Slowing the Progression of Chronic Kidney Disease

The increasing incidence and prevalence of chronic kidney disease (CKD) make treatment and management to slow the progression of this condition of essential interest to nurse practitioners (NPs) in primary care settings. Early identification and monitoring of patients at risk for CKD can be facilitated by annual testing for albuminuria and serial monitoring of estimated glomerular filtration rate and serum creatinine. Diagnostic evaluation used to determine underlying cause, type, and severity of CKD can help to reduce associated cardiovascular complications by preserving cardiac function. Aggressive primary care treatment and management during the early stages of CKD can reduce associated morbidity and mortality and reduce costs associated with end-stage renal disease.     

Obesity and coronary artery disease risk in Native Americans

With the aging of the US population and the increase in hypertension, diabetes mellitus, and obesity, the prevalence of chronic kidney disease (CKD) is increasing in the United States. Its prevalence rate has risen to 13.1% of the US population. Patients with CKD experience poor outcomes and have high health care costs. Chronic kidney disease is also a major cardiovascular disease risk factor. In fact, most people with CKD die of heart disease before they progress to end-stage renal disease. The National Kidney Foundation has produced evidencebased guidelines known as the Kidney Disease Outcomes Quality Initiative (KDOQI). These guidelines outline many things that the primary care physician can do to delay the progression of CKD, and to arrange for early referral for the prevention of future complications. However, there is limited knowledge and uptake of these guidelines because of their length and and complexity. Patients with CKD risk factors, hypertension, diabetes mellitus, cardiovascular disease, a family history of CKD, and those older than 60 years should be screened using 2 tests: 1) the estimated glomerular filtration rate and 2) the urinary albumin-creatinine ratio. These tests allow the diagnosis and stratification of CKD into 5 stages. This article synthesizes the key evidence-based behaviors and clinical action plan that primary care physicians can implement to treat CKD and its complications.     

Understanding health decisions using critical realism: home-dialysis decision-making during chronic kidney disease

Understanding health decisions using critical realism: home-dialysis decision-making during chronic kidney disease This paper examines home-dialysis decision making in people with Chronic Kidney Disease (CKD) from the perspective of critical realism. CKD programmes focus on patient education for self-management to delay the progression of kidney disease and the preparation and support for renal replacement therapy e.g.) dialysis and transplantation. Home-dialysis has clear health, societal and economic benefits yet service usage is low despite efforts to realign resources and educate individuals. Current research on the determinants of modality selection is superficial and insufficient to capture the complexities embedded in the process of dialysis modality selection. Predictors of home-dialysis selection and the effect of chronic kidney disease educational programmes provide a limited explanation of this experience. A re-conceptualization of the problem is required in order to fully understand this process. The epistemology and ontology of critical realism guides our knowledge and methodology particularly suited for examination of these complexities. This approach examines the deeper mechanisms and wider determinants associated with modality decision making, specifically who chooses home dialysis and under what circumstances. Until more is known regarding dialysis modality decision making service usage of home dialysis will remain low as interventions will be based on inadequate epistemology.     

New concept of chronic kidney disease and blockade of renin-angiotensin system

Chronic kidney disease (CKD) is increasingly recognized not only as a cause of end-stage renal disease but also as a cause of cardiovascular disease. Importantly, it is intimately associated with non-healthy lifestyles such as obesity, metabolic syndrome, hypertension, diabetes mellitus, smoking, and heavy drinking. To define CKD direct measurement of GFR or estimation of GFR (eGFR) is required. Japan Society of Nephrology is asking nationwide project to create "original" equation without using ethnic factor to obtain eGFR. Early detection and early treatment are vital to prevent not only CKD progression but also cardiovascular events. A comprehensive health education campaign and screening of the general populace are needed in order to detect CKD early. The control of hypertension, dyslipidemia, proteinuria, obesity, are intervention strategies that retard or prevent progression of CKD. Blockade of the renin-angiotensin system can be beneficial, especially if proteinuria is present.     

Uremic syndrome and end-stage renal disease: physical manifestations and beyond

PURPOSE: This review summarizes data concerning the incidence, definition, pathophysiology, and physical manifestations of patients with uremic syndrome. DATA SOURCES: Data sources utilized in writing this article included the National Kidney Foundation Guidelines, the United States Renal Data System, textbooks of medicine and pathophysiology, and medical care and nursing journals. CONCLUSIONS: Early identification of kidney disease in the early stages is essential to preserving kidney function for as long as possible. The progression of chronic kidney disease (CKD) and the manifestations of uremic syndrome leading to end-stage renal failure (ESRF) are often not addressed in the literature for nurse practitioners. IMPLICATIONS FOR PRACTICE: Patients with progressing CKD and ESRF often present in the primary care setting for treatment of acute and chronic conditions not pertaining to their renal status (e.g., viral upper respiratory infections, diabetes, hypertension). Nurse practitioners need to be knowledgeable about the subtle early presentation of uremic syndrome and ESRF, risk factors for kidney disease, assessment tools to make the diagnosis and stage the disease, treatment of this disease, as well as psychological, economic, and the social impact that ESRF imposes on individuals, families, communities, and the healthcare system as a whole when the chronic disease has progressed to end stage.     

Abnormalities in renal hemodynamics

Chronic kidney disease (CKD) is a major risk factor for the development of cardiovascular disease (CVD). Abnormalities of renal hemodynamics are associated with CKD. Abnormalities in renal hemodynamics include blood flow into glomeruli, and tubulointerstitial tissue. Renin-angiotensin system, oxidative stress and NOS system affect abnormalities of renal hemodynamics in CKD. Further, intrarenal hemodynamic abnormalities are strongly associated with systemic arteriosclerosis. Appropriate regulation of renal hemodynamics and controls of hypertension and diabetes mellitus retard the progression of both CKD and CVD.     

Systemic complications of chronic kidney disease. Pinpointing clinical manifestations and best management

The kidney plays a critical role in the maintenance of homeostasis. As kidney function diminishes, excretory, regulatory, and endocrine function is lost, and complications develop in essentially every organ system. Kidney failure is the last stage in the continuum of progressive CKD. Management of the complications associated with CKD mainly includes dietary counseling, adequate control of volume and blood pressure, and use of phosphate binders, calcitriol (Calcijex, Rocaltrol), and erythropoietin. Many of these complications can be prevented or attenuated with optimal CKD care, which involves early detection of progressive kidney disease, interventions to retard its progression, prevention of uremic complications, attenuation of comorbid conditions, adequate preparation for kidney replacement therapy, and timely initiation of dialysis (figure 2). Closer attention to CKD care is likely to be the key to improved outcomes among patients with kidney failure.     

Epidemiology and risk factors for chronic kidney disease

Kidney disease is highly prevalent in the United States population and groups at high risk for increased prevalence of CKD include individuals with a family history of ESRD, diabetes, hypertension, and cardiovascular disease. Despite the increased risk of ESRD observed for blacks compared with whites, racial disparities in the prevalence of kidney disease have not been consistently demonstrated in the United States population. Although the reasons for discrepancy in risk of ESRD and CKD have not been established, clinicians should be aware that more rapid progression of CKD among blacks is a possible explanation for this observation and that closer monitoring and intensive care of risk factors associated with progressive renal injury is warranted for blacks with CKD and in other high-risk groups. Therapeutic interventions that delay or prevent progressive kidney disease are well established and incorporated into widely disseminated clinical practice guidelines. These interventions include aggressive blood pressure control with agents that block the renin-angiotensin system, reduction of dietary protein to recommended levels for the American diet, weight loss, smoking cessation, and control of hyperlipidemia. These interventions also reduce the risk of cardiovascular disease and should be regarded as essential components of care of CKD. Achieving high levels of medically appropriate care of CKD patients and reduction in risk of progression to ESRD may be delayed by barriers created by individual and regional poverty.     

Causes and characteristics of CKD

Chronic kidney disease (CKD) is common in Japan and worldwide. The estimated prevalence of CKD in Japanese adults was 10.6% in 2005, based on the survey conducted by the Japanese Society of Nephrology. The most common risk factors for CKD include diabetes, hypertension and cardiovascular disease. Major outcomes of CKD include progression to kidney failure and increased risk for cardiovascular disease. CKD is usually silent until its late stages, thus many patients with CKD are detected only shortly before the onset of symptomatic kidney failure, when there are few opportunities to prevent adverse outcomes. Earlier detection allows for more time for evaluation and treatment but requires explicit testing strategies for asymptomatic individuals at increased risk. Understanding the strengths and limitations of CKD testing and risk factors of CKD is critical for appropriate management of CKD patients. The goal of this paper is to discuss CKD testing and early detection in clinical practice and its application to public health initiatives, with attention to limitations and appropriate interpretation.     

The benefits of IV iron therapy in treating anemia in patients with renal disease and comorbid cardiovascular disease.

It is important for nephrology nurses to understand the relationship that exists between renal disease, cardiac disease, and anemia. Even mild cases of chronic kidney disease (CKD) have been associated with an increase in adverse cardiovascular outcomes. And anemia, which can result from both CKD and congestive heart failure, has been shown to exacerbate the adverse consequences of these conditions. An early, aggressive correction of anemia in patients with CKD can be implemented to break this cycle and stop disease progression. Studies have shown that anemia correction improves both cardiac and renal function and can result in increased hemoglobin levels, decreased number of hospital days, and improved quality of life. An effective strategy for managing anemia in patients with renal disease and comorbid cardiovascular disease includes the administration of both recombinant human erythropoietin and intravenous iron. In addition, the nephrology nurse plays an integral role in managing anemia and improving outcomes in these patients. Therefore, the nephrology nurse should have an increased awareness of the link between anemia and renal/cardiac disease as well as available treatment options.     

Cardiovascular Screening and Early Detection of Heart Disease in Adults With Chronic Kidney Disease

Cardiovascular disease (CVD) and chronic kidney disease (CKD) are among the most common disease states that nurse practitioners encounter in various health care settings. In many cases, patients with CVD and CKD have overlapping risk factors and underlying medical conditions. CVD is one of the most common causes of death in patients with CKD, and therefore, appropriate recognition and screening are important for preventing disease progression and complications. Nurse practitioners can become familiar with various risk factors, screen patients, and provide nonpharmacologic and pharmacologic measures for CVD in CKD patients.     

Measuring quality of life in chronic kidney disease patients: reflections and prospects

Quality of life is a complex and multidimensional concept. Understanding a patient'squality of life can assist healthcare providers to assess risk factors associated with hospitalization and mortality, and, potentially, delay disease progression. As chronic kidney disease (CKD) symptoms vary during different stages of the disease, instruments must be properly adjusted to measure quality of life accurately. This article explores comprehensively the development and appropriateness of relevant instruments, and recommends specific instruments for use at specific CKD stages.     

Improving Prognostic and Chronicity Evaluation of Chronic Kidney Disease with Contrast‐Enhanced Ultrasound Index-Derived Peak Intensity

The capability of contrast‐enhanced ultrasound (CEUS) to assess the prognosis and chronicity of chronic kidney disease (CKD) was evaluated in patients diagnosed with CKD in 2014 at Ren Ji Hospital, Shanghai, China. Time–intensity curves and quantitative indexes were created using QLab quantification software. Kidney biopsies were analyzed with α-smooth muscle actin immunohistochemistry. According to the renal chronicity score, patients were divided into four groups: minimal (n = 14), mild (n = 73), moderate (n = 49) and severe (n = 31). Multivariate logistic regression analysis revealed that the derived peak intensity (DPI) was independently associated with the renal chronicity score. Of 167 CKD patients (median follow-up: 30.4 ± 18.7 mo), 31 (18.6%) exhibited CKD progression, with a decline in the glomerular filtration rate of more than 25% or end-stage renal disease. Multivariate Cox regression analysis revealed that a lower DPI was independently associated with CKD progression. This study indicates that DPI is a reliable CEUS parameter for evaluating chronic renal changes and an independent prognostic factor of CKD.     

Is “chronic kidney disease” a disease?

Several philosophers of medicine have attempted to answer the question “what is disease?” In current clinical practice, an umbrella term “chronic kidney disease” (CKD) encompasses a wide range of kidney health states from commonly prevalent subclinical, asymptomatic disease to rare end‐stage renal disease requiring transplant or dialysis to support life. Differences in severity are currently expressed using a “stage” system, whereby stage 1 is the least severe, and stage 5 the most. Early stage CKD in older patients is normal, of little concern, and does not require treatment. However, studies have shown that many patients find being informed of their CKD distressing, even in its early stages. Using existing analyses of disease in the philosophy literature, we argue that the most prevalent diagnoses of CKD are not, in fact, diseases. We conclude that, in many diagnosed cases of CKD, diagnosing a patient with a “disease” is not only redundant, but unhelpful.     

Chronic kidney disease and cardiovascular disease--using the ANNA Standards and Practice Guidelines to improve care. Part 1: the epidemiology of chronic kidney disease: the risk factors and complications that contribute to cardiovascular disease.

Recent National Kidney Foundation Kidney Disease Outcome Quality Initiative Guidelines for cardiovascular disease recommend that patients with chronic kidney disease be considered at highest risk for development of cardiovascular disease and that cardiac risk factor reduction begin with diagnosis of chronic kidney disease. Risk factors for cardiovascular disease in patients with chronic kidney disease include both traditional and nontraditional renal-related cardiac risk factors. The ANNA Nephrology Nursing Standards of Practice and Guidelines for Care can provide the foundation for planning care to patients with CKD and not only slow the progression of CKD but reduce exposure to cardiac risk factors. This article, on the epidemiology of chronic kidney disease and the risk factors and complications that contribute to cardiovascular disease, is the first in a series of three articles on the risk factors and complications related to chronic kidney disease and its impact on cardiovascular disease.     

Background of measures against chronic kidney disease

The number of chronic kidney disease (CKD) in Japan is estimated to be 6-13 million. The actions against CKD are urgently requested, because 1) CKD is a strong risk factor for the development of chronic renal failure and cardio-vascular diseases, 2) the numbers of end stage renal failure and cardiovascular events are increasing, and 3) CKD is a treatable disease. To prevent the increase in patients on dialysis and cardio-vascular events, the establishment of the system to detect and treat CKD patients is essential. In addition, the advice regarding healthy lifestyle is also valuable to prevent the development and progression of CKD. Since CKD is harmful but treatable, nephrologists and family doctors should collaborate in the action against CKD.     

Economic burden of chronic kidney disease

Objectives To define the cost of care and evaluate interventions associated with improving outcomes and delaying the progression of chronic kidney disease (CKD). Methods Using the PubMed database, a systematic review of the literature was conducted describing (i) the cost of care associated with treating earlier stages of CKD, and (ii) the role of early referral, erythropoiesis‐stimulating proteins and anti‐hypertensive agents in improving clinical outcomes and reducing the cost of CKD. Results The higher costs associated with treatment of the CKD population are largely due to higher rates and duration of comorbidity‐driven hospitalizations. Studies suggest that early referral to a nephrologist, use of erythropoiesis‐stimulating proteins and anti‐hypertensive agents may be associated with better outcomes and lower costs. In some instances, however, higher target haemoglobin levels could have harmful effects in CKD patients. Conclusion The substantial costs incurred during earlier stages of CKD increase markedly during the transition to renal replacement and remain elevated thereafter. An increase in awareness among health care providers may result in more timely interventions. More proactive management, in turn, can lead to improved clinical and economic outcomes through the slowing of disease progression and prevention of comorbidities.     

The self-management experience of people with mild to moderate chronic kidney disease.

This qualitative, exploratory study examined the self-management experiences of people with mild to moderate chronic kidney disease (CKD, Stages 1-3) to elicit participants' perceptions of health, kidney disease, and supports needed for self-management. Findings revealed a process of renegotiating life with chronic kidney disease, which encompassed Discovering Kidney Disease and Learning To Live With Kidney Disease. A number of themes were identified including searching for evidence, realizing kidney disease is forever, managing the illness, taking care of the self and the need for disease-specific information. The findings indicate participants with early CKD want to self-manage their illness in collaboration with health care providers. As well, people with early CKD need guidance and support from health professionals to successfully self-manage. Nephrology nurses are uniquely positioned to provide this support while collaborating with other care providers to facilitate self-management.     

The role of renin-angiotensin-aldosterone system inhibition in chronic kidney disease

Chronic kidney disease (CKD) is emerging as a new health pandemic. Underlying the global rise in CKD is an increase in diabetes, hypertension and other cardiovascular risk factors leading to progressive renal dysfunction. Emerging evidence strongly suggests that achieving target blood pressure goals via inhibition of the renin-angiotensin-aldosterone system confers significant renal and cardioprotection for patients with CKD. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) lower blood pressure, reduce proteinuria and reduce both the progression of CKD and adverse cardiovascular events. The role of aldosterone inhibition and combination therapy, such as ACEI/ARB, in CKD are under investigation. As our understanding of the basic mechanisms underlying CKD progression advances, novel therapies targeting post-translational endothelial and mesangial messengers downstream from angiotensin II and aldosterone may become available for clinical use.     

Roadmap to HIPAA: keeping occupational health nurses on track.

So what does HIPAA require most covered entities to do? At this point, the Privacy Rule compliance date has already passed for all covered entities except small health plans. Most of the requirements under the Privacy Rule dictate the development of appropriate policies and procedures, a notice of privacy practices and other forms, implementation of measures to secure the privacy of PHI, contracting with Business Associates, and training of all involved. For covered entities, testing of the electronic standard transactions to exchange data between participating parties should have begun by April 16, 2003. Although full implementation of the electronic transactions should have taken place by October 16, 2003, the government has allowed covered entities that are still actively working toward compliance to operate under contingency plans. It remains unclear when the use of such plans will be disallowed. After standards are published for claim attachments and first report of injury, these electronic standard transactions will be incorporated by the designated compliance date. Appropriate use of national identifiers will be implemented after final rules and standards are published. For the occupational health nurse who is not a covered entity, the most critical implementation factor is a HIPAA compliant authorization form so the occupational health nurse can continue to obtain necessary PHI. This is essential when attempting to obtain medical information, even for workers' compensation or disability case management. Although these plans are not considered health plans under HIPAA and, therefore, would not require the designation of covered entity, the occupational health nurse frequently needs to obtain PHI to manage these cases. Most providers in the health care community will be covered entities under HIPAA and will not be able to release PHI without a signed HIPAA compliant authorization form. In addition, providers will want a HIPAA compliant authorization form signed when requesting health information from the occupational health nurse. The HIPAA's privacy regulations are considered "the floor" or minimum standard for the protection of PHI. As such, it is likely that these privacy regulations will become the "industry standard" to which all health care professionals will be held. Even though the occupational health nurse may not be a covered entity, implementing appropriate HIPAA procedures is recommended. Knowing that most of HIPAA's privacy rule contains requirements already in place and in practice for most occupational health nurses can take some of the worry out of this complex regulation. Additionally, the nurse interacts with the health care system in a variety of roles. As a health care consumer, occupational health nurses can assert their own patient rights when interacting with covered entities. As the trusted advisor and consultant to many employees, the occupational health nurse can play a vital role in educating employees about HIPAA and assisting employees with navigating an ever-complex health care system. As a health care professional, the occupational health nurse continues to protect and safeguard all PHI while respecting employees' rights and delivering quality care. Staying knowledgeable and up-to-date on the HIPAA regulations as they continue to evolve and change allows occupational health nurses to stay on the right course while mapping their way toward regulatory compliance (see Sidebar for recommended resources).