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CE: Continuing Education Article PATIENT MANAGEMENT IN CKD STAGES 1 TO 3 Fiona Murphy1, RGN, RNT, BSc (Hons) Renal Nurs, BSc (Hons) Health Stud, PGDip Adv Nurs Scie, PGDip CHScie Edu, MA, MSc, Karen Jenkins2, RGN, PGDip HE, MSc Nursing, Melissa Chamney3, RGN, Dip N, BN, MN (Nephrology), Margaret McCann1, RGN, RNT, BNS (Hons), MSc, FFNMRCSI, John Sedgewick4, RN, RMN, Dip Nurs., Renal Cert, CertEd/RNT, BSc (Hons), MSc (Nursing), MSc (Research) 1Trinity College Dublin, Ireland 2Department of Renal Medicine, East Kent Hospitals NHS Trust, Kent & Canterbury Hospital, Canterbury, UK 3City University, London, UK 4University of Teesside, Durham Tees Valley, UK
Murphy F., Jenkins K., Chamney M., McCann M., Sedgewick J. (2008). Patient management in CKD stages 1 to 3. Journal of Renal Care 34(3), 127-135.
SUMMARY This is the first article in a two-part Continuing Education (CE) series on the management of patients with Chronic Kidney Disease (CKD). CKD is now recognised as a global public health concern. It has been classified into five stages to assist healthcare professionals to care for patients presenting with this chronic illness. Numerous risk factors are associated with CKD including anaemia, hypertension and cardiovascular risk. Nephrology nurses play an important role in the monitoring and management of these factors along with educating patients and their families/carers to encourage self-management of their illness
K E Y W O R D S Chronic kidney disease • Co-morbidities • Patient education • Psychological • Risk factors
AIM
Learning outcomes:
The aim of this CE article is to provide a broad overview of CKD stages 1 to 3 so enabling nephrology nurses and associated healthcare professionals to manage patients presenting with this chronic illness.
After reading this CE article the reader should be able to:
B I O D ATA Fiona Murphy is the renal educational facilitator and a lecturer at Trinity College Dublin, Ireland. She is undertaking her PhD on sexuality in renal patients and is a member of the Education Research Board of the EDTNA/ERCA. Karen Jenkins is a Consultant Nurse at the Department of Renal Medicine, East Kent Hospitals NHS Trust, Kent & Canterbury Hospital, Canterbury, UK and honorary lecturer at Kent University. She is the chair of the EDTNA CKD interest group and a member of the British Renal Society CKD Forum. Melissa Chamney is the renal lecturer at City University, London, UK. She is also a member of the Education Research Board of the EDTNA/ERCA. Margaret McCann is a Lecturer at Trinity College Dublin, Ireland. John Sedgewick is principal Lecturer in nephrology at University of Teesside. CORRESPONDENCE
Fiona Murphy School of Nursing and Midwifery Trinity College 24 D’Olier Street Dublin 2, Ireland Tel.: +003531 8963108; Fax: +003531 8963001
[email protected]
• Identify the prevalence and the different classifications of CKD. • Discuss how kidney function can be measured. • Using evidence based practice, explore the risk factors for CKD and the role of nephrology nurses and other health care professionals in their prevention and management. • Outline patient education which will assist patients and their families/carers to self manage their chronic illness.
INTRODUCTION This article will, first, overview the epidemiology, the measurement of kidney function and staging of CKD; and secondly, focus on the clinical manifestations of CKD, highlighting areas for nursing input. CKD is a global public health concern associated with adverse outcomes of kidney failure including cardiovascular disease (CVD), which can lead to premature death (Levey et al. 2005). CKD should not be viewed in isolation due to its complex inter-relationship with hypertension, CVD and diabetes. It is, therefore, imperative to develop both screening and prevention programmes to detect and treat individuals with multiple co-morbidities as well as CKD (Atkins 2005). CKD is defined as either evidence of kidney damage or an eGFR < 60mL/min/1.73m2 for ⱖ3 months. It is manifested by either pathological abnormalities or markers of kidney damage
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including abnormalities in imaging tests or blood or urine composition (NKF K/DOQI 2002).
EPIDEMIOLOGY There is a need to have a better understanding of the epidemiological characteristics of CKD in the early stages before renal replacement therapy (RRT) is necessary so as to develop strategies that will identify and manage these patients. There is a tendency to extrapolate data from the RRT population, assuming that CKD is a precursor to end stage renal disease (ESRD) in the majority of patients. It is, therefore, highly likely that the number of patients with ESRD underestimates the total burden of CKD, as the numbers with the earlier stages of disease are likely to surpass by as much as 50 times those reaching stage 5 (Lameire et al. 2005). In the United States, data derived from the third National Health and Nutrition Examination Survey (NHANES 111) ascertains that up to 11% of the total adult US population (19.2 million) is affected by some degree of CKD (Coresh et al. 2003).
• conditions associated with a high risk of silent development of obstructive and parenchymal kidney disease • conditions that require long term treatment with potentially nephrotoxic drugs • multi-system diseases that can affect the kidney (Jenkins 2007) One of the specific formulae to measure eGFR is the Modification of Diet in Renal Disease (MDRD) (Table 1) which is recommended by the NKF K/DOQI (2002) Guidelines for CKD and the National Service Framework for Renal Services in the UK (DoH, 2005). This formula requires the patient’s age, gender, serum creatinine and ethnicity (black/non-black). It can be assumed that the patient is Caucasian if the ethnicity is unknown (Levey et al. 1999). The 4-variable Modification of Diet in Renal Disease (MDRD) equation: GFR (ml/min/1.73 m2) = 186 ⴛ {[Serum Creatinine mol/l/88.4]–1.154} ⴛ {age (years) ⴚ 0.203} ⴛ 0.742 if female and ⴛ 1.21 if African-American Table 1: MDRD Calculation: Levey et al. (1999).
Time out activity Does your country have a dedicated renal register? If so can you identify how many patients have CKD (stages 1 to 3) on this register?
Time out activity Jane is a 52-years-old Caucasian with a serum creatinine of 140. Estimate the eGFR of this patient using the online calculator at www.renal.org or www.nephron.com
Measurement of Kidney Function Kidney function has traditionally been measured by serum creatinine alone. The value of serum creatinine is established by the rate of creatinine production which is reliant on both muscle mass and excretion rate. Serum creatinine is not a precise measurement of kidney function since an individual’s body size, weight and muscle mass can all vary. It is now recommended that kidney function be measured using the estimated glomerular filtration rate (eGFR) which is measured using a simple blood test. In the United Kingdom, for example, it is now proposed that hospital laboratories should report eGFR whenever a serum creatinine test is requested (Thomas 2007). At the initial assessment, the patient’s eGFR should be measured and then at least yearly in all adult patients with the following: • those previously diagnosed with CKD
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STAGING OF CKD The NKF K/DOQI (2002) stages CKD according to classification from 1 to 5 (Table 2). The different stages of CKD are defined by the level of eGFR with higher stages representing lower GFR levels. These internationally recognised guidelines suggest that all individuals with eGFR
