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Renal Physiology a Clinical Approach Renal Physiology A Clinical Approach LWBK1036-FM_pi-xiv.indd 1 12/01/12 1:16 PM LWBK1036-FM_pi-xiv.indd 2 12/01/12 1:16 PM Renal Physiology A Clinical Approach John Danziger, MD Instructor in Medicine Division of Nephrology Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA Mark Zeidel, MD Herrman L. Blumgart Professor of Medicine Harvard Medical School Physician-in-Chief and Chair, Department of Medicine Beth Israel Deaconess Medical Center Boston, MA Michael J. Parker, MD Assistant Professor of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine Beth Israel Deaconess Medical Center Senior Interactive Media Architect Center for Educational Technology Harvard Medical School Boston, MA Series Editor Richard M. Schwartzstein, MD Ellen and Melvin Gordon Professor of Medicine and Medical Education Director, Harvard Medical School Academy Vice President for Education and Director, Carl J. Shapiro Institute for Education Beth Israel Deaconess Medical Center Boston, MA LWBK1036-FM_pi-xiv.indd 3 12/01/12 1:16 PM Acquisitions Editor: Crystal Taylor Product Managers: Angela Collins and Jennifer Verbiar Marketing Manager: Joy Fisher-Williams Designer: Doug Smock Compositor: Aptara, Inc. Copyright © 2012 Lippincott Williams & Wilkins, a Wolters Kluwer business. 351 West Camden Street Two Commerce Square Baltimore, MD 21201 2001 Market Street Philadelphia, PA 19103 Printed in China All rights reserved. This book is protected by copyright. No part of this book may be reproduced or trans- mitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data Danziger, John. Renal physiology : a clinical approach / John Danziger, Mark Zeidel, Michael J. Parker. — 1st ed. p. ; cm. — (Integrated physiology series) Includes bibliographical references and index. ISBN 978-0-7817-9524-1 I. Zeidel, Mark. II. Parker, Michael J. III. Title. IV. Series: Integrated physiology series. [DNLM: 1. Kidney—physiology. WJ 301] 616.614—dc23 2011050922 DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publica- tion. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is par- ticularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care pro- vider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Proudly sourced and uploaded by [StormRG] Kickass Torrents | TPB | ET | h33t Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST. LWBK1036-FM_pi-xiv.indd 4 12/01/12 1:16 PM To my parents, Avril and Julius, whose support enabled me to become a physician —John Danziger To my wife, Susan —Mark Zeidel To my wonderful wife, Yuanzhen, and my parents, Leonard and Gloria: for their boundless support, enthusiasm, inspiration, and love —Michael Parker LWBK1036-FM_pi-xiv.indd 5 12/01/12 1:16 PM LWBK1036-FM_pi-xiv.indd 6 12/01/12 1:16 PM Preface Introduction The goal of Renal Physiology: A Clinical Approach is to provide a clear, clinically oriented exposition of the essentials of renal physiology for medical students, residents, nurses, and allied health professionals. We present the physiology in the context of a system to emphasize that the functions we associate with the renal system depend upon more than the kidney. This approach is essential for a complete understanding of the clinical prob- lems that affect the elimination of toxic substances from the body and the fine-tuning, not only of our water status, but of our blood pressure as well. This book is the third in The Integrated Physiology Series, a sequence of monographs on physiology. The first book, Respiratory Physiology: A Clinical Approach, describes the essen- tial principles underlying breathing. The second book, Cardiovascular Physiology: A Clinical Approach, helps you navigate the complexities of the circulation. Each book is designed to meet the needs of the learners outlined below, and uses the same style and pedagogical tools. In addition, we have attempted to design common frameworks upon which the stu- dent can hang the large amounts of information confronting us in medicine today, and with which a foundation can be built to support the incorporation of new data in the future. In this book, for example, we describe the renal system in the context of filtration (the regu- lation of the factors that control how much and what kinds of substances are filtered by the glomerulus), reabsorption (the determinants of the selective reabsorption, and in some cases secretion, of key electrolytes and water in the different sections of the renal tubule), and the important renal-endocrine links that are essential for water handling and modula- tion of blood pressure, not only for the kidney but for the body as a whole. The series addresses “integrated” physiology by its focus on systems rather than organs, and by making explicit links between systems. Understanding blood pressure control, for example, requires one to be conversant with the details of both cardiovascular and renal physiology. To provide care to a patient with an acid–base problem, one must be able to explain how the respiratory and renal systems combine to keep the pH in a range that enables enzymes to function normally. Our goals are to present physiology in a clinically meaningful way, to emphasize that physiology is best understood within the context of an organ system, to demonstrate prin- ciples that are common to different systems, and to utilize an interactive style that engages and challenges the reader. Level The level of the book is intended to fit a range of needs from students who have had no previous exposure to physiology to residents who are now in the thick of patient care but vii LWBK1036-FM_pi-xiv.indd 7 12/01/12 1:16 PM viii PREfACE feel the need to review relevant physiology in a clinical context. We have drawn upon many years of experience teaching students, residents, and fellows in making decisions with respect to the topics emphasized and the clinical examples used to illustrate key concepts. The book is not intended as a comprehensive review of renal physiology nor is it designed for the advanced, research oriented physiologist. Rather, we have focused on issues that are most relevant for the care of patients while, at the same time, we provide sufficient physiological detail to provide you with the foundation to examine and analyze new data on these topics in the future. Most of the concepts presented in the book are well established, and we do not burden you with long reference lists for this information. When we present newer and, in some cases, more controversial issues, however, we do provide relevant primary source citations. Content The book begins with two chapters that serve to provide context for the study of renal physiology. In Chapter 1, we lay out the basic challenges confronting humans as land crea- tures who must conserve water but must also devise a system that filters from the blood potentially toxic byproducts of metabolism without losing all of the essential nutrients and electrolytes upon which we depend every minute of the day. We also introduce the concept of “steady state” conditions, which is critical to many aspects of physiology. Chapter 2 begins an exploration of the compartments in the body that contain water, which makes up approximately 60% of our total body weight. Within this context, you will learn about the forces (osmotic and Starling forces) that control movement of water between the compartments. This chapter is an absolutely critical foundation for much of what will follow and we strongly urge you to spend as much time as is necessary to master these concepts. Chapter 3 focuses on functional anatomy, linking the essential elements of the structure of the kidney, its vasculature and urinary collecting system to their physiological roles.
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