The Chronic Kidney Disease Client

1. The Chronic Kidney Disease Client Valerie Goodnight RN, CNN Missouri Kidney Program Center for Chronic Kidney Disease Education

2. Goals: • Define Chronic Kidney Disease (CKD) • CKD Statistics • Renal Anatomy and Physiology Overview • Brief Review of Kidney Function • Side Effects of Uremia • Patients at Risk • Identify Risk Factors • Complications of CKD

3. Goals Continued… • Stages of CKD • Early Detection • Early Intervention • Education

4. Definition of CKD: • K/DOQI defines CKD as: • Kidney damage > or = 3 months, as defined by structural or functional abnormalities of the kidney with or without decreased GFR, manifest by either: • Pathological Abnormalities • Markers of Kidney Damage • Or • GFR < 60 mL/min/1.73 m² for > or = 3 months with or without kidney damage • According to the National Institutes of Health* • Serum Creatinine of >1.2 mg/dL in females • Serum Creatinine of > 1.5 mg/dL in males *Note that serum creatinine alone is a poor indicator of kidney function since one half of the kidney function may be lost before there is a detectable rise in serum creatinine

5. What Is Uremia? • Uremia is a build up of waste products in the blood resulting in a variety of symptoms.

6. Side Effects of Uremia: • Poor Appetite • Nausea/Vomiting • Itching • “Restless leg” syndrome • Insomnia • Fatigue • Difficulty Concentrating

7. CKD Statistics: • CKD is an increasingly common problem in the United States. More than 31 million Americans have CKD. Moreover, 20 million more are at increased risk. More than 90,000 people die each year from diseases of the kidney and urinary tract.

8. Statistics in Missouri: • CKD is a growing problem in Missouri2 • 2,047 new patients began treatment for kidney failure in 2006 • 9,442 patients were receiving treatment for kidney failure on 12/31/2006

9. Review of the Urinary System: • 2 Kidneys (normally) • 2 Ureters (normally) • 1 Bladder • 1 Urethra

10. The Nephron:

11. Large SubstancesRemain in Capillary Na+ K+ K+ Na+ Urea K+ Na+ Urea Na+ K+ Na+ Urea Albumin K+ Urea Albumin Urea K+ Na+ Urea Na+ Na+ K+ K+ Urea Na+ Urea Na+ K+ *Solutes consist of molecules <68,000 daltons

12. What Do the Kidneys Do? • Maintain constant amount of water in the body (Fluid Balance) • Urine Formation • Maintain constant amount of salts in the body (Electrolyte Balance) • Eliminates metabolic Waste Products from the blood • Eliminates excess acid in blood & preserves normal amount of bicarbonate (Acid-Base Balance) • Prostaglandin Synthesis • Hormonal Functions • Renin-Angiotensin System • Erythropoiesis • Activation of Vitamin D

13. Who Is at Risk? • Sociodemographic Factors • Patients over the age of 65 years old • African Americans • American Indians • Hispanic • Asian • Pacific Islander • Chemical and Environmental Conditions Exposure • Low Income/Education

14. Risk Factors for CKD: • Elderly and those with a family history of diabetes mellitus, hypertension, or CKD

15. What Causes Kidney Damage? • Diabetes Mellitus • Hypertension • Autoimmune Diseases • Recovery from ARF • UTI or Urinary Tract Infection • Kidney Stones • Lower Urinary Tract Obstruction • Systemic Infection • Drug Toxicity • Neoplasia

16. What Factors Increase Kidney Damage? • Uncontrolled hypertension • Uncontrolled diabetes • Smoking • Hypercholesterolemia • Excessive proteinuria

17. Most Common Causes of CKD: • According to the USRDS data, the most common cause of CKD in the US is diabetes, which accounts for 44% of patients on dialysis • Hypertension is the second leading cause of CKD which accounts for 27% of patients on dialysis

18. What Complications Are Associated With CKD? • Cardiovascular Disease • Hypertension • Anemia • Bone Disease • Metabolic Acidosis • Malnutrition • Dyslipidemia • Decreased overall function and sense of well being

19. Management of Chronic Kidney Failure The main goal is to delay the progression of the disease toward end-stage kidney failure and dialysis. This can be attained by education and: • Treatment of the Disease Process • Blood pressure/Blood Sugar Control • Avoiding Nephrotoxic Agents • Dietary Restrictions of Protein • Management of Extrarenal Manifestations of CKD

20. Treatment of Chronic Renal Failure • Dietary and Fluid Management • Kidney Replacement Therapy • Hemodialysis • Peritoneal Dialysis • Kidney Transplantation • Medication • Non-treatment

21. What Medications Are Commonly Prescribed? • Antihypertensives • Calcimimetics • Erythropoiesis Stimulating Agents • Iron Supplements • Laxatives • Phosphate Binders • Statins • Vitamin D • Multivitamins

22. A Clinical Action Plan for CKD:

23. Indications for Dialysis Becomes necessary when clearances fall below 15% • Uremic Pericarditis • Malnutrition • Fluid Overload • Central Nervous System Disorders • Hyperkalemia • Metabolic Acidosis

24. How Can Kidney Damage Be Detected Early? • Screening Tests for Patients at Increased Risk for CKD: • Family history of kidney disease, hypertension, or diabetes • Blood pressure measurement • Glucose measurement • Serum creatinine to estimate GFR • Urine testing for microalbumin (using an albumin specific dipstick) • Urinalysis and sediment for RBC and WBC

25. Normal Protein Excretion: • Microalbuminuriais defined as > 30 mg/d in a urine collection

26. How to Slow Progression of Kidney Disease? • Treatment of Hypertension • Patient with CKD and/or proteinuria, targeted blood pressure should be <130/80 mm/Hg • Intensive glycemic control will slow the progression of CKD • American Diabetes Association recommends HbgA1c < 6.5 • MDRD study suggests that low-protein diets may slow the progression of CKD stages 3-4

27. How to Improve Outcomes in CKD • Management of CKD should begin early. An initial visit with a Nephrologist is important to assess the causes and customize the treatment for each patient and for co-management of the patient with the primary care provider.

28. Improving Outcomes Continued… • Once the GFR is below 30 ml/min/1.73 m² the Nephrologist will: • Evaluate nutritional status and refer to a dietitian • Refer to a kidney disease educator • Encourage patient to save the non-dominant arm for vascular access (no IV access in that arm or central lines on that side) • Explain kidney replacement therapy options including transplantation • Evaluate potential donors for transplantation

29. Improving Outcomes Continued… • Once the GFR is below 20 ml/min/1.73 m² • Permanent access should be established if hemodialysis is selected • Social work evaluation for financial needs • Referral to patient/family support group

30. University of MissouriMissouri Kidney Program:Patient Education Program An education solution for healthcare providers for the CKD patient

31. Why Provide Education? • In today’s fast-paced, demanding, and cost conscious healthcare environment, it is important to evaluate the cost effectiveness of any program. Patient education is an arena where research has documented cost effectiveness. For example:

32. Blue-collar workers are the most at risk for losing their jobs due to kidney failure. Those who have multidisciplinary education before starting treatment are more likely to keep their jobs [Rasgon S, Schwankovsky OL, James-Rogers A, Widrow L, Glick J, Butts E. An intervention for employment maintenance among blue collar workers with end-stage renal disease. Am J Kidney Dis 2293):403-12, 1993

33. Program Objectives: • To provide comprehensive, objective information about treatment options for kidney failure to patients who have not yet started treatment • To provide comprehensive, objective information about treatment options for kidney failure to patients on treatment for kidney failure who may be interested in changing treatment or learning more • To provide a brief orientation for new dialysis and transplant staff

34. Program Objectives Continued… • To promote information seeking and sharing of experiences among patients, loved ones, and staff • To empower patients to become active partners in their care, to make informed treatment decisions, to manage their illness and adhere more closely with their treatment prescription, and to resume their usual activities • To prepare patients and their families emotionally to deal with kidney disease and its treatment by serving as an “informal” support group for patients and their loved ones • To reduce the cost of treating kidney failure

35. PEP Outcomes: • Over 5,000 patients and family members have attended three or more of the six classes since MoKP first began the PEP program in 1983. • Patient and family evaluations of the program have been overwhelmingly positive. • Surveys have consistently shown improvement in knowledge scores for those who attend PEP. • Most patients report they feel better emotionally after attending the classes. • Some patients who had not considered home dialysis or transplant before attending PEP have stated interest in these treatment options after attending PEP.

36. PEP Format • Most PEP groups have fewer than 50 patients and family members. Attendance varies by location and season. Each PEP group consists of six classes: • Intro to Kidney Disease • Diet and Kidney Disease • Financing and Coping • Hemodialysis • Peritoneal Dialysis • Kidney Transplantation

37. How Can I Find a Class? • You can find a class on our website: http://som.missouri.edu/mokp • Call the main office • 1-800-733-7345

38. Other Way to Hear About the PEP: • Community Activities • Articles in the newspaper or television • Hospital inservices • Displays at professional and patient seminars • Physician offices

39. Take Control of Your Illness Before it Takes Control of YOU!