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OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of
Dialysis
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Oxford Handbook of
Dialysis
FOURTH EDITION

Jeremy Levy
Consultant Nephrologist
and Adjunct Professor of Medicine
Imperial College Healthcare NHS Trust, London, UK

Edwina Brown
Consultant Nephrologist
and Honorary Professor of Renal Medicine
Imperial College Healthcare NHS Trust,
London, UK

Anastasia Lawrence
Senior Renal Lecturer Practitioner
and Honorary Senior Lecturer
Imperial College Healthcare NHS Trust & Buckinghamshire
New University, London, UK

1
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 2016
The moral rights of the authors‌have been asserted
First Edition published in 2001
Second Edition published in 2004
Third Edition published in 2009
Fourth Edition published in 2016
Impression: 1
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, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 2015941610
ISBN 978–0–19–964476–6
Printed and bound in China by
C&C Offset Printing Co., Ltd.
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-pregnant
adult who is not breast-feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
 v

Foreword

Dialysis is at the same time one of the most exciting aspects of the care
of kidney patients, yet to the beginner also the most mysterious and
daunting. Unfamiliar concepts, impressive technology, new jargon, expert
patients—all of these can make for anxious times for the young doctor,
nurse, or other health worker joining the multiprofessional team which
cares for people with end-stage renal disease.
This Oxford Handbook provides much solace for the beginner. It pro-
vides plenty of easily navigable practical advice across every aspect of
dialysis and its related challenges, with sufficient theoretical background
to make sense of the day-to-day clinical decision-making. And all in a true
handbook—both small enough and light enough to fit in most pockets.
Since I was a tyro nephrologist much has changed in the world of dialysis.
For one thing there are many more patients, and many are older and frailer.
There has been greater creativity in strategies to improve clinical outcomes
and increase independence for the hospital environment—frequent home
haemodialysis, and assisted peritoneal dialysis are just two examples. And
we need a proper understanding of the complex end-of-life issues which
arise for more patients on dialysis and their carers.
This new edition addresses these recent issues and many more with
advice which is both authoritative and practical, as well as refreshing all the
content familiar to the readers of earlier editions.
Although its authors are all from the UK, this book has global value, espe-
cially in the several parts of the world where the provision of dialysis has
been inadequate for many reasons, but is now rapidly expanding. When
there is such rapid expansion, the education and training needs of the local
clinical team in ensuring high-quality dialysis care, can easily outstrip locally
available resources. In such situations this Oxford Handbook will be an
invaluable pragmatic educational tool.
I wish this book had been available when I started out in nephrology. It
would have saved me many anxieties, and I am sure would have improved
the care I was able to give.

John Feehally
University of Leicester, UK
 vii

Preface

Welcome to the fourth, completely updated, edition of the Oxford

Handbook of Dialysis, which we hope you will find useful. It has been 7 years
since the last edition, and amazingly 15 years since the first edition, and
in that time there have been many developments in dialysis and in treat-
ing patients with end-stage kidney disease. We now have much better evi-
dence for various interventions (although renal medicine remains relatively
poorer at generating high-quality evidence than other areas of medicine),
and for the first time now some good trial data to support choices in treat-
ing patients, ranging from managing their anaemia or bone disease through
to haemodialysis strategies.
We have therefore updated every section of the book which now covers
all haemodialysis techniques, haemodiafiltration, nocturnal and home dialy-
sis, frequent dialysis, peritoneal dialysis in all its forms, plasma exchange,
the medical, nursing, and psychosocial aspects of managing patients with
end-stage kidney disease, nutrition, the acute management of renal trans-
plantation particularly with reference to dialysis patients, palliative and
end-of-life care in renal disease and use of analgesics, a completely new
section on renal replacement therapy in acute kidney injury, updated drug
dosing guidelines including new drugs, and summaries of the most recent
guidelines from Europe (European Best Practice Guidelines), the UK Renal
Association, the USA (KDOQI and KDIGO) and Australasia. Bone disease,
anaemia, cardiovascular disease, infections, pain, and the widespread com-
plications of chronic kidney disease are all discussed, with practical guidance
and management, presented in a compact and easy-to-use format.
We have added new sections on home haemodialysis, frequent haemo-
dialysis, new intradialytic monitoring techniques, new peritoneal dialysis
fluids, encapsulating peritoneal sclerosis, sleep disorders, management of
patients with stroke, care of dying patients with kidney disease or on dialy-
sis, and a new section on acute kidney injury. New drugs such as the new
epoetins and phosphate binders are included. We have ensured that the
sections on nursing and nutrition for dialysis patients have been written by
the appropriate experts, experienced renal nurses and dieticians respec-
tively, and both completely refreshed and updated.
We hope we ensured the book remains easy to use and read, which has
always been one of our primary aims, but also comprehensive, focussed,
and practical, and clearly aimed at the whole multiprofessional team of col-
leagues looking after patients on dialysis. We hope this book will have a
home in every renal unit, dialysis centre, intensive care unit, renal ward,
and be close to hand for every nephrologist, intensivist, renal trainee, renal
nurse, dietician, technician, and pharmacist, and that it helps improve the
care of patients with kidney disease.
 ix

Contents

Contributors xi
Symbols and abbreviations xiii

1 The new patient with renal failure    1

2 Haemodialysis   71
3 Nursing a patient on haemodialysis 195
4 Home and frequent haemodialysis 237
5 Peritoneal dialysis 253
6 Nursing issues in peritoneal dialysis 353
7 Renal replacement therapy in acute kidney injury 365
8 Nutrition on dialysis 393
9 Special situations 415
10 Complications of ESKD: anaemia 457
11 Complications of ESKD: bone mineral disorders 481
12 Complications of ESKD: cardiovascular disease 513
13 Complications of ESKD: infection 529
14 Symptoms related to ESKD 539
15 Other complications of ESKD 559
16 Death in dialysis patients 591
17 Transplantation for dialysis patients 611
18 Drug dosing 621
19 Standards and guidelines 651

Index 659
 xi

Contributors

Rania Betmouni Wendy Lawson

Department of Pharmacy Lead Pharmacist
Hammersmith Hospital Infectious Diseases Imperial College
London, UK Healthcare NHS Trust London, UK
Lina Johansson
Specialist Renal Dietitian
Imperial College Healthcare
NHS Trust
London, UK
 xiii

Symbols and abbreviations

E cross-reference
7 approximately
n normal
i increased
d decreased
l leading to
♂ male
♀ female
ACEI angiotensin-converting enzyme inhibitor
AGE advanced glycation end-product
AKI acute kidney injury
ALP alkaline phosphatase
ALT alanine aminotransferase
ANA antinuclear antibody
ANCA antineutrophil cytoplasmic antibody
APD automated peritoneal dialysis
aPPT activated partial thromboplastin time
ARB angiotensin II receptor blocker
AST aspartate aminotransferase
AVF arteriovenous fistula
AVG arteriovenous graft
AVP arginine vasopressin
β2m β2 microglobin
β2mA β2 microglobin amyloidosis
bd twice daily
BP blood pressure
BVM bag-valve-mask
Ccrea creatinine clearance
CABG coronary artery bypass grafting
CAD coronary artery disease
CAPD continuous ambulatory peritoneal dialysis
cfu colony-forming units
CNS central nervous system
CPR cardiopulmonary resuscitation
CRP C-reactive protein
CRRT continuous renal replacement therapy
xiv SYMBOLS AND ABBREVIATIONS

CVC central venous catheter

CVP central venous pressure
CVVH(F) continuous venovenous haemofiltration
CVVHDF continuous venovenous haemodiafiltration
DEXA dual energy X-ray analysis
DNAR do not attempt resuscitation
DOPPS Dialysis Outcomes and Practice Patterns Study
DTPA diethylenetriamine pentaacetic acid
eGFR estimated glomerular filtration rate
EPO erythropoietin
EPS encapsulating peritoneal sclerosis
ESA erythropoietin-simulating agent
ESKD end-stage kidney disease (also known as ESRD/ESRF)
FBC full blood count
FDA Food and Drug Agency
GBM glomerular basement membrane
GDP glucose degradation product
GFR glomerular filtration rate
GGT gamma-glutamyltranspeptidase
GI gastrointestinal
GP general practitioner
Hb haemoglobin
HBsAg hepatitis B surface antigen
Hct haematocrit
HD haemodialysis
HDF haemodiafiltration
HDL high-density lipoprotein
HLA human leucocyte antigen
HUS haemolytic uraemic syndrome
IBW ideal body weight
ICU intensive care unit
IDH intradialytic hypotension
Ig immunoglobulin
IHD ischaemic heart disease
INR international normalized ratio
IP intraperitoneal
IPD intermittent peritoneal dialysis
iPTH intact parathyroid hormone
ISPD International Society of Peritoneal Dialysis
IV intravenous
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