MANUAL OF CLINICAL NEPHROLOGY

ROGOSIN KIDNEY CENTER

DEVELOPMENTS IN NEPHROLOGY

VOLUME 1

MANUAL OF CLINICAL NEPHROLOGY of the Rogosin Kidney Center

edited by

JHOONG S. CHEIGH, M.D.

KURT H. STENZEL, M.D.

ALBERT L. RUBIN, M.D.

The New York Hospital-Cornell University Medical Center. Rogosin Kidney Center

• 1981

MARTINUS NIJHOFF PUBLISHERS

THE HAG UE / BOSTON / LONDON

Distributors:

for the United States and Canada

Kluwer Boston, Inc. 190 Old Derby Street Hingham, MA 02043 USA

for all other countries

KJuwer Academic Publishers Group Distribution Center P.O. Box 322 3300 AH Dordrecht The Netherlands

Library of Congress Cataloging in Publication Data

Main entry under title:

Manual of clinical nephrology of the Rogosin Kidney Center.

(Developments in nephrology; 1) Includes index. I. Kidneys-Diseases. 2. Nephrology. I. Cheigh, Jhoong S. II. Stenzel, Kurt H.

III. Rubin, Albert L. IV. Rogosin Kidney Center. V. Series. [DNLM: 1. Kidney diseases. WI DE998Eb v. I/WJ300 M294] RC902. MI9 616.6'1 80-22605

ISBN-13: 978-94-009-8212-3 e-ISBN-I3: 978-94-009-8210-9 DOl: 10.1007/978-94-009-8210-9

Copyright © 1981 by Martinus NijhQflPublishers bl', The Hague. Softcover reprint of the hardcover 1st edition 1981 All rights reserved. No part Ql 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 Ql the publisher, Martinus NiihQtr Publishers bv, P.O. Box 566, 2501 CN The Hague, The Netherlands.

PREFACE

Over the past two decades remarkable progress has been made in the understanding and treatment of kidney disease. The solid foundations of renal physiology have been added to by further understanding of the pathophysiology brought about by renal biopsy and improved pathologic techniques. At the same time, recent advances in the treatment of renal disease with dialysis and renal transplantation have led to further immunologic and biochemical approaches to our understanding of the disease process. Clearly the understanding, treatment, and investigation of renal disease involves many disciplines. To this end, the Rogosin Kidney Center was organized as a categorical disease center devoted to the care of patients with kidney disease. The core of the Kidney Center is the Nephrology Division of the Department of Medicine. There are also major and vital inputs from Departments of Surgery, Pediatrics, Psychiatry, Radiology, and Obstetrics and Gynecology; and the Basic Science Departments of Biochemistry, Immunology, Pharmacology, Pathology, and Physiology are actively involved in basic research. The Kidney Center has its own nursing staff, social workers, dieticians, and technical staff. It serves as the hub of a major network with over 40 hospitals referring patients for consultation, dialysis, and transplanta­tion.

The major purpose of this book is to establish an approach to kidney disease from a major center that has interdisciplinary teams working closely together. The information contained herein is a result of over 20 years' experience with contributions from many who have participated in the activities of the Kidney Center. This experience provides the basis for the judgements and principles that we use to treat patients with renal disease. As more and more tertiary care centers develop, it becomes increasingly important for those participating in these activities to clearly define the principles they follow in diagnosis and treatment. We trust that these principles will be useful to the student and house­officer as well as to the practicing physicians and other individuals engaged in the care of patients with renal disease.

November 1980

ALBERT L. RUBIN, M.D. JHOONG S. CHEIGH, M.D. KURT H. STENZEL, M.D.

TABLE OF CONTENTS

Preface

List of contributors

1.

2.

Evaluation of patients with renal disease

KENYON B. FIELD, M.D.

I. Introduction 1

2. Identifying Renal Disease 2 2.1. History 2 2.2. Family history 4 2.3. Physical examination 5 2.4. Urinalysis 6 2.5. The chemical data base 13 2.6. Radiologic techniques 14 2.7. Percutaneous renal biopsy 20 2.8. Risks and cost of procedures 21

3. Syndromes of Renal Disease 22 3.1. Acute renal failure 22 3.2. Chronic renal fail ure 22 3.3. Acute nephritic syndrome 23 3.4. Nephrotic syndrome 23 3.5. Urinary tract infection 23 3.6. Obstructive nephropathy 24 3.7. Renal tubular dysfunction 25 3.8. Nephrolithiasis 26 3.9. Accelerated hypertension 26

4. Conclusion 27

Disorders of water, sodium and potassium metabolism

MICHAEL C. RUDDY, M.D. and KURT H. STENZEL, M.D.

I. Maintenance of Osmotic Homeostasis 30 1.1. General considerations 30 1.2. Free-water clearance 31 1.3. Renal concentrating and diluting mechanisms 32 1.4. Antidiuretic hormone 34 1.5. Summary of requirements for maximum water diuresis

(CHlOl 35

v

xix

30

viii

2 2.1. 22 2.3.

2A. 2.5. 2.6. 2.7. 2.8.

3. 3.1. 3.2.

3.3.

4. 4.1. 4.2. 4.3.

5. 5.1. 5.2. 5.3. 5 A.

Clinical States Associated with Hypo-osmolality 35 True dilutional hyponatremia 35 Renal failure 36 Decreased delivery of filtrate to diluting segment of the neph­ron 36 Syndrome of inappropriate ADH (SIADH) 38 Drugs associated with impaired free-water clearance 40 Endocrine deficiencies 41 Reset osmostat 42 Summary of the diagnostic approach to hyponatremia 42

Hypernatremia and Disorders of Urine Concentration 43 Low circulating levels of ADH 43 Renal tubular hyporesponsiveness to ADH (nephrogenic diabetes insipidus) 46 Diagnostic approach to the patient with a disorder of urinary con, centration 48

Disorders of Sodium Metabolism 49 Determinants of renal sodium excretion 50 Sodium retaining states (edema) 51 Diuretic therapy 53

Disorders of Potassium Metabolism 58 Internal potassium balance 58 External potassium balance 58 Hyperkalemia 59 Hypokalemia 62

3. Acid-base disturbances

KURT H. STENZEL, M.D.

I. Introduction 68 1.1. Physiologic buffers 68 1.2. Respiratory control of pH 69 1.3. Renal control of H + excretion 69 IA. Clinical definitions 70 1.5. Diagnostic approach 70

2. Metabolic Acidosis 71 2.1. Anion gap 72 2.2. Metabolic acidosis with an increased anion gap 74 2.3. Metabolic acidosis associated with a normal anion gap (hyper­

chloremic) 77 2A. Treatment of metabolic acidosis 83

3. Metabolic Alkalosis 84 3.1. Metabolic alkalosis associated with low urinary CI - 85 3.2. Metabolic alkalosis associated with normal or increased urinary

CI- 85 3.3. Treatment of metabolic alkalosis 86

4. Respiratory Alkalosis 87

5. Respiratory Acidosis 87

6. Mixed Acid-Base Disorders 88

68

4. Glomerulonephropathies

STUART D. SAAL, M.D.

I. Introduction 90

2. Asymptomatic Urinary Abnormalities 91 2.1. Hematuria 91 2.2. Asymptomatic proteinuria 95 2.3. Asymptomatic proteinuria and hematuria 98

3. Nephrotic Syndrome 99 3.1. Definition 99 3.2. Pathogenesis of proteinuria 99 3.3. Patient presentation and evaluation 10 I 3.4. Clinicopathological correlation 102

4. Acute Nephritic Syndrome 110 4.1. Definition 110 4.2. Patient presentation and evaluation 110 4.3. Clinicopathological correlation III 4.4. Management of acute nephritic syndrome 113 4.5. Prognosis 114

5. Rapidly Progressive Glomerulonephritis (RPGN) 115 5.1. Definition 115 5.2. Patient presentation and evaluation 115 5.3. Clinicopathological correlation 117

6. Chronic Nephritic Syndrome 120 6.1. Definition 120 6.2. Patient presentation and evaluation 121

7. Glomerulonephritis and Systemic Disease 121 7.1. Metabolic and inherited diseases 122 7.2. Hereditary nephritis 124 7.3. Infectious disease 126 7.4. Toxic nephropathy 128 7.5. Collagen vascular disease 129 7.6. Dysproteinemias 135 7.7. Pregnancy 135

5. Urinary tract infection and pyelonephritis

LUIs TAPIA, M.D.

I. Prevalence 143 1.1. Overall incidence 143 1.2. Prevalence of urinary tract infection in children 144 1.3. Prevalence of urinary tract infection in adults 144

2. Clinical Significance of Bacteriuria 145 2.1. Pregnancy and urinary tract infection 145 2.2. Hypertension and urinary tract infection 145 2.3. Diabetes and urinary tract infection 146 2.4. Bacteriuria in non-pregnant women 146 2.5. Bacteriuria in children 146

ix

90

143

x

2.6. Bacteriuria in men 147 2.7. Nosocomial urinary tract infections 147

3. Pathogenesis 148 3.1. Local barriers of invasion 148 3.2. Cervico-vaginal antibodies 148 3.3. Uroepithelial antibodies 149 3.4. Systemic antibody response 149 3.5. Other mechanisms 149 3.6. Vesicoureteral valve ISO

4. Etiology 152 4.1. Bacterial infection 152 4.2. Fungal infections 153 4.3. Viral infection 153

5. Clinical Manifestations 153

6. Diagnosis 154 6.1. Urine collection 154 6.2. Microscopic examination 154 6.3. Localization ISS

7. Management 156 7.1. Asymptomatic bacteriuria 156 7.2. Acute pyelonephritis 156 7.3. Recurrent infections 157 7.4. Antibiotics 157 7.5. Prophylaxis 158

6. Tubulo-interstitial nephritis

LUIS TAPIA, M.D.

I. Hereditary Kidney Diseases 164 1.1. Medullary cystic disease 164 1.2. Medullary sponge kidney 164 1.3. Hereditary familial nephritis (Alport's syndrome) 165

2. Metabolic Kidney Diseases 165 2.1. Hypercalcemia 165 2.2. Hypokalemia 166 2.3. Oxalate nephropathy 166 2.4. Gouty nephropathy 168

3. Hematologic Diseases 171 3.1. Hemolytic-uremic syndrome 171 3.2. Sickle cell anemia 171

4. Vascular Diseases 172

5. Neoplastic Diseases 172

6. Infections 173

7. Immunological Diseases 173 7.1. Antitubular basement membrane antibodies 174 7.2. Immune complex interstitial nephritis 175

162

xi

7.3. Reflux nephropathy 175 7.4. Drug-related interstitial nephritis 176 7.5. Renal allografts 176 7.6. Sjogren's syndrome 176

8. Analgesic Nephropathy 177 8.1. Aspirin 177 8.2. Phenacetin 178 8.3. Pathology 178 8.4. Pathogenesis 179 8.5. CE:1ical manifestations 179

9. Heavy Metals 180

10. Balkan Nephropathy 180

11. Radiation Nephritis 181

7. Cystic diseases of the kidney 185

LEWIS REISMAN, M.D. and MATTHEW R. KAPLAN, M.D.

I. Introduction 185

2. Cystic Dysplasia 186 2.1. Renal aplasia 186 2.2. Congenital multicystic kidney 186 2.3. Pathology 186 2.4. Etiology and pathogenesis 187 2.5. Clinical presentation 187 2.6. Diagnosis 187 2.7. Prognosis and therapy 188

3. Polycystic Disease 188 3.1. Infantile polycystic disease 188 3.2. Adult polycystic disease 190

4. Medullary Cysts of the Kidney 192 4.1. Medullary sponge kidney 192 4.2. Medullary cystic disease 194 4.3. Renal-retinal dysplasia 197

5. Cysts of the Renal Cortex 197

6. Renal Cysts in Hereditary Syndromes 199

8. Urolithiasis 202

JOHN J. WILLIAMS, M.D.

1. Introduction 202

2. Pathogenesis of Stone 203

3. Diagnosis of Stone Disease 206 3.1. History 206 3.2. Physical examination 208 3.3. Urinalysis 208 3.4. Radiography 208

xii

4. Management of Stone Disease 210 4.1. General principles 210 4.2. Identification of anatomic or metabolic disorders 210 4.3. Fluid intake 210 4.4. Diet 211 4.5. Urinary tract infection 211 4.6. Classification of stone activity 211

5. Cystine Stones 212

6. Uric Acid Stones 214

7. Xanthine Stones 216

8. Calcium Stones 216 8.1. Hypercalciuria 218 8.2. Other causes of calcium stone formation 221

9. The Evaluation of the Recurrent Stone Former 225

10. Timing of Surgical Intervention 226

9. Drug-related nephropathy

JHOONG S. CHEIGH, M.D.

I. Introduction 229

2. Acute Tubular Necrosis 231 2.1. Predisposing factors 231 2.2. Incidence 232 2.3. Clinical features 234

3. Tubulo-Interstitial Disease 235 3.1. Acute tubulo-interstitial disease 235 3.2. Chronic tubulo-interstitial disease 237

4. Glomerulonephritis, Nephrotic Syndrome and Vasculitis 238 4.1. Acute glomerulonephritis 238 4.2. Chronic glomerulopathy 239 4.3. Vasculitis 240

5. Hemolytic-Uremic Syndrome 241

6. Obstructive Uropathy 242

7. Fluid, Electrolyte and Acid-Base Disorders 244 7.1. Antidiuresis and dilutional hyponatremia 244 7.2. Diabetes insipidus 244 7.3. Potassium imbalance 245 7.4. Acid-base imbalance 246

10. Acute renal failure

BRUCE R. LESLIE, M.D.

I. Clinical Recognition of Acute Renal Failure 253 1.1. Urine volume 253 1.2. Azotemia 255

229

253

1.3. Urine sediment 256 1.4. Urine chemistries 256 1.5. Radiologic investigation 258

2. Management of ARF 259 2.1. Prevention 259 2.2. Established parenchymal ARF 261

3. The Recovery Phase 267

11. Chronic renal failure

JHOONG S. CHEIGH, M.D. and ALBERT L. RUBIN, M.D.

I. Introduction 269

2. Pathophysiology of Chronic Renal Failure 2.1. Compensatory growth 272 2.2. Adaptive mechanisms 272

3. Uremia 276 3.1. Pathogenesis of uremia 277 3.2. Uremic complications 278

4. Preparation for Dialysis and Transplantation

12. Renal hypertension

BRUCE R. LESLIE, M.D.

1. Renovascular Hypertension 289 1.1. Renal artery stenosis 290

271

285

1.2. Hypertension in other forms of unilateral renal disease 294

2. Acute Renal Failure 295 2.1. Acute glomerulonephritis 295 2.2. Ischemic and nephrotoxic acute renal failure 295 2.3. Obstructive uropathy 296

3. Chronic Renal Failure 296 3.1. Sodium-volume factors 296 3.2. Vasoconstrictor factors 297

4. Transplantation 298 4.1. Persistence of pre-transplant hypertension - The role of the reci-

pient's kidneys 298 4.2. Acute rejection 298 4.3. Corticosteroids 299 4.4. Transplant renal artery stenosis 299 4.5. Hypercalcemia 300 4.6. Chronic rejection 300

5. Pharmacologic Therapy of Hypertension in Renal Disease 300 5.1. Diuretics 300 5.2. Beta-adrenergic blockers 301 5.3. Drugs acting on the central nervous system 302 5.4. Vasodilators 302 5.5. Parenteral drugs for hypertensive emergencies 303

xiii

269

289

xiv

13. Divalent ion metabolism and renal osteodystrophy

DAVID S. DAVID, M.D.

I. Introduction 307

2. Metabolism of Vitamin D 307

3. Pathogenesis of Abnormalities in Divalent Ion Metabolism in Chronic Renal Failure 308

3.1. Phosphate retention 308 3.2. Bone resistance to the calcemic effect of parathormone 308 3.3. Abnormalities in Vitamin D metabolism 308

4. Clinical Consequences of Abnormal Calcium and Phosphate Meta-bolism 309

4.1. Skeletal abnormalities 309 4.2. Non-skeletal complications 311

5. Management 312 5.1. General guidelines for therapy 312 5.2. Control of phosphorus 312 5.3. Vitamin D therapy 313 5.4. Calcium supplementation 314 5.5. Other medical therapy 315 5.6. Subtotal parathyroidectomy 315

6. Post-Transplant Mineral Homeostasis 317

7. Mineral Homeostasis in Acute Renal Failure 317

8. Mineral Replacement Therapy 318 8.1. Calcium and magnesium 318 8.2. Phosphorus 318

14. Dialysis treatment

JOHN F. SULLIVAN, M.D. and JACQUELINE CHAM!, M.D.

I. Introduction 322

2. Hemodialysis 322 2.1. Principles of hemodialysis 322 2.2. Indications for dialysis 324 2.3. Type of dialyzer 324 2.4. Fluid delivery systems 325 2.5. Acute problems during dialysis treatment 326 2.6. Chronic problems in hemodialysis 329 2.7. Options in types of hemodialysis 333 2.8. General management of hemodialysis patients 333 2.9. Medication for dialysis patients 334 2.10. Acute hemodialysis 335

3. Peritoneal Dialysis 336 3.1. Peritoneal membrane characteristics 336 3.2. Peritoneal dialysate 337 3.3. Permanent peritoneal catheters 338 3.4. Automated peritoneal dialysis devices 338 3.5. Management of peritoneal dialysis patients 339

307

322

3.6. Complications of peritoneal dialysis 340 3.7. Continuous ambulatory peritoneal dialysis 342

4. Conclusion 342

15. Kidney transplantation

MANIKKAM SUTHANTHIRAN, M.D. and ROBERT R. RIGGIO, M.D.

I. Introduction 345

2. Donors and Recipients 345 2.1. Living related donors 345 2.2. Cadaveric donors 346 2.3. Recipients 347

3. Immunological Aspects of Renal Transplantation 347 3.1. Human major histocompatibility complex 348 3.2. Genetic and inheritance patterns of the MHC 348 3.3. Identification of HLA- A, B, C antigens 348 3.4. Identification of DRw antigens 349 3.5. Mixed lymphocyte culture 349 3.6. Role of HLA antigens in renal transplantation 350 3.7. Role of ABO blood group antigens in renal transplantation 351 3.8. In vitro techniques to detect alloimmunity 351

4. Medical Management of the Transplant Recipient 352 4.1. Pre-transplant evaluation 352 4.2. Immunosuppressive therapy 352 4.3. Post-transplant management 355 4.4. Immunologic problems 357 4.5. Results and factors affecting transplantation 358 4.6. Immunologic monitoring of the renal allograft recipient 360

5. Complications 361 5.1. Primary non-function 361 5.2. Urinary leakage 361 5.3. Lymphocele 363 5.4. Infections 363 5.5. Hypertension 363 5.6. Lipid abnormalities 364 5.7. Gastrointestinal system 364 5.8. Bone disease 364 5.9. Malignancy 365 5.10. Recurrence of the original disease in renal grafts 365 5.11. Miscellaneous complications 366

6. Future Prospects 366

16. Dialysis and transplantation: dietary management

JACQUELINE CHAMI, M.D.

1. Dietary Management for Patients with Chronic Renal Failure Not Treated with Dialysis 369

1.1. General principles 369 1.2. Protein intake 370

xv

345

369

xvi

1.3. 1.4. 1.5. 1.6.

2.

2.1. 2.2.

2.3. 2.4. 2.5. 2.6. 2.7.

3.

4.

Caloric supply 372 Fluid, sodium and potassium intake 374 Vitamin supplements 375 Mineral requirements 375

Dietary Management for Patients with Chronic Renal Failure Treated with Dialysis 376 Dietary protein intake for patients treated with .hemodialysis 377 Dietary protein intake for patients treated with peritoneal dialysis 378 Caloric requirements during maintenance dialysis 378 Vitamin requirements during maintenance dialysis 379 Anabolic steroids 379 Management of inadequate protein and caloric intake 380 Evaluation of adequate dietary intake 380

Dietary Management for Patients with Acute Renal Failure 381

Parenteral Nutrition 381

17. Dialysis and transplantation: psychological management 384

MILTON VIEDERMAN, M.D. and GARY H. RUSK, M.D.

I. Introduction 384 2. The Advent of Terminal Renal Failure 385 2.1. Minimization and denial 385 2.2. Hypervigilant behavior 386

3. The Meaning of Hemodialysis and its Impact upon Adapta-tion 387

4. The Process of Adaptation 388

5. Transplantation 389

6. Personality Types and Medical Management 393 6.1. The non-compliant denying patient and the need to accept limita­

tions 394 6.2. The dependent clinging patient and the need to set limits 395 6.3. The entitled demanding patient and the need to allow the patient

some control 396

7. Specific Clinical Syndromes and their Management 397 7.1. Painful feeling states 397 7.2. Organic brain syndrome and functional psychosis 400

18. Dialysis and transplantation: surgical management

WILLIAM T. STUBENBORD, M.D.

I. Introduction 405

2. General Principles 405 2.1. Timing of surgery 405 2.2. Anemia 406 2.3. Hypertension 406 2.4. Corticosteroids 406 2.5. Operative and postoperative fluid management 407

405

xvii

2.6. Hemostasis 407 2.7. Postoperative dialysis 407 2.8. Wound healing 407

3. Anesthetic Management 408 3.1. General evaluation 408 3.2. Choice of agents 408

4. Surgical Aspects of Dialysis 409 4.1. Peritoneal dialysis 409 4.2. Hemodialysis 409

5. Surgical Considerations of Transplant Candidates 413 5.1. Indications for pre-transplant nephrectomy and ureterectomy 414 5.2. Indications for pre-transplant lower urinary tract corrective

surgery 416

6. Cadaveric Kidneys 417 6.1. Cadaveric donors 417 6.2. Cadaveric nephrectomy 418 6.3. Cadaveric kidney storage 418

7. Surgical Aspects of Renal Transplantation 419 7.1. Transplant procedure 419 7.2. Surgical problems following transplantation 422

19. Drug metabolism and dose adjustment in patients with renal failure 428

JHOONG S. CHEIGH, M.D. and MARCUS M. REIDENBERG, M.D.

I. Drug Metabolism in Uremia 428 1.1. Biotransformation 428 1.2. Effect of renal failure 429 1.3. Retention of active drug metabolites 431 1.4. Retention of inactive metabolites 432

2. Dose Adjustment in Renal Failure 432 2.1. Antimicrobial drugs 434 2.2. Urinary antiseptics 437 2.3. Antimycotic drugs 437 2.4. Antituberculosis drugs 438 2.5. Antimalarial drugs 439 2.6. Diuretics 439 2.7. Antihypertensive drugs 441 2.8. Drugs acting on the heart 443 2.9. Antiarthritic drugs 445 2.10. Analgesic drugs 447 2.11. Anticonvulsant drugs 447 2.12. Immunosuppressive drugs 448 2.13. Hypoglycemic drugs 449 2.14. Anticoagulants 450

3. Dialysis of Drugs and Poisons 450

xviii

Appendices

I. Composition of Electrolyte and Colloid Solutions 455

Index

2.

3.

4.

5.

6.

7.

8.

Normal Arterial Blood Pressure 456

Nomogram for Estimation of Endogenous Creatinine Clearance 458

Nomogram for Calculating the Body Surface Area of Adults 459

Conversion Tables Temperature 460 Weight 461 Height 462

WHO Nomenclature for Factors of the HLA System 463

Elements and Atomic Weights 464

Normal Chemical Values of Body Fluids 465

453

469

LIST OF CONTRIBUTORS

CHAMI, JACQUELINE, M.D. Assistant Professor of Medicine, Cornell University Medical College, New York, New York Dialysis and Transplantation: Dietary Management Dialysis Treatment

CHEIGH, JHOONG S., M.D. Associate Professor of Clinical Biochemistry, Medicine and Surgery, Cornell University Medical College, New York, New York; Director, In-Patient Care, Rogosin Kidney Center, The New York Hospital, New York, New York Drug-related Nephropathy Chronic Renal Failure Drug Metabolism and Dose Adjustment in Patients with Renal Failure

DA VID, DAVID S., M.D. Associate Clinical Professor of Medicine, University of California at Los Angeles School of Medicine, Los Angeles, California; Former Associate Profes­sor of Biochemistry, Medicine and Surgery, Cornell University Medical College, New York, New York Divalent Ion Metabolism and Renal Osteodystrophy

FIELD, KENYON 8., M.D. Assistant Professor of Biochemistry, Medicine and Surgery, Cornell University Medical College, Director of Continuing Medical Education for Affiliations, The New York Hospital - Cornell University Medical Center, New York, New York Evaluation of Patients with Renal Disease

KAPLAN, MATTHEW R., M.D. Assistant Professor of Pediatrics, Cornell University Medical College, Acting Director, Division of Pediatric Nephrology, The New York Hospital, New York, New York Cystic Diseases q/ the Kidney LESLIE, BRUCE R., M.D. Assistant Professor of Biochemistry, Medicine and Surgery, Cornell University Medical College, New York, New York Acute Renal Failure Renal Hypertension

REIDENBERG, MARCUS M., M.D. Professor of Pharmacology, Professor of Medicine, Cornell University Medical College, Head, Division of Clinical Pharmacology, Cornell University Medical

xx

College, New York, New York Drug Metabolism and Dose Adjustment in Patients with Renal Failure

REISMAN, LEWIS, M.D. Senior Research Fellow in Pediatric Nephrology, Cornell University Medical College, New York, New York Cystic Diseases of the Kidney

RIGGIO, ROBERT R., M.D. Associate Professor of Biochemistry, Medicine and Surgery, Cornell University Medical College, Associate Medical Director, Rogosin Kidney Center, The New York Hospital, New York, New York Kidney Transplantation

RUBIN, ALBERT L., M.D. Professor of Biochemistry, Medicine and Surgery, Cornell University Medical College, Director, Rogosin Kidney Center, The New York Hospital, New York, New York Chronic Renal Failure

RUDDY, MICHAEL c., M.D. Assistant Professor of Medicine - CMDNJ Rutgers Medical School, Piscata­way, New Jersey; Former Senior Fellow of Biochemistry, Medicine and Surgery, Rogosin Kidney Center, Cornell University Medical College, New York, New York Disorders of Water, Sodium and Potassium Metabolism

RUSK, GARY H., M.D. Clinical Assistant Professor of Psychiatry, Cornell University Medical College, Assistant Attending Psychiatrist, The New York Hospital, New York, New York Dia~l'sis and Transplantation." Psychological Management

SAAL, STUART D., M.D. Assistant Professor of Biochemistry, Medicine and Surgery, Cornell University Medical College, New York, New York Glomerulonephropathies

STENZEL, KURT H., M.D. Professor of Biochemistry and Medicine, Cornell University Medical College, Chief of the Division of Nephrology, The New York Hospital, Cornell Univer­sity Medical College, Medical Director, Rogosin Kidney Center, The New York Hospital, New York, New York Acid-Base Disturbances Disorders of Water, Sodium and Potassium Metabolism

STUBENBORD, WILLIAM T., M.D. Associate Professor of Surgery, Cornell University Medical College, Surgical Director, Rogosin Kidney Center, The New York Hospital, New York, New York Dia~ysis and Transplantation." Surgical Management

xxi

SULLIVAN, JOHN F., M.D. Associate Professor of Clinical Biochemistry, Medicine and Surgery, Cornell University Medical College, Director of Dialysis, Rogosin Kidney Center, The New York Hospital, New York, New York Dialysis Treatment

SUTHANTHIRAN, MANIKKAM, M.D. Assistant Professor of Biochemistry, Medicine and Surgery, Cornell University Medical College, Director, Immunologic Monitoring Laboratory, Rogosin Kid­ney Center, The New York Hospital, New York, New York Kidney Transplantation

TAPIA, LUIS, M.D. Assistant Professor of Biochemistry, Medicine and Surgery, Cornell University Medical College, Director of Out-Patient Service, Rogosin Kidney Center, The New York Hospital, New York, New York Urinary Tract Infection and Pyelonephritis Tubulo-Interstitial Nephritis

VIEDERMA],;, MILTON, M.D.

Professor of Clinical Psychiatry, Cornell University Medical College, Director, Consultation-Liaison Service, The New York Hospital, Psychiatric Service, Rogosin Kidney Center, The New York Hospital, New York, New York Dialysis and Transplantation: Psychological Management

WILLIAMS, JOHN 1., M.D.

Assistant Professor of Surgery (Urology), Cornell University Medical College, Attending Surgeon (Urology), The New York Hospital, New York, New York Urolithiasis