreiner, M.D. Professor of Medicine Director, Division of Nephrology Georgetown University School of Medicine

PREFACE

In the last fifteen years, many books and monographs have been published which deal with different aspects of renal structure and function, and the various renal dis­eases. The number of published works reflects the explo­sion of scientific knowledge about the kidney and its diseases. Parallel with this increased knowledge have come major advances in the handling and management of patients suffering from disorders of the kidney. These advances, many of which are life-saving, in large mea­sure have been responsible for the emergence of nephro­logy as a full-fledged medical specialty.

In spite of the progress made in the therapy of renal diseases and related disorders, there has not been a text devoted fully to this subject. The present text attempts to bring together in one ready reference what is known about renal therapeutics today thereby focusing atten­tion on this vital aspect of nephrology and recording the present state-of-the-art.

The major strides forward in renal therapy shall be clear to the reader of this volume. Areas where advances or breakthroughs are still needed or where solid, objec­tive proof of efficacy is still lacking shall be equally clear. The rapid pace of new research on renal therapy continued during the period that this text was in prepa­ration, and this rapid pace attests to the vitality of neph­rology as a discipline. We look forward to the prepara­tion of new editions of this volume reflecting substan­tive advances which will continue to be made.

It is fitting, in closing, to acknowledge the generosity of each of the contributing authors who have given self­lessly of their precious time to prepare their respective chapters, and the forbearance of our publisher, who has waited patiently as the process of assembling and editing this volume proceeded.

Wadi N. Suki Shaul G. Massry

Foreword ..

Preface ...

Contributors

CONTENTS

PART ONE: DISORDERS OF FLUID, ELECTROLYTE, AND ACID-BASE BALANCE

1. Treatment of hypoosmolar and hyperosmolar states MOSHE LEVI, DANIEL G. BICHET and TOMAS BERL

2. Polyuric syndromes DOUGLAS R. WILSON . . . . . . . . . . . . .

3. Treatment of edematous states JULES B. PUSCHETT and ARTHUR GREENBERG

4. Therapy and management of acute renal failure DONALD F. NORTMAN and STANLEY S. FRANKLIN

5. Disorders of potassium metabolism JEROME P. KASSIRER and JAY B. WISH

6. Hypocalcemia and hypercalcemia MARK R. HUGHES and WADI N. SUKI

7. Hypomagnesemia and hypermagnesemia SHAUL G. MASSRY ........ .

8. Hyper- and hypophosphatemia NACHMAN BRAUTBAR and CHARLES R. KLEEMAN

9. Metabolic alkalosis SANDRA SABATINI and NEIL A. KURTZMAN ....

10. Metabolic acidosis MANUEL A. CRUZ-SOTO and MANUEL MARTINEZ-MALDONADO

11. Renal tubular acidosis ELISABETH M. McSHERRY ....... .

12. Respiratory acid-base disorders HORACIO 1. ADROGUE and WADI N. SUKI

PART TWO: INTRINSIC PARENCHYMAL DISEASE

A. Glomerular 13. The acute glomerulonephritis syndrome

V

VII

XIII

23

31

47

63

83

101

105

131

145

155

173

JOEL NEUGARTEN and DAVIS S. BALDWIN 183

14. The management of the nephrotic syndrome WAYNE A. BORDER and RICHARD 1. GLASSOCK 195

15. The treatment of rapidly progressive crescentic glomerulonephritis and of Goodpasture's syndrome J. STEWART CAMERON ...... .................... 209

IX

X Contents

B. Tubulo-interstitial

16. The management of urinary tract infections MARVIN FORLAND ..... .

17. Vesicoureteral reflux and reflux nephropathy PRISCILLA KINCAID-SMITH .

18. Management of genitourinary tuberculosis HERMAN WECHSLER

PART THREE: RENAL INVOLVEMENT IN SYSTEMIC DISEASE

19. Systemic lupus erythematosus DAVID P. HUSTON

20. Vasculitic diseases of the kidney

221

235

255

259

JAMES E. BALOW and HOWARD A. AUSTIN III 273

21. Noninflammatory vascular diseases of the kidney GARABED EKNOYAN ............ 283

22. Hemolytic uremic syndrome and thrombotic thrombocytopenic purpura EDWARD D. GOMPERTS and ELLIN LIEBERMAN 297

23. Renal involvement in dysproteinemias FRANCISCO LLACH and SOLOMON PAPPER 315

24. The hyperuricemic nephropathies WILLIAM E. SMITH and THOMAS H. STEELE 327

25. Therapy of renal disorders in liver disease MURRAY EPSTEIN ............ 335

26. Management of renal complications of pregnancy: Management of pregnancy in renal disease, in patients undergoing chronic haemodialysis and in renal transplant patients

JOHN M. DAVISON, ADRIAN I. KATZ and MARSHALL D. LINDHEIMER 347

27. Therapy of diabetic renal disease ELI A. FRIEDMAN . . . . . . . . . . . . . . . . . . . . . . . . . . 371

PART FOUR: HEREDITARY AND CONGENITAL DISEASE

28. Management of renal cystic disorders JARED J. GRANTHAM and SHARON L. SLUSHER

29. Therapy of renal disorders in sickle hemoglobinemia ROBERT M. ROSA .............. .

PART FIVE: NEOPLASIA

30. Neoplasia: Cancers of the kidney, renal pelvis and ureter, bladder and prostate PETER T. SCARDINO and C. EUGENE CARLTON, Jr. . ....

PART SIX: CHEMICAL AND PHYSICAL INJURIES

31. Therapy of toxic nephropathies JOHN F. MAHER

32. Treatment of acute drug intoxications with hemodialysis and hemoperfusion WARREN D. DAVIDSON . . . . . . . . . . . . . . . . . .

383

405

413

429

451

Contents XI

PART SEVEN: UREMIA

33. Nutritional management .. ANDERS ALVESTRAND and JONAS BERGSTROM . 459

34. Cardiovascular complications of uremia and dialysis J. CARLOS A YUS, J. PEDRO FROMMER and JAMES B. YOUNG 481

35. The management of renal insufficiency WOLFGANG TSCHOPE and EBERHARD RITZ 495

36. Management of renal osteodystrophy KIYOSHI KUROKA WA . . . . . . . . . . . 505

37. Peritoneal dialysis RAMESH KHANNA and DIMITRIOS G. OREOPOULOS 515

A. Hemodialysis

38. Dialysis access surgery GEORGE P. NOON and H. DAVID SHORT 533

39. Dialyzers and water treatment N.K. MAN and J.L. FUNCK-BRENTANO 545

40. Dialysis, ultrafiltration and hemofiltration N. A. HOENICH and S. RINGOIR ... 555

41. Use of drugs in uremia and dialysis WILLIAM A. BRIGGS, FRANKLIN D. McDONALD, DALE H. SILLIX and MARGARET L. MacDOUGALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 567

B. Transplantation and transplantation complications

42. Donor and recipient selection in renal transplantation JEAN CROSNIER and HENRI KREIS . . . . . . . . . . .

43. Immunosuppression and treatment of rejection in renal transplantation YVES F. Ch: VANRENTERGHEM and MARK J.A. WAER

44. Renal tubular and metabolic dysfunction following kidney homotransplantation J. GREEN, D. AGMON and O.S. BETTER . . . . .

45. Transplantation complications: Infectious, malignant, surgical ISRAEL PENN . . . . . . . . . . . .

46. Nephrolithiasis and nephrocalcinosis JOAN H. PARKS and FREDRIC L. COE

PART EIGHT: MISCELLANEOUS

47. The catheter JOHN A. HEANEY and EDWIN M. MEARES, Jr.

48. Non-surgical management of vesicourethral dysfunction LEONARD D. GAUM and WILLIAM R. FAIR

Index

587

595

617

631

651

669

681

695

Horacio J. Adrogue, M.D. Associate Professor of Medicine Renal Section Baylor College of Medicine The Methodist Hospital Houston, TX 77030, USA Chapter 12

D. Agrnon, M.D. Department of Nephrology Rambam Medical Center Technicon, School of Medicine Haifa, Israel Chapter 44

Anders Alvestrand, M.D. Karolinska Institute Huddinge University Hospital 141 86 Huddinge, Sweden Chapter 33

Howard A. Austin III, M.D. Attending Nephrologist Clinical Nephrology Service National Institutes of Health Bethesda, MD 20205, USA Chapter 20

Juan Carlos Ayus, M.D., F.A.C.P. Assistant Professor Chief Renal Service Ben Taub General Hospital Baylor College of Medicine Houston, TX 77030, USA Chapter 35

David S. Baldwin, M.D. Professor of Medicine Director, Hypertension & Renal Disease Section New York University Medical Center New York, NY 10016, USA Chapter 13

James E. Balow, M.D. Chief, Clinical Nephrology Service Senior Investigator, NIADDK National Institutes of Health Bethesda, MD 20205, USA Chapter 20

Jonas Bergstrom, M.D. Professor of Renal Medicine Director the Department of Renal Medicine Karolinska Institute Huddinge University Hospital 86 Huddinge, Sweden Chapter 33

CONTRIBUTORS

Tomas Berl, M.D. Associate Professor of Medicine University of Colorado Health Sciences Center Denver, CO 80262, USA Chapter 1

O.S. Better, M.D. Dean Faculty of Medicine Technicon-Israel Institute of Technology and the B. Rappapor Institute for Research in the Medical Sciences Chief Department of Neprhology Rambam Hospital Haifa, Israel Chapter 44

Daniel G. Bichet, M.D. Assistant Professor of Medicine Hopital du Sacre-Creur Montreal PQ, Canada Chapter 1

Wayne A. Border, M.D. Chief, Department of Nephrology University of Utah Salt Lake City, UT 84113, USA Chapter 14

Nachman Brautbar, M.D. Associate Professor of Medicine and Pharmacology Director of Renal Research Laboratory University of Southern California School of Medicine Los Angeles County Medical Center Los Angeles, CA 90033, USA Chapter 8

William A. Briggs, M.D. Byrnes Medical Center Petosky, MI 49770, USA Chapter 41

XIII

XIV Contributors

1. Stewart Cameron, M.D. Professor of Renal Medicine Consultant Physician Director of Clinical Science Laboratories Guy's Hospital Medical School London Bridge London SEI 9RT, UK Chapter 15

C. Eugene Carlton, Jr., M.D. Professor and Chairman Department of Urology Baylor College of Medicine Houston, TX 77030, USA Chapter 30

Fredric L. Coe, M.D. Professor, Medicine & Physiology Director, Nephrology University of Chicago Billings & Michael Reese Hospitals 29th Street and Ellis Ave Chicago, IL 60616, USA Chapter 46

Jean R. Crosnier, M.D. Professor Head, Department of Nephrology Universite Rene Descartes Hopital Necker 161 rue de Sevres F-75730 Paris, France Chapter 42

Manuel A. Cruz-Soto, M.D. Assistant Professor of Medicine Staff Nephrologist University of Puerto Rico School of Medicine V A Medical & Regional Office Center San Juan, Puerte Rico 00936 Chapter 10

Warren D. Davidson, M.D. Professor of Medicine UCLA School of Medicine Director, Dialysis Facilities Harbor-UCLA Medical Center Los Angeles, CA 90033, USA Chapter 32

1.M. Davison, M.D. Scientific Staff, Medical Research Council Human Reproduction Group Consultant Obstetrician and Gynaecologist Princess Mary Maternity Hospital and Royal Victory Infirmary Newcastle upon Tyne, NE2 3BD, UK Chapter 26

Garabed Eknoyan, M.D. Professor of Medicine Department of Medicine Section of Nephrology Baylor College of Medicine Houston, TX 77030, USA Chapter 21

Murray Epstein, M.D. Professor of Medicine Associate Chief Nephrology Section University of Miami School of Medicine Miami, FL 33125, USA Chapter 25

William R. Fair, M.D. Professor and Chairman Division of Urology Washington University School of Medicine 4960 Audubon Drive S1. Louis, MI 63110, USA Chapter 48

Sidney S. Franklin, M.D. Adjunct Professor of Medicine University of California at Los Angeles School of Medicine Associate Director of Hypertension UCLA Center for the Health Sciences Los Angeles, CA 90033, USA Chapter 4

Marvin Forland, M.D. Professor of Medicine Deputy Chairman for Clinical Activities Associate Dean for Clinical Affairs University of Texas Health Science Center San Antonio, TX 78284, USA Chapter 16

Eli A. Friedman, M.D. Professor of Medicine Renal Diseases Division Downstate Medical Center Brooklyn, NY 11203, USA Chapter 27

1. Pedro Frommer, M.D. Instructor of Medicine Section of Nephrology University of Illinois Chicago, IL 60612, USA Chapter 34

Jean-Louis Funck-Brentano, M.D. Professor of Nephrology Director INSERM Research Laboratory on Renal Diseases Universite Rene Descartes Faculte de Medecine Necker-Enfants-Malades Hopital Necker 161 rue de Sevres F-7S730 Paris, France Chapter 39

Leonard D. Gaum, M.D., F.R.C.S.(c) Assistant Professor of Surgery/Urology Washington University School of Medicine The Jewish Hospital of S1. Louis 4960 Auduban Drive S1. Louis, MI 63110, USA Chapter 48

Richard 1. Glassock, M.D. Professor of Medicine Chairman, Department of Medicine UCLA School of Medicine Harbor-UCLA Medical Center Torrance, CA 90509, USA Chapter 14

Edward D. Gomperts, M.D. Associate Hematologist Division of Hematology/Oncology Childrens Hospital of Los Angeles and Associate Professor of Clinical Pediatrics & Pathology University of Southern California School of Medicine Los Angeles, CA 90054, USA Chapter 22

Jared 1. Grantham, M.D. Professor of Medicine Director Division of Nephrology University of Kansas School of Medicine College of Health Sciences and Hospital Kansas City, KS 66103, USA Chapter 28

1. Green, M.D. Department of Nephrology Rambam Medical Center Technion, School of Medicine Haifa, Israel Chapter 44

Arthur Greenberg, M.D. Assistant Professor of Medicine Univesity of Pittsburgh School of Medicine Pittsburg, PA 15260, USA Chapter 3

John A. Heaney, M.D. Associate Professor Divison of Urology Tufts University School of Medicine New England Medical Center Boston, MA 02111, USA Chapter 47

Nicholas Hoenich, Ph.D Lecturer in Clinical Science Department of Medicine University of Newcastle-upon-Tyne Newcastle upon Tyne, NEI 4LP, UK Chapter 40

Mark Hughes Assistant Professor of Cell Biology Department of Cell Biology Baylor College of Medicine Houston, TX 77030, USA Chapter 6

David P. Huston, M.D. Assistant Professor of Medicine, Microbiology and Immunulogy Director, Immunotherapy Unit Baylor College of Medicine The Methodist Hospital Houston, TX 77030, USA Chapter 19

Jerome P. Kassirer, M.D.

Contributors XV

Professor of Medicine and Associate Chairman Department of Medicine Associate Physician-in-Chief Department of Medicine and Senior Physician Renal Division and Clinical Decision Making Division Tufts University School of Medicine New England Medical Center Boston, MA 02111, USA Chapter 5

Adrian I. Katz, M.D. Professor of Medicine The University of Chicago Chicago, IL 60637, USA Chapter 26

Ramesh Khanna, M.D. Associate Professor of Medicine Department of Medicine University of Missouri Health Science Columbia, MO 65212, USA Chapter 37

Priscilla Kincaid-Smith, M.D. Professor Department of Medicine University of Melbourne and Director of Nephrology Royal Melbourne Hospital Parkville, Victoria, Australia 3050 Chapter 17

Charles R. Kleeman, M.D. Professor of Medicine Director of the Center for Health Enhancement Factor Family Foundation UCLA School of Medicine The Center for the Health Sciences Los Angeles, CA 90024, USA Chapter 8

Henri A. Kreis, M.D. Associate Professor Director of Transplantation Unit Department of Nephrology Universite Rene Descartes Hopital Necker 161 rue de Sevres F-75730 Paris, France Chapter 42

XVI Contributors

Kiyoshi Kurokawa, M.D. Professor of Medicine Chief, Nephrology Section UCLA School of Medicine V A Wadsworth Hospital Los Angeles, CA 90073, USA Chapter 36

Neil A. Kurtzman, M.D. Professor of Medicine & Physiology Chief, Section of Nephrology University of Illinois College of Medicine Chicago, IL 60612, USA Chapter 9

Moshe Levi, M.D. Assistant Professor of Medicine V A Medical Center Dallas, TX 75216, USA Chapter 1

Ellin Lieberman, M.D. Head, Division of Nephrology, Dialysis and Transplantation Childrens Hospital of Los Angeles and Professor of Pediatrics University of Southern California School of Medicine Los Angeles, CA 90054, USA Chapter 22

Marshall D. Lindheimer, M.D. Professor of Medicine and Obstetrics & Gynecology University of Chicago Pritzker School of Medicine University of Chicago Hospitals and Clinics Chicago, IL 60637, USA Chapter 26

Francisco Llach, M.D. Professor of Medicine Chief, Nephrology University of Oklahoma Health Science Center Chief, Nephrology VA Hospital Oklahoma City, OK 73190, USA Chapter 23

Margaret L. MacDougall, M.D., Ph.D. Assistant Professor of Medicine University of Kansas Medical Center Kansas City, Kansas Assistant Chief of Nephrology Veteran's Administration Kansas City, MS 66103, USA Chapter 41

John F. Maher, M.D. Professor of Medicine Director, Nephrology Division Uniformed Services University of the Health Sciences Bethesda, MD 20814, USA Chapter 31

N.K. Mann, M.D. Department of Nephrology Hopital Necker 161 rue de SCvres F-75730 Paris, France Chapter 39

Manuel Martinez- Maldonado, M.D. Professor of Medicine & Physiology Chief, Medical Service University of Puerto Rico School of Medicine V A Medical & Regional Office Center San Juan, Puerte Rico 00936 Chapter 10

Shaul G. Massry, M.D. The Bernard J. Hanley Professor of Medicine Professor of Physiology and Biophysics Chief, Division of Nephrology University of Southern California School of Medicine Los Angeles, CA 90033, USA Chapter 7

Franklin D. McDonald, M.D. Professor and Vice-Chairman Department of Internal Medicine Wayne State University School of Medicine Chief of Medicine Hutzel Hospital Detroit, MI 48201, USA Chapter 41

Elisabeth McSherry, M.D. HSRD V A Hospital 1400 VFW Parkway West Roxbury, MA 02132, USA Chapter 11

Edwin M. Meares, Jr., M.D. Professor and Chairman Department of Urology Tufts University School of Medicine New England Medical Center 171 Harison Ave Boston, MA 02111, USA Chapter 47

Joel Neugarten, M.D. Asistant Professor of Medicine New York University Medical Center School of Medicine Department of Medicine New York, NY 10016, USA Chapter 13

George P. Noon, M.D. Professor of Surgery Baylor College of Medicine The Methodist Hospital 1200 Moursund Houston, TX 77030, USA Chapter 38

Donald F. Nortman, M.D. Assistant Oinical Professor of Medicine University of California at Los Angeles School of Medicine Los Angeles, CA 90033, USA Chapter 4

Dimitrios G. Oreopoulos, M.D., Ph.D. Professor of Medicine University of Toronto Director, Peritoneal Dialysis Program Toronto Western Hospital Toronto, Ontario, Canada Chapter 37

Solomon Papper, M.D. Distinguished Professor of Medicine Head, Department of Medicine University of Oklahoma College of Medicine VA Medical Center Oklahoma City, OK 73190, USA Chapter 23

Joan H. Parks, M.B.A. Project Coordinator Nephrolithiasis Program University of Chicago Billings & Michael Reese Hospitals 29th Street and Ellis Ave Chicago, IL 60616, USA Chapter 46

Israel Penn, M.D. Professor of Surgery Chief of Surgery V A Medical Center University of Cincinnati Cincinnati, OH 45267, USA Chapter 45

Jules B. Puschett, M.D. Professor of Medicine Director, Renal-Electrolyte Division University of Pittsburgh School of Medicine Presbyterian-University & V A Hospitals Pittsburgh, PA 15260, USA Chapter 3

S. Ringoir, M.D., Ph.D. Professor of Medicine Chairman of Medicine Director Renal Division University of Gent University Hospital De Pintelaan 135 B-9000 Gent, Belgium Chapter 40

Professor Dr. Med. Eberhard Ritz Chief Department of Nephrology University of Heidelberg D-69oo Heidelberg, FRG Chapter 35

Robert M. Rosa, M.D. Assistant Professor of Medicine Associate Director Clinical Research Center Harvard Medical School Beth Israel Hospital Boston, MA 02215, USA Chapter 29

Sandra Sabatini, Ph.D., M.D. Assistant Professor of Medicine Medical Director, Hemodialysis Unit University of Illinois College of Medicine Chicago, IL 60612, USA Chapter 9

Peter T. Scardino, M.D. Associate Professor of Urology Department of Urology Baylor College of Medicine Houston, TX 77030, USA Chapter 30

H. David Short, M.D. Assistant Professor of Surgery Baylor College of Medicine 1200 Moursand Houston, TX 77030, USA Chapter 38

Dale H. Sillix, M.D. Nephrology Research Fellow Wayne State University School of Medicine Detroit, MI 48201, USA Chapter 41

Sharon Slusher, R.N., B.S.N. Nephrology Nurse Oinician University of Kansas School of Medicine College of Health Sciences & Hospital Kansas City, KS 66103, USA Chapter 28

William E. Smith, M.D. Fellow in Nephrology University of Wisconsin Department of Medicine Madison, WI 53792, USA Chapter 24

Thomas H. Steele, M.D. Professor of Medicine University of Wisconsin Department of Medicine Madison, WI 53792, USA Chapter 24

Wadi N. Suki, M.D. Professor of Medicine and Physiology Chief, Renal Section Baylor College of Medicine The Methodist Hospital Houston, TX 77030, USA Chapter 12

Contributors XVII

XVIII Contributors

PD Dr. Med. Wolfgang Tschope Department of Internal Medicine Division of Nephrology University of Heidelberg (Ruperto Carola) Heidelberg, FRG Chapter 35

Yves Vanrenterghem, M.D. Joint Clinical Head Department of Nephrology and Renal Transplantation Universitair Ziekenhuis St. Rafael K.u. Leuven Kapucijnenvoer 33-35 B-3ooo Leuven, Belgium Chapter 43

Mark J.A. Waer, M.D. Department of Nephrology and Renal Transplantation Universitair Ziekenhuis St. Rafael K.U. Leuven Kapucijnenvoer 33-35 B-30oo Leuven, Belgium Chapter 43

Herman Wechsler, M.D. Clinical Associate Professor of Urology Albert Einstein School of Medicine Einstein College Hospital Bronx, NY 10468, USA Chapter 18

Douglas R. Wilson, M.D., F.R.C.P. Professor of Medicine University of Toronto Head, Division of Nephrology Toronto General Hospital 101 College Street Toronto, Ontario M5G IL7, Canada Chapter 2

Jay Wish, M.D. Nephrology Division Case Western Medical School Cleveland, OH 44106, USA Chapter 5

James B. Young, M.D. Assistant Professor of Medicine Baylor College of Medicine Chief, Cardiology Section Ben Taub General Hospital Houston, TX 77030, USA Chapter 34