Book Review

Acute Renal Failure: New Concepts and Therapeutic Strategies

Renal Failure: Diagnosis and treatment

N Engl J Med 1996; 334:1341-1343May 16, 1996

Article

Acute Renal Failure: New Concepts and Therapeutic Strategies
(Contemporary Issues in Nephrology. Vol. 30.) Edited by Michael S. Goligorsky. 499 pp. New York, Churchill Livingstone, 1995. $89. ISBN: 0-443-07580-8

Renal Failure: Diagnosis and treatment
(Developments in Nephrology. Vol. 37.) Edited by J. Gary Abuelo. 276 pp. Boston, Kluwer Academic, 1995. $150. ISBN: 0-7923-3438-8

One of my most treasured possessions is an old textbook on the examination of the urine by James Tyson, one of the early chairmen of medicine at the University of Pennsylvania (A Guide to the Practical Examination of Urine: For the Use of Physicians and Students. First printed, Philadelphia: Lindsay and Blakiston, 1875). Whenever I wonder about the point of having medical textbooks in the age of the Internet, the CD-ROM, and the instantaneous dissemination of new information, I recall my delight in handling that book. There are more than data here, there are personal insights and the benefit of years of clinical experience. Although all this could be delivered on line, it would be hard to recreate the experience of feeling and turning the worn pages. Of course, Tyson's book is of only historical interest now, and this is the obvious problem with any textbook: it is out of date before it can be printed.

My uncertainty about the value of even a modern textbook is highlighted by the two books under review here. On the one hand, books cannot possibly compete for timeliness with the electronic media, but on the other hand, much of the readily available on-line data lack context and analysis. Of course, the published text requires intensive editorial precision. One solution to the question of timeliness is the textbook series, in which several authors concurrently review various topics in depth. Hardcover editions appear at regular intervals, from several times a year to annually, and the time from the start of the project to the final publication is relatively short, 12 to 18 months. To be useful, the textbook series should combine the best of both worlds: timeliness and coherence. Defining the goals and organizing the effort are crucial, and superb editorial support is indispensable.

Each of the books reviewed here is an example of this approach. One meets the standards impressively, and one is problematic. In Acute Renal Failure: New Concepts and Therapeutic Strategies, Goligorsky has assembled an excellent book on the pathogenesis, pathophysiology, and cellular and molecular biology of acute renal failure. I was recently asked to review new therapeutic strategies in acute renal failure at a national meeting, and I would have used this book to great benefit if it had been available. It is both laserlike in focus and comprehensive. It brings together important new concepts, such as the roles of apoptosis and adhesion molecules in initiating and maintaining acute renal failure. It adds context to the analysis of the roles of calcium, phospholipase A₂, and reactive oxygen species during the injury phase of acute renal failure and, in a particularly useful chapter, reviews the role of endothelin in the vascular abnormalities that initiate and maintain acute renal failure. It also covers some of the most recent strategies in the treatment of acute renal failure, including the role of arginine–glycine–aspartic acid peptides. The text is readable, and there is coherence to both the book's overall organization and the structure of individual chapters. The photographs of the classic single-nephron dissections performed by Jean Oliver in kidneys injured by ischemia or nephrotoxins that are used at the start of many chapters are a wonderful touch, charmingly recalling the single-authored textbooks by the early practitioners of nephrology and nephrologic research.

The Goligorsky book fills a niche admirably, with complete treatment of a very well circumscribed topic. The only evident problems are those inherent in published books. First, it is not completely up to date; most of the more recent references are at least one or two years old. This is an issue, given the cutting-edge topics considered. Second, the sharp focus on new information means that only a rather narrow audience will find the information useful. The book is written for those who seek to grasp emerging concepts and clinical approaches that are still years away from clinical practice and for researchers in the field wishing to keep abreast of developments that touch on their interests. For most practitioners, this book will have value only to maintain their medical literacy.

On the other hand, Renal Failure: Diagnosis and Treatment, edited by Abuelo as part of the Developments in Nephrology series, has a number of major weaknesses, some inherent in the multiauthored approach and some unique to this work. The goals of the book and its intended readership are not clearly defined. There is considerable unevenness: at times this is a very elementary textbook, at times a highly sophisticated analysis of the most complex renal syndromes. The introductory chapters are meant to be read in sequence, yet they are often confusing and idiosyncratic. It was unclear to me, even after reading several chapters and reviewing the preface, whether the book aims to clarify issues of acute renal failure or those of chronic renal disease. Both are addressed in an unfocused fashion.

Unexpectedly, in chapter 10, the emphasis shifts from the recognition of symptoms to a consideration of specific disease entities, and the book becomes a highly organized and effective analysis of current diagnostic and therapeutic approaches to a number of renal diseases. In the chapters on therapeutics, context is provided and the analysis is personal but compelling, making the book useful and timely.

The book concludes with a series of cases and brief analyses of particular patients. I found these to be of marginal value and somewhat odd, another example of the peculiar nature of the book. The rationale for the case presentations is never made clear, and thus they highlight the book's ambivalence about its role. Is it a textbook for the novice or a manual for the experienced practitioner? I do not believe that the inconsistency stems from the textbook-series approach; most of the chapters are written by Dr. Abuelo. Rather, what was needed was a skilled technical editor to organize the book, reduce repetition, and help define the scope. This editorial problem is exemplified by the use of a bewildering array of text styles, including small print, italics, and standard fonts. I could not discern the reason for these three type styles, which permeate the book, despite the statement in the preface that the small print “need not be read by everyone.” The book also contains an extraordinary number of citations — 10 pages of references in one chapter 15 pages long. Some chapters serve primarily as annotations of references rather than textual analyses. Readers may find such compendiums of citations useful.

The textbook-series approach can work well, as in the book edited by Goligorsky and the Contemporary Issues in Nephrology series in general, but unity of concept and organizational consistency are generally lacking in the Abuelo book. Some form of the textbook series probably represents the future of textbooks. The economic benefit of having a targeted audience that pays for regular updates is very attractive to publishers. The relative timeliness of the information is attractive to consumers. But success will require old-fashioned editorial talent, whether the material is presented on-line or in a book. I suppose that pioneers of the medical textbook, like Professor Tyson, would find that comforting.

Stanley Goldfarb, M.D.
Graduate Health System, Philadelphia, PA 19103