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Kidney failure
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<h2 id="classification">Classification</h2> <p class="note">See also: <a href="/facts/Hepatorenal_syndrome/L3oNQvJ2">Hepatorenal syndrome</a></p> <p>Kidney failure can be divided into two categories: <a href="/facts/Acute_kidney_failure/dYg8l5P8">acute kidney failure</a> or <a href="/facts/Chronic_kidney_failure/4YKH9wpo">chronic kidney failure</a>. The type of renal failure is differentiated by the trend in the serum <a href="/facts/Creatinine/gkebqj2L">creatinine</a>; other factors that may help differentiate acute kidney failure from chronic kidney failure include <a href="/facts/Anemia/AgEPPmg8">anemia</a> and the kidney size on <a href="/facts/Sonography/Ju5BFuuV">sonography</a> as chronic kidney disease generally leads to anemia and small kidney size. </p> <h3>Acute kidney failure</h3> <p class="note">Main article: <a href="/facts/Acute_kidney_injury/dYg8l5P8">Acute kidney injury</a></p> <p><a href="/facts/Acute_kidney_injury/dYg8l5P8">Acute kidney injury</a> (AKI), previously called acute renal failure (ARF),<a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a><a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a> is a rapidly progressive loss of <a href="/facts/Renal_function/PFmxX01G">renal function</a>,<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a> generally characterized by <a href="/facts/Oliguria/T7t2onvx">oliguria</a> (decreased <a href="/facts/Urine/oNUYVtvX">urine</a> production, quantified as less than 400 <a href="/facts/Millilitres/QKwbQz8I">mL</a> per day in adults,<a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a> less than 0.5 mL/kg/h in children or less than 1 mL/kg/h in infants); and <a href="/facts/Water-electrolyte_imbalance/mmb7W3A0">fluid and electrolyte imbalance</a>. AKI can result from a variety of causes, generally classified as <i>prerenal</i>, <i>intrinsic</i>, and <i>postrenal</i>. Many people diagnosed with <a href="/facts/Paraquat/QBq3lFCx">paraquat intoxication</a> experience AKI, sometimes requiring <a href="/facts/Hemodialysis/oB7fIKP7">hemodialysis</a>. The underlying cause must be identified and treated to arrest the progress, and <a href="/facts/Kidney_dialysis/KQgUGz8p">dialysis</a> may be necessary to bridge the time gap required for treating these fundamental causes. </p> <h3>Chronic kidney failure</h3> <p class="note">Main article: <a href="/facts/Chronic_kidney_disease/4YKH9wpo">Chronic kidney disease</a></p> <p><a href="/facts/Chronic_kidney_disease/4YKH9wpo">Chronic kidney disease</a> (CKD) can also develop slowly and, initially, show few symptoms.<a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a> CKD can be the long term consequence of irreversible acute disease or part of a disease progression. CKD is divided into 5 different stages (1–5) according to the estimated glomerular filtration rate (eGFR). In CKD1 eGFR is normal and in CKD5 eGFR has decreased to less than 15 ml/min.<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> </p> <h3>Acute-on-chronic kidney failure</h3> <p>Acute kidney injuries can be present on top of chronic kidney disease, a condition called acute-on-chronic kidney failure (AoCRF). The acute part of AoCRF may be reversible, and the goal of treatment, as with AKI, is to return the person to baseline kidney function, typically measured by serum <a href="/facts/Creatinine/gkebqj2L">creatinine</a>. Like AKI, AoCRF can be difficult to distinguish from chronic kidney disease if the person has not been monitored by a <a href="/facts/Physician/qJ3woFvG">physician</a> and no baseline (i.e., past) blood work is available for comparison. </p> <h2 id="signs-and-symptoms">Signs and symptoms</h2> <p>Symptoms can vary from person to person. Someone in early stage kidney disease may not feel sick or notice symptoms as they occur. When the kidneys fail to filter properly, waste accumulates in the blood and the body, a condition called <a href="/facts/Azotemia/UabMYrvk">azotemia</a>. Very low levels of azotemia may produce few, if any, symptoms. If the disease progresses, symptoms become noticeable (if the failure is of sufficient degree to cause symptoms). Kidney failure accompanied by noticeable symptoms is termed <a href="/facts/Uraemia/3apTNTm6">uraemia</a>.<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> </p><p>Symptoms of kidney failure include the following:<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a><a class="footnote-ref" id="fnref:33" href="#fn:33"><sup>33</sup></a><a class="footnote-ref" id="fnref:34" href="#fn:34"><sup>34</sup></a><a class="footnote-ref" id="fnref:35" href="#fn:35"><sup>35</sup></a> </p> <ul><li>High levels of <a href="/facts/Urea/6j84AoCG">urea</a> in the blood, which can result in: <ul><li><a href="/facts/Vomiting/R2vQkHqV">Vomiting</a> or <a href="/facts/Diarrhea/6TBHaRdA">diarrhea</a> (or both) that may lead to <a href="/facts/Dehydration/2RXJ8GGI">dehydration</a></li> <li><a href="/facts/Nausea/dyhkcbeD">Nausea</a></li> <li>Weight loss</li> <li>Nocturnal urination (<a href="/facts/Nocturia/PUHHGPBW">nocturia</a>)</li> <li>More frequent urination, or in greater amounts than usual, with pale urine</li> <li>Less frequent urination, or in smaller amounts than usual, with dark coloured urine</li> <li><a href="/facts/Blood_in_the_urine/KSAMIxvK">Blood in the urine</a></li> <li>Pressure, or difficulty urinating</li> <li>Unusual amounts of urination, usually in large quantities</li></ul></li> <li>A buildup of <a href="/facts/Phosphates/FDGVCxUG">phosphates</a> in the blood that diseased kidneys cannot filter out may cause: <ul><li>Itching</li> <li>Bone damage</li> <li><a href="/facts/Nonunion/AthlSHkm">Nonunion</a> in broken bones</li> <li><a href="/facts/Muscle_cramps/h42IKvK6">Muscle cramps</a> (caused by low levels of calcium which can be associated with <a href="/facts/Hyperphosphatemia/mbCIQHbx">hyperphosphatemia</a>)</li></ul></li> <li>A buildup of <a href="/facts/Potassium/FWPwS7Rj">potassium</a> in the blood that diseased kidneys cannot filter out (called <a href="/facts/Hyperkalemia/epfvUg5w">hyperkalemia</a>) may cause: <ul><li>Abnormal heart rhythms</li> <li>Muscle paralysis<a class="footnote-ref" id="fnref:36" href="#fn:36"><sup>36</sup></a></li></ul></li> <li>Failure of kidneys to remove excess fluid may cause: <ul><li>Swelling of the hands, legs, ankles, feet, or face</li> <li>Shortness of breath due to extra fluid on the lungs (may also be caused by anemia)</li></ul></li> <li><a href="/facts/Polycystic_kidney_disease/PteG8tuR">Polycystic kidney disease</a>, which causes large, fluid-filled cysts on the kidneys and sometimes the liver, can cause: <ul><li>Pain in the back or side</li></ul></li> <li>Healthy kidneys produce the hormone <a href="/facts/Erythropoietin/jgYFo1R6">erythropoietin</a> that stimulates the <a href="/facts/Bone_marrow/4dfudk0H">bone marrow</a> to <a href="/facts/Haematopoiesis/VRDwMymd">make oxygen-carrying red blood cells</a>. As the kidneys fail, they produce less erythropoietin, resulting in decreased production of red blood cells to replace the natural breakdown of old red blood cells. As a result, the blood carries less <a href="/facts/Hemoglobin/RsD1MzYA">hemoglobin</a>, a condition known as <a href="/facts/Anemia/AgEPPmg8">anemia</a>. This can result in: <ul><li>Feeling tired or weak</li> <li>Memory problems</li> <li>Difficulty concentrating</li> <li><a href="/facts/Dizziness/eI8UvmS5">Dizziness</a></li> <li>Low blood pressure</li></ul></li> <li>Normally proteins are too large to pass through the kidneys. However they are able to pass through when the glomeruli are damaged. This does not cause symptoms until extensive kidney damage has occurred,<a class="footnote-ref" id="fnref:37" href="#fn:37"><sup>37</sup></a> after which symptoms include: <ul><li>Foamy or bubbly urine</li> <li>Swelling in the hands, feet, abdomen, and face</li></ul></li> <li>Other symptoms include: <ul><li>Appetite loss, which may include a bad taste in the mouth</li> <li><a href="/facts/Insomnia/C1TnQTb2">Difficulty sleeping</a></li> <li>Darkening of the skin</li> <li>Excess protein in the blood</li> <li>With high doses of <a href="/facts/Penicillin/Abo8VQ3p">penicillin</a>, people with kidney failure may experience <a href="/facts/Seizures/zuIrQyze">seizures</a><a class="footnote-ref" id="fnref:38" href="#fn:38"><sup>38</sup></a></li></ul></li></ul> <h2 id="causes">Causes</h2> <h3>Acute kidney injury</h3> <p class="note">Main article: <a href="/facts/Acute_kidney_injury/dYg8l5P8">Acute kidney injury</a></p> <p>Acute kidney injury (previously known as acute renal failure) – or AKI – usually occurs when the blood supply to the kidneys is suddenly interrupted or when the kidneys become overloaded with toxins. Causes of acute kidney injury include accidents, injuries, or complications from surgeries in which the kidneys are deprived of normal blood flow for extended periods of time. Heart-bypass surgery is an example of one such procedure. </p><p>Drug overdoses, accidental or from chemical overloads of drugs such as antibiotics or chemotherapy, along with bee stings<a class="footnote-ref" id="fnref:39" href="#fn:39"><sup>39</sup></a> may also cause the onset of acute kidney injury. Unlike chronic kidney disease, however, the kidneys can often recover from acute kidney injury, allowing the person with AKI to resume a normal life. People with acute kidney injury require supportive treatment until their kidneys recover function, and they often remain at increased risk of developing future kidney failure.<a class="footnote-ref" id="fnref:40" href="#fn:40"><sup>40</sup></a> </p><p>Among the accidental causes of renal failure is the <a href="/facts/Crush_syndrome/a4F4GM9N">crush syndrome</a>, when large amounts of <a href="/facts/Toxin/11oUNk7n">toxins</a> are suddenly released in the <a href="/facts/Blood_circulation/WXwudzzc">blood circulation</a> after a long compressed <a href="/facts/Limb_(anatomy)/AqasUdSC">limb</a> is suddenly relieved from the pressure obstructing the blood flow through its tissues, causing <a href="/facts/Kidney_Ischemia/zKJNlx2n">ischemia</a>. The resulting overload can lead to the clogging and the destruction of the kidneys. It is a <a href="/facts/Reperfusion_injury/3MWNux98">reperfusion injury</a> that appears after the release of the crushing pressure. The mechanism is believed to be the release into the bloodstream of muscle breakdown products – notably <a href="/facts/Myoglobin/n6h2yBCJ">myoglobin</a>, <a href="/facts/Potassium/FWPwS7Rj">potassium</a>, and <a href="/facts/Phosphorus/27xCeIqs">phosphorus</a> – that are the products of <a href="/facts/Rhabdomyolysis/Cs08YHfR">rhabdomyolysis</a> (the breakdown of skeletal muscle damaged by <a href="/facts/Ischemia/ySL9xbCl">ischemic</a> conditions). The specific action on the <a href="/facts/Kidney/HBspPrv9">kidneys</a> is not fully understood, but may be due in part to <a href="/facts/Nephrotoxicity/QaWn5pwB">nephrotoxic</a> <a href="/facts/Metabolite/nAyywVtA">metabolites</a> of myoglobin. </p> <h3>Chronic kidney failure</h3> <p class="note">Main article: <a href="/facts/Chronic_kidney_disease/4YKH9wpo">Chronic kidney disease</a></p> <p>Chronic kidney failure has numerous causes. The most common causes of chronic failure are <a href="/facts/Diabetes_mellitus/2xeHXbsI">diabetes mellitus</a> and long-term, uncontrolled <a href="/facts/Hypertension/wlAvBfcf">hypertension</a>.<a class="footnote-ref" id="fnref:41" href="#fn:41"><sup>41</sup></a> <a href="/facts/Polycystic_kidney_disease/PteG8tuR">Polycystic kidney disease</a> is another well-known cause of chronic failure. The majority of people affected with polycystic kidney disease have a family history of the disease. Systemic lupus erythematosus (SLE) is also a known cause of chronic kidney failure. Other genetic illnesses cause kidney failure, as well. </p><p>Overuse of common drugs such as <a href="/facts/Ibuprofen/vsKBTfVl">ibuprofen</a>, and <a href="/facts/Acetaminophen/SNDfQWcf">acetaminophen</a> (paracetamol) can also cause chronic kidney failure.<a class="footnote-ref" id="fnref:42" href="#fn:42"><sup>42</sup></a> </p><p>Some infectious disease agents, such as <a href="/facts/Hantavirus/a6VWRvDR">hantavirus</a>, can attack the kidneys, causing kidney failure.<a class="footnote-ref" id="fnref:43" href="#fn:43"><sup>43</sup></a> </p> <h3>Genetic predisposition</h3> <p>The <i><a href="/facts/APOL1/zEK3Abo2">APOL1</a></i> gene has been proposed as a major genetic risk locus for a spectrum of nondiabetic renal failure in individuals of African origin, these include <a href="/facts/HIV-associated_nephropathy/jT6lXuUg">HIV-associated nephropathy</a> (HIVAN), primary nonmonogenic forms of <a href="/facts/Focal_segmental_glomerulosclerosis/3lxBFXPk">focal segmental glomerulosclerosis</a>, and hypertension affiliated <a href="/facts/Chronic_kidney_disease/4YKH9wpo">chronic kidney disease</a> not attributed to other etiologies.<a class="footnote-ref" id="fnref:44" href="#fn:44"><sup>44</sup></a> Two western African variants in APOL1 have been shown to be associated with end stage kidney disease in African Americans and Hispanic Americans.<a class="footnote-ref" id="fnref:45" href="#fn:45"><sup>45</sup></a><a class="footnote-ref" id="fnref:46" href="#fn:46"><sup>46</sup></a> </p> <h2 id="diagnostic-approach">Diagnostic approach</h2> <h3>Measurement for CKD</h3> Stages of kidney failure <p>Chronic kidney failure is measured in five stages, which are calculated using the person's GFR, or <a href="/facts/Glomerular_filtration_rate/kJKJge0o">glomerular filtration rate</a>. Stage 1 CKD is mildly diminished renal function, with few overt symptoms. Stages 2 and 3 need increasing levels of supportive care from their medical providers to slow and treat their renal dysfunction. People with stage 4 and 5 kidney failure usually require preparation towards active treatment in order to survive. <a href="/facts/Chronic_kidney_disease/4YKH9wpo">Stage 5 CKD</a> is considered a severe illness and requires some form of renal replacement therapy (<a href="/facts/Kidney_dialysis/KQgUGz8p">dialysis</a>) or <a href="/facts/Kidney_transplantation/WMeCmTBL">kidney transplant</a> whenever feasible. </p> Glomerular filtration rate <p>A normal GFR varies according to many factors, including sex, age, body size and ethnic background. Renal professionals consider the glomerular filtration rate (GFR) to be the best overall index of kidney function.<a class="footnote-ref" id="fnref:47" href="#fn:47"><sup>47</sup></a> <a href="/facts/The_National_Kidney_Foundation/7R8gsDqj">The National Kidney Foundation</a> offers an easy to use on-line GFR calculator<a class="footnote-ref" id="fnref:48" href="#fn:48"><sup>48</sup></a> for anyone who is interested in knowing their glomerular filtration rate. (A serum <a href="/facts/Creatinine/gkebqj2L">creatinine</a> level, a simple blood test, is needed to use the calculator.) </p> <h3>Use of the term <i>uremia</i></h3> <p>Before the advancement of modern medicine, renal failure was often referred to as uremic poisoning. Uremia was the term for the contamination of the blood with urea. It is the presence of an excessive amount of urea in blood. Starting around 1847, this included reduced urine output, which was thought to be caused by the urine mixing with the blood instead of being voided through the urethra. The term <i><a href="/facts/Uremia/3apTNTm6">uremia</a></i> is now used for the illness accompanying kidney failure.<a class="footnote-ref" id="fnref:49" href="#fn:49"><sup>49</sup></a> </p> <h3>Renal failure index</h3> <p>Two other urinary indices, are the <a href="/facts/Fractional_sodium_excretion/4LDvK0xN">fractional sodium excretion</a> (FENa) index and the renal failure index (RFI).<a class="footnote-ref" id="fnref:50" href="#fn:50"><sup>50</sup></a> The renal failure index is equal to urine sodium times plasma creatinine divided by urine <a href="/facts/Creatinine/gkebqj2L">creatinine</a>.<a class="footnote-ref" id="fnref:51" href="#fn:51"><sup>51</sup></a> A FENa score greater than 3% or a renal failure index (RFI) greater than 3 are helpful in confirming acute renal failure.<a class="footnote-ref" id="fnref:52" href="#fn:52"><sup>52</sup></a> </p> <h2 id="complications">Complications</h2> <p>Those with end stage renal failure who undergo haemodialysis have higher risk of spontaneous intra-abdominal bleeding than the general population (21.2%) and <a href="/facts/Intestinal_ischemia/DvReleG4">non-occlusive mesenteric ischemia</a> (18.1%). Meanwhile, those undergoing <a href="/facts/Peritoneal_dialysis/tRvsE8nz">peritoneal dialysis</a> have a higher chance of developing <a href="/facts/Peritonitis/pWjYb4MB">peritonitis</a> and <a href="/facts/Gastrointestinal_perforation/TjuCNtyk">gastrointestinal perforation</a>. However, the rate of <a href="/facts/Acute_pancreatitis/d15Wh2q2">acute pancreatitis</a> does not differ from the general population.<a class="footnote-ref" id="fnref:53" href="#fn:53"><sup>53</sup></a> </p> <h2 id="treatment">Treatment</h2> <p>The treatment of acute kidney injury depends on the cause.<a class="footnote-ref" id="fnref:54" href="#fn:54"><sup>54</sup></a> The treatment of chronic kidney failure may include renal replacement therapy: <a href="/facts/Hemodialysis/oB7fIKP7">hemodialysis</a>, <a href="/facts/Peritoneal_dialysis/tRvsE8nz">peritoneal dialysis</a>, or <a href="/facts/Kidney_transplant/WMeCmTBL">kidney transplant</a>.<a class="footnote-ref" id="fnref:55" href="#fn:55"><sup>55</sup></a> </p> <h3>Diet</h3> <p>In non-diabetics and people with <a href="/facts/Type_1_diabetes/IkuQadGx">type 1 diabetes</a>, a low protein diet is found to have a preventive effect on progression of chronic kidney disease. However, this effect does not apply to people with <a href="/facts/Type_2_diabetes/zCMXksmt">type 2 diabetes</a>.<a class="footnote-ref" id="fnref:56" href="#fn:56"><sup>56</sup></a> A whole food, <a href="/facts/Plant-based_diet/6ndyLvjX">plant-based diet</a> may help some people with kidney disease.<a class="footnote-ref" id="fnref:57" href="#fn:57"><sup>57</sup></a> A high protein diet from either animal or plant sources appears to have negative effects on kidney function at least in the short term.<a class="footnote-ref" id="fnref:58" href="#fn:58"><sup>58</sup></a> </p> <h3>Slowing progression</h3> <p>People who receive earlier referrals to a nephrology specialist, meaning a longer time before they must start dialysis, have a shorter initial hospitalization and reduced risk of death after the start of dialysis.<a class="footnote-ref" id="fnref:59" href="#fn:59"><sup>59</sup></a> Other methods of reducing disease progression include minimizing exposure to <a href="/facts/Nephrotoxicity/QaWn5pwB">nephrotoxins</a> such as <a href="/facts/Nonsteroidal_anti-inflammatory_drug/coIkzl4s">NSAIDs</a> and <a href="/facts/Radiocontrast_agent/JefNS98C">intravenous contrast</a>.<a class="footnote-ref" id="fnref:60" href="#fn:60"><sup>60</sup></a> </p> <h2 id="external-links">External links</h2> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>"Kidney Failure". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 11 November 2017. <a href="https://www.niddk.nih.gov/health-information/Kidney-disease/kidney-failure" target="_blank">https://www.niddk.nih.gov/health-information/Kidney-disease/kidney-failure</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>"What is renal failure?". Johns Hopkins Medicine. Archived from the original on 18 June 2017. Retrieved 18 December 2017. <a href="https://web.archive.org/web/20170618054600/http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/end_stage_renal_disease_esrd_85,P01474/" target="_blank">https://web.archive.org/web/20170618054600/http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/end_stage_renal_disease_esrd_85,P01474/</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>"Kidney Failure". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 11 November 2017. <a href="https://www.niddk.nih.gov/health-information/Kidney-disease/kidney-failure" target="_blank">https://www.niddk.nih.gov/health-information/Kidney-disease/kidney-failure</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Blakeley S (2010). Renal Failure and Replacement Therapies. Springer Science & Business Media. p. 19. ISBN 9781846289378. <a href="9781846289378" target="_blank">9781846289378</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Liao MT, Sung CC, Hung KC, Wu CC, Lo L, Lu KC (2012). "Insulin resistance in patients with chronic kidney disease". Journal of Biomedicine & Biotechnology. 2012: 691369. doi:10.1155/2012/691369. PMC 3420350. PMID 22919275. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3420350" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3420350</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>"Kidney Failure". MedlinePlus. Retrieved 11 November 2017. <a href="https://medlineplus.gov/kidneyfailure.html" target="_blank">https://medlineplus.gov/kidneyfailure.html</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>"What is renal failure?". Johns Hopkins Medicine. Archived from the original on 18 June 2017. Retrieved 18 December 2017. <a href="https://web.archive.org/web/20170618054600/http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/end_stage_renal_disease_esrd_85,P01474/" target="_blank">https://web.archive.org/web/20170618054600/http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/end_stage_renal_disease_esrd_85,P01474/</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>"What is renal failure?". Johns Hopkins Medicine. Archived from the original on 18 June 2017. Retrieved 18 December 2017. <a href="https://web.archive.org/web/20170618054600/http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/end_stage_renal_disease_esrd_85,P01474/" target="_blank">https://web.archive.org/web/20170618054600/http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/end_stage_renal_disease_esrd_85,P01474/</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>Blakeley S (2010). Renal Failure and Replacement Therapies. Springer Science & Business Media. p. 19. ISBN 9781846289378. <a href="9781846289378" target="_blank">9781846289378</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>Cheung AK (2005). Primer on Kidney Diseases. Elsevier Health Sciences. p. 457. ISBN 1416023127. <a href="1416023127" target="_blank">1416023127</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>Cheung AK (2005). 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