Continuing professional development
An overview of chronic kidney disease in older people NOP526 Lewis R (2013) An overview of chronic kidney disease in older people. Nursing Older People. 25, 10, 31-38. Date of submission: September 12 2013. Date of acceptance: October 22 2013.
Abstract There is a lack of consensus about how early chronic kidney disease (CKD) should be diagnosed and managed in older people. Some believe that reduced renal function in older age is usually benign and that identifying it as a condition requiring medical intervention is inappropriate, whereas others believe it represents an important public health issue. This uncertainty is not reflected in management guidelines. There is no controversy, however, that advanced CKD is particularly dangerous in older people. They are at risk of acute kidney injury, often worsened by unenlightened medical management. As CKD advances towards end stage in older people, treatment choices are even more difficult to make and there is a need for insightful input from carers to optimise outcomes.
Aims and intended learning outcomes The aims of this article are twofold: first, to improve understanding of how early chronic kidney disease (CKD) is diagnosed in older people to reduce inappropriate management, and second, to minimise harm and maximise quality of care in those with advanced CKD. It is not feasible to provide an in-depth description of diagnosis, management and natural history of CKD in one article. However, after reading this article, you should be able to: ■■ Describe the tests used to define and classify early CKD. ■■ Discuss the controversy surrounding use of these diagnostic tests in older patients and how significant CKD can be distinguished from a more benign ageing process. ■■ Detail the complications of advanced CKD and understand why management needs to take account of these complications in older patients. NURSING OLDER PEOPLE
■■ Describe how advanced and end-stage CKD is managed in older people, particularly those who decline the option of dialysis. Introduction CKD describes a long-term condition in which the kidneys’ capacity to filter waste products from the blood, defined by the glomerular filtration rate (GFR), slowly declines. Its end point is reached when the build up of toxic substances in the blood is sufficient to cause systemic symptoms and, ultimately, death. CKD is usually irreversible and management is aimed at slowing the rate of progression to end-stage renal disease (ESRD) and treating complications. When ESRD is reached, death can be averted by renal replacement therapy (RRT), which includes haemodialysis, peritoneal dialysis and renal transplantation. Non-dialytic, or conservative, management can also improve patients’ quality of life and longevity (Chandna et al 2011). People with CKD are at risk of progressing to ESRD. Furthermore, population studies (Weiner et al 2004, 2006) have shown that reduced renal function is associated with increased risk of cardiovascular disease, even when outcomes are corrected for other known cardiovascular risk factors that are associated with CKD, such as diabetes and hypertension. As simple tests are available for identifying people with early sub-clinical CKD, targeted screening for the condition has become part of the Quality and Outcomes Framework, which rewards GPs for identifying CKD and managing it appropriately (National Institute for Health and Care Excellence (NICE) 2013a). All people over the age of 18 years with CKD are entered onto a CKD register and managed similarly. This is contentious; while early management of CKD in a young person is likely to have lifelong benefits, it is more difficult to justify in people nearing the end of their lives, particularly when evidence supporting intervention in older people with early CKD is sparse.
Robert Lewis is a consultant nephrologist, Wessex Renal and Transplant Unit, Queen Alexandra Hospital, Portsmouth Correspondence [email protected] Conflict of interest None declared
Keywords Chronic kidney disease, conservative management, dialysis, end of life care This article has been subject to double-blind review and checked using antiplagiarism software. For related articles visit our online archive and search using the keywords
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Continuing professional development Age is also relevant to management when CKD is more advanced. Although RRT is feasible in most people with ESRD, it may be technically difficult in the presence of certain comorbidities that are common in older people. For instance, hand arthritis or visual impairment may affect capacity to undertake unassisted peritoneal dialysis, and cardiac failure may impair tolerance of fluid removal on haemodialysis. RRT may therefore not enhance older people’s quality of life. That we can undertake RRT does not mean we necessarily should. Therefore, there are two themes relating to CKD that are especially relevant to older people: first, how to interpret pathology tests to identify those at real risk of harm from early CKD, and second, how to tailor management of established CKD and ESRD to meet their specific needs.
Definition and classification To appreciate the controversies relating to older patients, it is necessary to understand how CKD is defined and classified. CKD is identified using two measurements: ■■ A blood test for estimated GFR (eGFR). ■■ A urine test for albumin:creatinine ratio (ACR) to identify and quantify albumin in the urine. The terms albuminuria and proteinuria are often used interchangeably, because in nearly all common cases of CKD, albumin is the protein in the urine. These two markers of kidney damage are used to define the extent of CKD according to an internationally agreed classification system (Box 1). This classification system is not particularly useful in clinical practice and contains a number of oddities, such as the irrelevance of the distinction between stages 1 and 2 and the splitting of stage 3 into stages 3a
and 3b, but rationalisation would require international consensus which has not yet been attained. For clinical purposes it is more useful to consider patients in the following categories: ■■ Stage 1-3a CKD: very low risk of progressing to ESRD but at increased risk of cardiovascular disease compared with people without CKD. ■■ Stage 3b-4 CKD: significant risk of progression to ESRD. ■■ Stage 5 CKD: at or very near ESRD. The presence of albuminuria at any stage of CKD increases the risk of developing cardiovascular disease and ESRD (Hillege et al 2002). Interpreting estimated glomerular filtration rate Estimated GFR is used because true GFR is too difficult to measure in everyday clinical practice. The eGFR is obtained by measuring the blood creatinine level and then entering this into a formula that takes account of the patient’s age, sex and race. The eGFR only reliably identifies significant loss of excretory function when it falls below 60mL/min (stage 3a or worse). The correlation of eGFR with true GFR is least reliable when the former is only slightly abnormal. To minimise the risk of misdiagnosis, three readings of eGFR less than 60mL/min, spread over a period of not less than 90 days, are required before a diagnosis of CKD should be made (NICE 2008). Estimated GFR is affected by diet and hydration. Meat contains a large amount of creatinine, which affects the creatinine assay and therefore the eGFR. Patients attending for testing should be counselled to maintain adequate fluid input, a minimum of 1.5 litres over 24 hours, and abstain from eating meat for 12 hours before the blood test (Kidney Disease Improving Global Outcomes (KDIGO) 2013).
Box 1 Classification of chronic kidney disease (CKD) Stage of CKD*
Estimated glomerular filtration rate
Stage 1
>90mL/min with blood or protein in the urine or abnormal renal anatomy
Stage 2
60-89mL/min with blood or protein in the urine or abnormal renal anatomy
Stage 3a
45-59mL/min
Stage 3b
30-44mL/min
Stage 4
15-29mL/min
Stage 5
30mg/mmol) (National Institute for Health and Care Excellence 2008)
32 December 2013 | Volume 25 | Number 10
Interpreting albumin:creatinine ratio The use of traditional urine reagent strips to test for proteinuria does not detect all those at risk and a laboratory test is now considered mandatory. The assay of choice is the ACR. Using a ratio of albumin to creatinine is more accurate than a measure of urinary albumin alone. The risk of developing cardiovascular disease and/or ESRD increases in proportion to the amount of albumin in the urine. Until now, significant albuminuria has been defined by a threshold ACR of 30mg/mmol (NICE 2008), but more recent guidelines (KDIGO 2013) state that anyone with an ACR 3mg/mmol or more should be considered at potential harm. This is the level that was formerly called ‘microalbuminuria’.
Challenges to accurate diagnosis Once a diagnosis of CKD is established, management is in accordance with published guidelines (NICE 2008, KDIGO 2013). Greater detail is available in NURSING OLDER PEOPLE
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should be treated with a much lighter touch. Over the age of 75, the following features identify people at risk (O’Hare et al 2007): ■■ EGFR 3mg/mmol). ■■ Progression of CKD (eGFR falling by more than 5mL/min/year). Note that proteinuria is not a feature of ageing and its presence should be taken as a marker of risk. Although it is not contained in any published guidelines, there is an emerging consensus that people over 75 years of age with no proteinuria and a stable eGFR of 45 to 60mL/ min should be managed no differently from people without CKD. Even where the pathology tests suggest putative risk from CKD, management should be adapted to suit patients’ comorbidities and life expectancy. For instance, it would be illogical to initiate vigorous management in someone with limited quality of life and a life expectancy greatly reduced by other conditions, such as chronic obstructive pulmonary disease, dementia or malignancy. Now do time out 1.
1
Diagnosis
Time out
Lewis (2012). It is notable that none of the available guidelines contains management tailored specifically to older people. This is because older people are often excluded from large studies and, as a consequence, there is little evidence on which to base age-specific advice. Recommendations suitable for middle-aged patients are therefore applied equally to the very old by a process of extrapolation. Kidney function declines with age. People over the age of 40 experience a loss of GFR of about 1mL/ min/year. This steady decline occurs in the context of widespread age-related tissue damage seen in all organs of the body. Since an eGFR of 60mL/min defines CKD regardless of age, the longer an individual lives the more likely it is that his or her eGFR will move into the ‘abnormal’ range, which was determined from observation of harm in the population as a whole. Although the formula used to calculate the eGFR takes age into account, its accuracy in identifying those older people at real risk is uncertain. There is therefore a possibility that healthy older people with age-related, ‘normal’ loss of kidney function might be misdiagnosed with CKD. This issue remains unresolved. An erroneous diagnosis of CKD is not benign. Management of CKD includes rigorous blood pressure control, which can be risky in older and infirm people. Polypharmacy and ‘medicalisation’ (identifying a condition as one that requires medical intervention) are inappropriate for healthy individuals, cause unnecessary anxiety, and waste resources. A diagnosis of CKD carries financial penalties for the patient too, such as higher premiums for health or holiday insurance policies. Therefore an incorrect diagnosis of CKD in an older individual has the potential to do more harm than good. The challenge is therefore to identify which of these older people with apparently reduced eGFR is at genuine risk that warrants intervention and which
An 81-year-old female patient is incidentally found to have an estimated glomerular filtration rate of 47mL/min on a single blood test. Does this constitute a diagnosis of chronic kidney disease? What other factors should be taken into account before making this diagnosis?
Causes When a patient is found to have an abnormal eGFR for the first time, the trajectory of previous results should be assessed. Results that are ‘out of character’ should be
Table 1 Common causes of chronic kidney disease in older people and distinguishing clinical and radiological features Diagnosis
Proteinuria
Kidney size on ultrasound
Other features
Diabetic nephropathy
Nearly always present and often heavy.
Normal but sometimes small.
Diabetic retinopathy often present.
Hypertensive nephropathy
Usually absent or minimal.
Small.
A history of longstanding, that is, more than ten years, hypertension.
Renovascular disease
Sometimes.
Small, irregular and asymmetrical.
Evidence of disseminated atheroma: coronary disease, peripheral vascular disease, cerebrovascular disease.
Obstructive uropathy
Usually absent.
Hydronephrosis.
History of prostatic symptoms.
(Lewis 2012)
NURSING OLDER PEOPLE
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Continuing professional development repeated in about one to two weeks. If a decline is seen, medical assessment is warranted to assess the patient’s hydration status and to review recent prescriptions. If a diagnosis of CKD is established, some thought should be given to the cause. In older people, the important causes, and how they may be distinguished, are shown in Table 1 (page 33) (Lewis 2012). Two conditions are of particular relevance in this group. Renovascular disease accounts for about 27 per cent of cases of ESRD in people over 75 and affects management decisions (Renal Association UK Renal Registry 2012). Obstructive uropathy, usually as a result of prostatic disease, is particularly common in older people, accounting for 22 per cent of cases of ESRD in people over 75, and one of the few causes of CKD that is potentially reversible (Renal Association UK Renal Registry 2012). A medical assessment of every new case of CKD is mandatory to exclude unusual important causes, which are not shown in Table 1 (page 33), and to identify people with potentially reversible disease. If doubt persists as to the cause, or if there is concern about the rate of decline, referral for specialist advice is usually sought.
Management Early CKD: stage 3a-3b Patients with stage 4 CKD or progressive decline should be referred to a specialist (NICE 2008). Patients with stable early CKD (stage 3a-3b) should be managed in primary care. At this stage of the disease, the patient is asymptomatic and is unlikely to develop any longterm complications. Accordingly, management can be summarised as follows: 1. Reassure patients that early CKD is unlikely to have any effect on their longevity. Be aware, however, that for some patients ‘stage 3 CKD’ sounds like a death sentence. 2. Ensure that blood pressure is controlled. The targets for blood pressure control in CKD are given in Box 2 Blood pressure targets for people with chronic kidney disease Estimated glomerular filtration rate less than 60mL/min with:
Target blood pressure (mmHg)
No diabetes or proteinuria
120-140/90
Diabetes or albumin:creatinine 120-130/80 ratio >70 (protein:creatinine ratio >100) Note that the targets are more stringent in the presence of diabetes or heavy proteinuria because of the known increase in vascular risk associated with these conditions (National Institute for Health and Care Excellence 2008)
34 December 2013 | Volume 25 | Number 10
Box 2. It is the author’s opinion that, in older people, these targets need to be applied with judgement, taking the following into account: ■■ Blood pressure readings are highly variable in older people. Isolated suboptimal readings should not necessarily lead to an increase in medication. ■■ Older people are especially prone to ‘white coat effect’, which is identified when an individual has uncharacteristically high blood pressure readings in the presence of a doctor and much lower readings at other locations, notably at home. Twenty four-hour blood pressure monitors should be used to establish if patients have hypertension and to guide treatment decisions. Where feasible, home monitoring of blood pressure is a good alternative. ■■ Isolated systolic hypertension is particularly common in older people. Vigorous antihypertensive treatment can lead to diastolic hypotension, which is potentially dangerous. Diastolic blood pressure should not be lowered below 50mmHg. All these special features of hypertension in older people make the condition difficult to treat (BejanAngoulvant et al 2010). Furthermore, older people are more prone to side effects of available antihypertensive drugs. Dizziness or syncope should prompt revision of the drug regimen guided by 24-hour blood pressure monitoring. Accepted blood pressure targets for people with CKD (Box 2) should be aimed for, provided they can be achieved without any adverse effect, most importantly, postural hypotension. If side effects arise or if blood pressure is resistant to three classes of agent, less stringent control, allowing blood pressure of up to 160/90mmHg, may be acceptable in older people. 3. CKD guidelines recommend the use of angiotensinconverting-enzyme (ACE) inhibitors, for example, ramipril, enalapril, or angiotensin receptor blockers (ARBs), for example, candesartan, losartan, for all patients with CKD and proteinuria (NICE 2008, KDIGO 2013). These drugs have a specific protective effect on renal function that is not present in blood pressurelowering drugs of other types. However, they should be used with caution in older people. There is a high incidence of renovascular disease in this age group, a condition which makes use of ACE inhibitors and ARBs dangerous. All older people prescribed one of these agents should have their renal function checked seven to ten days later. If serum creatinine rises by 25 per cent or more the agents should be withdrawn (NICE 2008). 4. Because CKD is an independent risk factor for cardiovascular disease, the usual lifestyle advice on this issue should be applied. Use of lipid-lowering and antiplatelet agents is no different from patients without CKD. 5. Patients with CKD require monitoring of their eGFR, ACR and blood pressure. The frequency of monitoring of renal function depends on the individual NURSING OLDER PEOPLE
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Blood pressure management An 84-year-old female patient is being managed for stage 2 chronic kidney disease and hypertension. Despite taking amlodipine, doxazosin and ramipril at high doses, her blood pressure reading in clinic is 165/70mmHg. She says she occasionally feels dizzy on standing. What measures should be taken to optimise her blood pressure management and to minimise future risk?
Advanced CKD: stage 3b-4 Some patients with CKD remain stable for years and show no ill-effects from their condition. Some, however, may progress and start to develop long-term complications. There are three particular issues in older people: Anaemia Anaemia, due to failure of erythropoietin production by the kidney, can sometimes become evident at stage 3b. A haemoglobin level that is lower than 100g/L may be sufficient to cause symptoms in older people and may have an adverse effect on comorbidities such as angina and heart failure. Often there is accompanying iron deficiency and it is therefore important to check ferritin levels and treat deficiencies in all patients with CKD and anaemia. Intravenous iron given as a single infusion is the best way to ensure that iron stores are replete. In patients with stage 3b CKD or worse, where there are no ferritin deficiencies and other causes of anaemia have been excluded, the use of erythropoiesis-stimulating agents (ESAs) may be considered, often referred to as ‘epo’. These agents are administered by subcutaneous injection, usually once or twice a week. Community nurses may need to help administer the injections in older people. Prescriptions are issued by the local renal unit where a specialist anaemia service is provided. The ESAs are delivered to patients’ homes in refrigerated packaging and stored in their kitchen refrigerator. Community and specialist nursing teams, who work in partnership, monitor a patient’s response to ESAs. With adequate treatment, haemoglobin should be maintained between 110-120g/L (UK Renal Association 2010). Acute kidney injury (AKI) The term now used for any abrupt decline in kidney function is AKI. The condition is usually detected by a reduction in urine output or through blood tests that show an abrupt increase in NURSING OLDER PEOPLE
serum creatinine. However, if left undiagnosed, it can lead to symptomatic uraemia and, ultimately, death. Older people are particularly susceptible to AKI because they have limited renal reserve to counteract insults to renal function, such as sepsis or dehydration. This is further compounded by the large number of older people taking agents that may affect renal function. Diuretics are implicated in 40 per cent of cases of AKI and non-steroidal anti-inflammatory drugs (NSAIDs) increase the risk of AKI threefold (Abdel-Kader and Palevsky 2009). Use of ACE inhibitors is also associated with an increased risk of AKI in older people. AKI complicates 10 per cent of hospital admissions in people over 80 and it is estimated that 50 per cent of these admissions are avoidable (Abdel-Kader and Palevsky 2009). AKI is also associated with increased mortality in hospital inpatients. All older people with a systemic infection, particularly if accompanied by dehydration as a result of diarrhoea and vomiting, should be advised to keep hydrated and to withhold any NSAIDs, diuretics, ACE inhibitors and ARBs until they are feeling systemically well. If they are known to have CKD and remain unwell for more than two days, their renal function should be checked. There should be a low threshold for admitting these people to hospital for hydration if their renal function has declined significantly. Early rehydration reduces the severity of AKI and can be lifesaving. All older people admitted to hospital should be assessed for their risk of developing AKI. If initial blood tests show evidence of renal impairment, oral or parenteral hydration should be instigated, fluid input and output should be monitored, and tests for renal function should be repeated within 24 hours. A study found that these simple measures are only put in place 50 per cent of the time (National Confidential Enquiry into Patient Outcome and Death 2009). The high incidence of AKI in older patients is largely attributable to inadequate care (NICE 2013b). Now do time out 3.
3
Acute kidney injury
Time out
2 Time out
but, generally, patients with stage 3a CKD should be monitored annually and those with stage 3b every six months (NICE 2008). Now do time out 2.
Reflect on why older people are at particular risk of acute kidney injury. What factors lead to this predisposition and what can healthcare staff do to minimise this risk?
Polypharmacy A diagnosis of CKD often results in an increase in medication. As already mentioned, control of hypertension often requires multiple agents. CKD is also associated with the following (Davison et al 2005): December 2013 | Volume 25 | Number 10 35
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Continuing professional development ■■ Hyperphosphataemia, which is often treated with three to six pills/capsules daily to bind phosphate in the diet. ■■ Acidosis, which requires six to eight bicarbonate tablets a day. ■■ Gout, which requires allopurinol. ■■ Pruritus, which requires antihistamines and various emollient creams. Older people have a high burden of comorbidities, especially diabetes and heart failure, and often require yet more medication to treat these. They may also require dietary supplements such as iron, folate, vitamin B complex and build-up drinks because of poor nutritional intake. The problem of polypharmacy is compounded by the lack of confidence among doctors without specialist knowledge to ‘interfere’ with drug regimens started at various hospital clinics – the prescription list just gets longer and longer. It is well recognised that complicated drug regimens cause confusion and anxiety in older people, which contribute to poor concordance. There is also a high risk of drug interaction and side effects. Drug regimens should be reviewed regularly to identify agents that are non-essential and to stop as many as possible (Murray and Kroenke 2001). Stage 5 CKD In older people CKD usually remains stable and does not progress to ESRD. It is estimated that people with stage 3a CKD have a 1 per cent chance of developing ESRD in five years (Johnson et al 2008). This means that most people over 75 with CKD die from other causes, usually cardiovascular disease (O’Hare et al 2007). Nonetheless, some older people develop progressive renal impairment, which has the potential to be life-limiting. In older people, decisions about RRT require consideration of multiple health-related and social factors that are less prominent in younger patients (Isles et al 2011). About half of patients over the age of 75 who reach ESRD have at least one comorbidity that significantly affects their quality of life, usually heart failure or ischaemic heart disease. Even among those considered well enough to be taken on to RRT, 50 per cent die within a year of starting (Tamura et al 2012). RRT is therefore not a panacea that can restore older people to health: patient and family expectations should be managed accordingly. The important principle is that patients should always make informed decisions about RRT themselves, with the help of their families and carers, using advice and guidance from specialist staff. Anyone who wishes to be considered for RRT, regardless of age, should be assessed and advised. Modalities of treatment for ESRD RRT is often difficult to undertake in older people. Comorbidities, frailty, 36 December 2013 | Volume 25 | Number 10
functional and cognitive impairment all have a bearing on whether patients would benefit from RRT and, if so, which modality they should choose. Potential transplant recipients need to be sufficiently robust to survive the surgery and to have a life expectancy of about five years after engraftment. The latter point arises because organs for transplantation are in short supply and it is important that they are given to patients who will gain the most benefit. UK transplant units have made a policy of not routinely considering patients aged over 80 for transplant. While haemodialysis can be undertaken at home in certain circumstances, for older patients it is more likely to be done in a dialysis centre where they have the help of specialist nurses. Treatments are undertaken three times a week and last about four hours. Patients are required to make substantial changes to their diet and to restrict their fluid intake significantly. The rigours of this treatment have a significant effect on older people’s quality of life, especially if they have poor cardiac function and cope poorly with the haemodynamic shock of a dialysis session. Nonetheless, it is often surprising how many older people, often in their 90s, cope with haemodialysis and report good quality of life. Dialysis units can also serve as a useful source of social interaction for people who might otherwise lead solitary lives. Health professionals cannot be dogmatic about whom they consider to be unsuitable for treatment. The decision to try haemodialysis rests with the patient. Patients undertake peritoneal dialysis themselves in their homes. Automated machines are used to deliver the dialysate exchanges overnight, every night, and the patient is required to set the machine up at the start of treatment using a pre-programmed cartridge. In older people, peritoneal dialysis has the advantage of being gentler on the cardiovascular system than haemodialysis and it requires less stringent dietary and fluid restrictions. However, the home must be reasonably clean and have space for dialysis stores. Patients must also be able to lift dialysate bags and have sufficient cognitive function and manual dexterity to work the machines. These issues have led to peritoneal dialysis being offered less often to older people than haemodialysis; a situation which many would wish to reverse (Brown et al 2010). A recent innovation has been assisted peritoneal dialysis where patients who cannot undertake dialysis themselves are visited in their homes morning and night by a nurse who initiates and terminates the procedure for them (Oliver et al 2007). The service is limited by cost. Dialysis can have a significant negative effect on quality of life and many older people decide that it is not for them. Active conservative management provides an alternative to RRT and can provide a good quality of life. Indeed, studies have shown that the life expectancy of patients over 80 is little different if NURSING OLDER PEOPLE
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4
Renal replacement therapy
Time out
Low-clearance clinics Making decisions about RRT or conservative management is difficult, particularly for older people who may become bewildered by the amount of information they have to assimilate. Specialist low-clearance clinics are established in all renal units designed specifically to undertake holistic assessment of patient needs. In these clinics patients and their carers are given written and verbal information to make a choice and time to make their decision. People with eGFR less than 20mL/min should be seen in this type of clinic. As RRT is not generally required before eGFR falls below 8mL/min, this gives plenty of time to prepare for the chosen modality, for example, creation of an arteriovenous fistula for haemodialysis or repair of a hernia for peritoneal dialysis, and ensures that patients make decisions before advanced CKD has too great an effect on their cognition (NICE 2008). Once patients decide on a care plan, this is kept under review at each clinic attendance and may change if patients wish. It should be understood that they are not letting anyone down if they switch chosen modality – or even opt to withdraw from RRT altogether. Now do time out 4.
Consider a patient. How do you think they would cope with the different types of renal replacement therapy (RRT)? What factors determine your opinion? If you have a patient on RRT, consider visiting the dialysis unit when they are on treatment. Observe how they cope with the environment, the interaction with other people and the physical process of dialysis itself.
NURSING OLDER PEOPLE
End of life care This is defined as care that helps people with advanced CKD to live as well as possible until they die. It enables the supportive and palliative care needs of patients and families to be identified and met throughout the last phase of life and into bereavement. It includes sharing the expected prognosis with patients and managing the symptoms of uraemia (Russon and Mooney 2010). Patients receiving end of life care include those coming to the end of a conservative management programme and those who have opted to withdraw from RRT because it no longer answers their needs. The prognosis of patients withdrawing from RRT varies according to their residual kidney function, but is usually eight to 11 days (Wong et al 2007). It is more difficult to judge the prognosis of people receiving conservative management because their decline is gradual. Indicators of a prognosis of less than three months include (Wong et al 2007): ■■ eGFR less than 7mL/min. ■■ Intractable symptoms. ■■ Weight loss of more than 10 per cent in six months. ■■ Hypoalbuminaemia (serum albumin less than 24g/L). In CKD, end of life care can and should be planned well in advance with close co-ordination between primary care, palliative care and the renal unit. It is important that a proactive care plan is agreed and documented to ensure continuity. The basis of end of life care is a stepped algorithm (Douglas et al 2009) that is especially configured for the needs of patients with advanced CKD. This is used to escalate intervention according to the patient’s needs. The symptoms commonly encountered in this circumstance and the measures used to ameliorate them are listed in Box 3 (page 38). A framework for end of life care in advanced kidney disease is available (Department of Health 2009), which describes in detail how care should be delivered and how the various agencies should work together optimally. Now do time out 5.
5
Appropriate management
Time out
they have conservative management instead of RRT (Carson et al 2009). Treatment is aimed at reducing the impact of ESRD; notably dietary restriction of protein to reduce uraemic symptoms and to slow progression of CKD, potassium to prevent dangerous hyperkalaemia, and phosphate to reduce blood phosphate which might contribute to pruritus. Symptom control such as antiemetics and anaemia management are also components of this approach. Conservative management is particularly applicable to people leading sedentary lives with comorbidities such as dementia and heart failure, which are likely to make RRT poorly tolerated. Patients on conservative management understand that they may change their minds and have RRT, although it is made clear that initiation of RRT when uraemia is advanced is associated with worse outcomes compared with a properly planned start (Chan et al 2007).
Are you confident that patients with chronic kidney disease in your care are receiving management that is appropriate to their disease stage, their age and their comorbidities? What aspects of their care might be improved?
Conclusion Making a diagnosis of CKD in older people is not straightforward. Insight into the characteristics of the available diagnostic tests is required to identify which people over 75 years of age are at risk. Once December 2013 | Volume 25 | Number 10 37
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Continuing professional development
Symptom
Intervention
Anorexia, nausea and vomiting
Dietary protein restriction can ease symptoms. Regular antiemetics are used at standard doses as required.
Pruritus
Optimise treatment of anaemia and hyperphosphataemia, which can worsen itching. Regular emollients with added antipruritic agents should be applied. Antihistamines and sedatives may be tried.
Fluid overload
Oral furosemide at doses up to 500mg/day. Add metolazone in resistant cases. In terminal phase, opiates should be used to relieve distress.
Restless legs
First, correct anaemia and iron deficiency. Clonazepam, pramipexole or gabapentin are often effective.
Muscle cramps
Quinine can be safely given at standard doses. If necessary, diazepam is a sedating alternative.
Pain
Chronic kidney disease causes accumulation of most opiates, including morphine and diamorphine. This can impair cognition, so fentanyl is the strong analgesic of choice. This can also be used to relieve agitation or distress.
(Lewis 2012)
a diagnosis is established, management of early CKD should be tailored to the individual, in particular avoiding over-aggressive blood pressure control which can be dangerous. In more advanced CKD, carers should be aware of the risk of AKI and take measures to avoid it. At ESRD, older patients expressing an interest in RRT should be assessed by the appropriate specialist team and guided, through education, towards the appropriate care plan.
6
Practice profile
Time out
Box 3 Common symptoms and interventions at end of life in people with chronic kidney disease
Now that you have completed the article you might like to write a practice profile. Guidelines to help you are on page 39.
References Abdel-Kader K, Palevsky P (2009) Acute kidney injury in the elderly. Clinics in Geriatric Medicine. 25, 3, 331-358.
Department of Health (2009) End of Life Care in Advanced Kidney Disease: a Framework for Implementation. DH, London.
Bejan-Angoulvant T, Saadatian-Elahi M, Wright J et al (2010) Treatment of hypertension in patients 80 years and older: the lower the better? A meta-analysis of randomized controlled trials. Journal of Hypertension. 28, 7, 1366-1372.
Douglas C, Murtagh F, Chambers E et al (2009) Symptom management for the adult patient dying with advanced chronic kidney disease: a review of the literature and development of evidence-based guidelines by a United Kingdom Expert Consensus Group. Palliative Medicine. 23, 2, 103-110.
Brown E, Johansson l, Farrington K et al (2010) Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients. Nephrology, Dialysis, Transplantation. 25, 11, 3755-3763. Carson R, Juszczak M, Davenport A et al (2009) Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clinical Journal of the American Society of Nephrology. 4, 10, 1611-1619. Chan M, Dall A, Fletcher K et al (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis. American Journal of Medicine. 120, 12, 1063-1070. Chandna S, Da Silva-Gane M, Marshall C et al (2011) Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrology, Dialysis, Transplantation. 26, 5, 1608-1614. Davison A, Cameron S, Grünfeld J-P et al (Eds) (2005) Oxford Textbook of Clinical Nephrology. Third edition. Oxford University Press, Oxford.
Hillege H, Fidler V, Diercks G et al (2002) Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population. Circulation. 106, 14, 1777-1782. Isles C, Robertson S, Almond A et al (2011) The challenges of renal replacement therapy and renal palliative care in the elderly. Journal of the Royal College of Physicians of Edinburgh. 41, 3, 238-243. Johnson E, Thorp M, Platt R et al (2008) Predicting the risk of dialysis and transplant among patients with CKD: a retrospective cohort study. American Journal of Kidney Diseases. 52, 4, 653-660. Kidney Disease Improving Global Outcomes (2013) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. tinyurl.com/m4hbcgm (Last accessed: November 11 2013.) Lewis R (2012) Understanding Chronic Kidney Disease: a Guide for the Non-Specialist. M & K Publishing, Keswick.
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Murray M, Kroenke K (2001) Polypharmacy and medication adherence: small steps on a long road. Journal of General Internal Medicine. 16, 2, 137-139.
Oliver M, Quinn R, Richardson E et al (2007) Home care assistance and the utilization of peritoneal dialysis. Kidney International. 71, 7, 673-678.
National Confidential Enquiry into Patient Outcome and Death (2009) Adding Insult to Injury: A Review of the Care of Patients who Died in Hospital with a Primary Diagnosis of Acute Kidney Injury (Acute Renal Failure). NCEPOD, London.
Renal Association UK Renal Registry (2012) 15th Annual Report. December 2012. www.renalreg.com/Reports/2012.html (Last accessed: November 11 2013.)
National Institute for Health and Care Excellence (2008) Chronic Kidney Disease: Early Identification and Management of Chronic Kidney Disease in Adults in Primary and Secondary Care. Clinical guideline 73. NICE, London. National Institute for Health and Care Excellence (2013a) About the Quality and Outcomes Framework (QOF). www.nice.org.uk/ aboutnice/qof/qof.jsp (Last accessed: October 30 2013.) National Institute for Health and Care Excellence (2013b) Acute Kidney Injury. Prevention, Detection and Management of Acute Kidney Injury up to the Point of Renal Replacement Therapy. Clinical guideline 169. http://guidance.nice.org.uk/CG169/ NICEGuidance/pdf/English (Last accessed: November 11 2013.) O’Hare A, Choi A, Bertenthal D et al (2007) Age affects outcomes in chronic kidney disease. Journal of the American Society of Nephrology. 18, 10, 2758-2765.
Russon L, Mooney A (2010) Palliative and end-of-life care in advanced renal failure. Clinical Medicine. 10, 3, 279-281. Tamura M, Tan J, O’Hare A (2012) Optimizing renal replacement therapy in older adults: a framework for making individualized decisions. Kidney International. 82, 3, 261-269. UK Renal Association (2010) Anaemia of CKD. www.renal.org/clinical/guidelinessection/ AnaemiaInCKD.aspx (Last accessed: November 11 2013.) Weiner D, Tighiouart H, Amin M et al (2004) Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies. Journal of the American Society of Nephrology. 15, 5, 1307-1315. Weiner D, Tabatabai S, Tighiouart H et al (2006) Cardiovascular outcomes and all-cause mortality: exploring the interaction between CKD and cardiovascular disease. American Journal of Kidney Diseases. 48, 3, 392-401. Wong C, McCarthy M, Howse M et al (2007) Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Renal Failure. 29, 6, 653-659.
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An overview of chronic kidney disease in older people NOP526 Lewis R (2013) An overview of chronic kidney disease in older people. Nursing Older People. 25, 10, 31-38. Date of submission: September 12 2013. Date of acceptance: October 22 2013.
Abstract There is a lack of consensus about how early chronic kidney disease (CKD) should be diagnosed and managed in older people. Some believe that reduced renal function in older age is usually benign and that identifying it as a condition requiring medical intervention is inappropriate, whereas others believe it represents an important public health issue. This uncertainty is not reflected in management guidelines. There is no controversy, however, that advanced CKD is particularly dangerous in older people. They are at risk of acute kidney injury, often worsened by unenlightened medical management. As CKD advances towards end stage in older people, treatment choices are even more difficult to make and there is a need for insightful input from carers to optimise outcomes.
Aims and intended learning outcomes The aims of this article are twofold: first, to improve understanding of how early chronic kidney disease (CKD) is diagnosed in older people to reduce inappropriate management, and second, to minimise harm and maximise quality of care in those with advanced CKD. It is not feasible to provide an in-depth description of diagnosis, management and natural history of CKD in one article. However, after reading this article, you should be able to: ■■ Describe the tests used to define and classify early CKD. ■■ Discuss the controversy surrounding use of these diagnostic tests in older patients and how significant CKD can be distinguished from a more benign ageing process. ■■ Detail the complications of advanced CKD and understand why management needs to take account of these complications in older patients. NURSING OLDER PEOPLE
■■ Describe how advanced and end-stage CKD is managed in older people, particularly those who decline the option of dialysis. Introduction CKD describes a long-term condition in which the kidneys’ capacity to filter waste products from the blood, defined by the glomerular filtration rate (GFR), slowly declines. Its end point is reached when the build up of toxic substances in the blood is sufficient to cause systemic symptoms and, ultimately, death. CKD is usually irreversible and management is aimed at slowing the rate of progression to end-stage renal disease (ESRD) and treating complications. When ESRD is reached, death can be averted by renal replacement therapy (RRT), which includes haemodialysis, peritoneal dialysis and renal transplantation. Non-dialytic, or conservative, management can also improve patients’ quality of life and longevity (Chandna et al 2011). People with CKD are at risk of progressing to ESRD. Furthermore, population studies (Weiner et al 2004, 2006) have shown that reduced renal function is associated with increased risk of cardiovascular disease, even when outcomes are corrected for other known cardiovascular risk factors that are associated with CKD, such as diabetes and hypertension. As simple tests are available for identifying people with early sub-clinical CKD, targeted screening for the condition has become part of the Quality and Outcomes Framework, which rewards GPs for identifying CKD and managing it appropriately (National Institute for Health and Care Excellence (NICE) 2013a). All people over the age of 18 years with CKD are entered onto a CKD register and managed similarly. This is contentious; while early management of CKD in a young person is likely to have lifelong benefits, it is more difficult to justify in people nearing the end of their lives, particularly when evidence supporting intervention in older people with early CKD is sparse.
Robert Lewis is a consultant nephrologist, Wessex Renal and Transplant Unit, Queen Alexandra Hospital, Portsmouth Correspondence [email protected] Conflict of interest None declared
Keywords Chronic kidney disease, conservative management, dialysis, end of life care This article has been subject to double-blind review and checked using antiplagiarism software. For related articles visit our online archive and search using the keywords
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Continuing professional development Age is also relevant to management when CKD is more advanced. Although RRT is feasible in most people with ESRD, it may be technically difficult in the presence of certain comorbidities that are common in older people. For instance, hand arthritis or visual impairment may affect capacity to undertake unassisted peritoneal dialysis, and cardiac failure may impair tolerance of fluid removal on haemodialysis. RRT may therefore not enhance older people’s quality of life. That we can undertake RRT does not mean we necessarily should. Therefore, there are two themes relating to CKD that are especially relevant to older people: first, how to interpret pathology tests to identify those at real risk of harm from early CKD, and second, how to tailor management of established CKD and ESRD to meet their specific needs.
Definition and classification To appreciate the controversies relating to older patients, it is necessary to understand how CKD is defined and classified. CKD is identified using two measurements: ■■ A blood test for estimated GFR (eGFR). ■■ A urine test for albumin:creatinine ratio (ACR) to identify and quantify albumin in the urine. The terms albuminuria and proteinuria are often used interchangeably, because in nearly all common cases of CKD, albumin is the protein in the urine. These two markers of kidney damage are used to define the extent of CKD according to an internationally agreed classification system (Box 1). This classification system is not particularly useful in clinical practice and contains a number of oddities, such as the irrelevance of the distinction between stages 1 and 2 and the splitting of stage 3 into stages 3a
and 3b, but rationalisation would require international consensus which has not yet been attained. For clinical purposes it is more useful to consider patients in the following categories: ■■ Stage 1-3a CKD: very low risk of progressing to ESRD but at increased risk of cardiovascular disease compared with people without CKD. ■■ Stage 3b-4 CKD: significant risk of progression to ESRD. ■■ Stage 5 CKD: at or very near ESRD. The presence of albuminuria at any stage of CKD increases the risk of developing cardiovascular disease and ESRD (Hillege et al 2002). Interpreting estimated glomerular filtration rate Estimated GFR is used because true GFR is too difficult to measure in everyday clinical practice. The eGFR is obtained by measuring the blood creatinine level and then entering this into a formula that takes account of the patient’s age, sex and race. The eGFR only reliably identifies significant loss of excretory function when it falls below 60mL/min (stage 3a or worse). The correlation of eGFR with true GFR is least reliable when the former is only slightly abnormal. To minimise the risk of misdiagnosis, three readings of eGFR less than 60mL/min, spread over a period of not less than 90 days, are required before a diagnosis of CKD should be made (NICE 2008). Estimated GFR is affected by diet and hydration. Meat contains a large amount of creatinine, which affects the creatinine assay and therefore the eGFR. Patients attending for testing should be counselled to maintain adequate fluid input, a minimum of 1.5 litres over 24 hours, and abstain from eating meat for 12 hours before the blood test (Kidney Disease Improving Global Outcomes (KDIGO) 2013).
Box 1 Classification of chronic kidney disease (CKD) Stage of CKD*
Estimated glomerular filtration rate
Stage 1
>90mL/min with blood or protein in the urine or abnormal renal anatomy
Stage 2
60-89mL/min with blood or protein in the urine or abnormal renal anatomy
Stage 3a
45-59mL/min
Stage 3b
30-44mL/min
Stage 4
15-29mL/min
Stage 5
30mg/mmol) (National Institute for Health and Care Excellence 2008)
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Interpreting albumin:creatinine ratio The use of traditional urine reagent strips to test for proteinuria does not detect all those at risk and a laboratory test is now considered mandatory. The assay of choice is the ACR. Using a ratio of albumin to creatinine is more accurate than a measure of urinary albumin alone. The risk of developing cardiovascular disease and/or ESRD increases in proportion to the amount of albumin in the urine. Until now, significant albuminuria has been defined by a threshold ACR of 30mg/mmol (NICE 2008), but more recent guidelines (KDIGO 2013) state that anyone with an ACR 3mg/mmol or more should be considered at potential harm. This is the level that was formerly called ‘microalbuminuria’.
Challenges to accurate diagnosis Once a diagnosis of CKD is established, management is in accordance with published guidelines (NICE 2008, KDIGO 2013). Greater detail is available in NURSING OLDER PEOPLE
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should be treated with a much lighter touch. Over the age of 75, the following features identify people at risk (O’Hare et al 2007): ■■ EGFR 3mg/mmol). ■■ Progression of CKD (eGFR falling by more than 5mL/min/year). Note that proteinuria is not a feature of ageing and its presence should be taken as a marker of risk. Although it is not contained in any published guidelines, there is an emerging consensus that people over 75 years of age with no proteinuria and a stable eGFR of 45 to 60mL/ min should be managed no differently from people without CKD. Even where the pathology tests suggest putative risk from CKD, management should be adapted to suit patients’ comorbidities and life expectancy. For instance, it would be illogical to initiate vigorous management in someone with limited quality of life and a life expectancy greatly reduced by other conditions, such as chronic obstructive pulmonary disease, dementia or malignancy. Now do time out 1.
1
Diagnosis
Time out
Lewis (2012). It is notable that none of the available guidelines contains management tailored specifically to older people. This is because older people are often excluded from large studies and, as a consequence, there is little evidence on which to base age-specific advice. Recommendations suitable for middle-aged patients are therefore applied equally to the very old by a process of extrapolation. Kidney function declines with age. People over the age of 40 experience a loss of GFR of about 1mL/ min/year. This steady decline occurs in the context of widespread age-related tissue damage seen in all organs of the body. Since an eGFR of 60mL/min defines CKD regardless of age, the longer an individual lives the more likely it is that his or her eGFR will move into the ‘abnormal’ range, which was determined from observation of harm in the population as a whole. Although the formula used to calculate the eGFR takes age into account, its accuracy in identifying those older people at real risk is uncertain. There is therefore a possibility that healthy older people with age-related, ‘normal’ loss of kidney function might be misdiagnosed with CKD. This issue remains unresolved. An erroneous diagnosis of CKD is not benign. Management of CKD includes rigorous blood pressure control, which can be risky in older and infirm people. Polypharmacy and ‘medicalisation’ (identifying a condition as one that requires medical intervention) are inappropriate for healthy individuals, cause unnecessary anxiety, and waste resources. A diagnosis of CKD carries financial penalties for the patient too, such as higher premiums for health or holiday insurance policies. Therefore an incorrect diagnosis of CKD in an older individual has the potential to do more harm than good. The challenge is therefore to identify which of these older people with apparently reduced eGFR is at genuine risk that warrants intervention and which
An 81-year-old female patient is incidentally found to have an estimated glomerular filtration rate of 47mL/min on a single blood test. Does this constitute a diagnosis of chronic kidney disease? What other factors should be taken into account before making this diagnosis?
Causes When a patient is found to have an abnormal eGFR for the first time, the trajectory of previous results should be assessed. Results that are ‘out of character’ should be
Table 1 Common causes of chronic kidney disease in older people and distinguishing clinical and radiological features Diagnosis
Proteinuria
Kidney size on ultrasound
Other features
Diabetic nephropathy
Nearly always present and often heavy.
Normal but sometimes small.
Diabetic retinopathy often present.
Hypertensive nephropathy
Usually absent or minimal.
Small.
A history of longstanding, that is, more than ten years, hypertension.
Renovascular disease
Sometimes.
Small, irregular and asymmetrical.
Evidence of disseminated atheroma: coronary disease, peripheral vascular disease, cerebrovascular disease.
Obstructive uropathy
Usually absent.
Hydronephrosis.
History of prostatic symptoms.
(Lewis 2012)
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Continuing professional development repeated in about one to two weeks. If a decline is seen, medical assessment is warranted to assess the patient’s hydration status and to review recent prescriptions. If a diagnosis of CKD is established, some thought should be given to the cause. In older people, the important causes, and how they may be distinguished, are shown in Table 1 (page 33) (Lewis 2012). Two conditions are of particular relevance in this group. Renovascular disease accounts for about 27 per cent of cases of ESRD in people over 75 and affects management decisions (Renal Association UK Renal Registry 2012). Obstructive uropathy, usually as a result of prostatic disease, is particularly common in older people, accounting for 22 per cent of cases of ESRD in people over 75, and one of the few causes of CKD that is potentially reversible (Renal Association UK Renal Registry 2012). A medical assessment of every new case of CKD is mandatory to exclude unusual important causes, which are not shown in Table 1 (page 33), and to identify people with potentially reversible disease. If doubt persists as to the cause, or if there is concern about the rate of decline, referral for specialist advice is usually sought.
Management Early CKD: stage 3a-3b Patients with stage 4 CKD or progressive decline should be referred to a specialist (NICE 2008). Patients with stable early CKD (stage 3a-3b) should be managed in primary care. At this stage of the disease, the patient is asymptomatic and is unlikely to develop any longterm complications. Accordingly, management can be summarised as follows: 1. Reassure patients that early CKD is unlikely to have any effect on their longevity. Be aware, however, that for some patients ‘stage 3 CKD’ sounds like a death sentence. 2. Ensure that blood pressure is controlled. The targets for blood pressure control in CKD are given in Box 2 Blood pressure targets for people with chronic kidney disease Estimated glomerular filtration rate less than 60mL/min with:
Target blood pressure (mmHg)
No diabetes or proteinuria
120-140/90
Diabetes or albumin:creatinine 120-130/80 ratio >70 (protein:creatinine ratio >100) Note that the targets are more stringent in the presence of diabetes or heavy proteinuria because of the known increase in vascular risk associated with these conditions (National Institute for Health and Care Excellence 2008)
34 December 2013 | Volume 25 | Number 10
Box 2. It is the author’s opinion that, in older people, these targets need to be applied with judgement, taking the following into account: ■■ Blood pressure readings are highly variable in older people. Isolated suboptimal readings should not necessarily lead to an increase in medication. ■■ Older people are especially prone to ‘white coat effect’, which is identified when an individual has uncharacteristically high blood pressure readings in the presence of a doctor and much lower readings at other locations, notably at home. Twenty four-hour blood pressure monitors should be used to establish if patients have hypertension and to guide treatment decisions. Where feasible, home monitoring of blood pressure is a good alternative. ■■ Isolated systolic hypertension is particularly common in older people. Vigorous antihypertensive treatment can lead to diastolic hypotension, which is potentially dangerous. Diastolic blood pressure should not be lowered below 50mmHg. All these special features of hypertension in older people make the condition difficult to treat (BejanAngoulvant et al 2010). Furthermore, older people are more prone to side effects of available antihypertensive drugs. Dizziness or syncope should prompt revision of the drug regimen guided by 24-hour blood pressure monitoring. Accepted blood pressure targets for people with CKD (Box 2) should be aimed for, provided they can be achieved without any adverse effect, most importantly, postural hypotension. If side effects arise or if blood pressure is resistant to three classes of agent, less stringent control, allowing blood pressure of up to 160/90mmHg, may be acceptable in older people. 3. CKD guidelines recommend the use of angiotensinconverting-enzyme (ACE) inhibitors, for example, ramipril, enalapril, or angiotensin receptor blockers (ARBs), for example, candesartan, losartan, for all patients with CKD and proteinuria (NICE 2008, KDIGO 2013). These drugs have a specific protective effect on renal function that is not present in blood pressurelowering drugs of other types. However, they should be used with caution in older people. There is a high incidence of renovascular disease in this age group, a condition which makes use of ACE inhibitors and ARBs dangerous. All older people prescribed one of these agents should have their renal function checked seven to ten days later. If serum creatinine rises by 25 per cent or more the agents should be withdrawn (NICE 2008). 4. Because CKD is an independent risk factor for cardiovascular disease, the usual lifestyle advice on this issue should be applied. Use of lipid-lowering and antiplatelet agents is no different from patients without CKD. 5. Patients with CKD require monitoring of their eGFR, ACR and blood pressure. The frequency of monitoring of renal function depends on the individual NURSING OLDER PEOPLE
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Blood pressure management An 84-year-old female patient is being managed for stage 2 chronic kidney disease and hypertension. Despite taking amlodipine, doxazosin and ramipril at high doses, her blood pressure reading in clinic is 165/70mmHg. She says she occasionally feels dizzy on standing. What measures should be taken to optimise her blood pressure management and to minimise future risk?
Advanced CKD: stage 3b-4 Some patients with CKD remain stable for years and show no ill-effects from their condition. Some, however, may progress and start to develop long-term complications. There are three particular issues in older people: Anaemia Anaemia, due to failure of erythropoietin production by the kidney, can sometimes become evident at stage 3b. A haemoglobin level that is lower than 100g/L may be sufficient to cause symptoms in older people and may have an adverse effect on comorbidities such as angina and heart failure. Often there is accompanying iron deficiency and it is therefore important to check ferritin levels and treat deficiencies in all patients with CKD and anaemia. Intravenous iron given as a single infusion is the best way to ensure that iron stores are replete. In patients with stage 3b CKD or worse, where there are no ferritin deficiencies and other causes of anaemia have been excluded, the use of erythropoiesis-stimulating agents (ESAs) may be considered, often referred to as ‘epo’. These agents are administered by subcutaneous injection, usually once or twice a week. Community nurses may need to help administer the injections in older people. Prescriptions are issued by the local renal unit where a specialist anaemia service is provided. The ESAs are delivered to patients’ homes in refrigerated packaging and stored in their kitchen refrigerator. Community and specialist nursing teams, who work in partnership, monitor a patient’s response to ESAs. With adequate treatment, haemoglobin should be maintained between 110-120g/L (UK Renal Association 2010). Acute kidney injury (AKI) The term now used for any abrupt decline in kidney function is AKI. The condition is usually detected by a reduction in urine output or through blood tests that show an abrupt increase in NURSING OLDER PEOPLE
serum creatinine. However, if left undiagnosed, it can lead to symptomatic uraemia and, ultimately, death. Older people are particularly susceptible to AKI because they have limited renal reserve to counteract insults to renal function, such as sepsis or dehydration. This is further compounded by the large number of older people taking agents that may affect renal function. Diuretics are implicated in 40 per cent of cases of AKI and non-steroidal anti-inflammatory drugs (NSAIDs) increase the risk of AKI threefold (Abdel-Kader and Palevsky 2009). Use of ACE inhibitors is also associated with an increased risk of AKI in older people. AKI complicates 10 per cent of hospital admissions in people over 80 and it is estimated that 50 per cent of these admissions are avoidable (Abdel-Kader and Palevsky 2009). AKI is also associated with increased mortality in hospital inpatients. All older people with a systemic infection, particularly if accompanied by dehydration as a result of diarrhoea and vomiting, should be advised to keep hydrated and to withhold any NSAIDs, diuretics, ACE inhibitors and ARBs until they are feeling systemically well. If they are known to have CKD and remain unwell for more than two days, their renal function should be checked. There should be a low threshold for admitting these people to hospital for hydration if their renal function has declined significantly. Early rehydration reduces the severity of AKI and can be lifesaving. All older people admitted to hospital should be assessed for their risk of developing AKI. If initial blood tests show evidence of renal impairment, oral or parenteral hydration should be instigated, fluid input and output should be monitored, and tests for renal function should be repeated within 24 hours. A study found that these simple measures are only put in place 50 per cent of the time (National Confidential Enquiry into Patient Outcome and Death 2009). The high incidence of AKI in older patients is largely attributable to inadequate care (NICE 2013b). Now do time out 3.
3
Acute kidney injury
Time out
2 Time out
but, generally, patients with stage 3a CKD should be monitored annually and those with stage 3b every six months (NICE 2008). Now do time out 2.
Reflect on why older people are at particular risk of acute kidney injury. What factors lead to this predisposition and what can healthcare staff do to minimise this risk?
Polypharmacy A diagnosis of CKD often results in an increase in medication. As already mentioned, control of hypertension often requires multiple agents. CKD is also associated with the following (Davison et al 2005): December 2013 | Volume 25 | Number 10 35
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Continuing professional development ■■ Hyperphosphataemia, which is often treated with three to six pills/capsules daily to bind phosphate in the diet. ■■ Acidosis, which requires six to eight bicarbonate tablets a day. ■■ Gout, which requires allopurinol. ■■ Pruritus, which requires antihistamines and various emollient creams. Older people have a high burden of comorbidities, especially diabetes and heart failure, and often require yet more medication to treat these. They may also require dietary supplements such as iron, folate, vitamin B complex and build-up drinks because of poor nutritional intake. The problem of polypharmacy is compounded by the lack of confidence among doctors without specialist knowledge to ‘interfere’ with drug regimens started at various hospital clinics – the prescription list just gets longer and longer. It is well recognised that complicated drug regimens cause confusion and anxiety in older people, which contribute to poor concordance. There is also a high risk of drug interaction and side effects. Drug regimens should be reviewed regularly to identify agents that are non-essential and to stop as many as possible (Murray and Kroenke 2001). Stage 5 CKD In older people CKD usually remains stable and does not progress to ESRD. It is estimated that people with stage 3a CKD have a 1 per cent chance of developing ESRD in five years (Johnson et al 2008). This means that most people over 75 with CKD die from other causes, usually cardiovascular disease (O’Hare et al 2007). Nonetheless, some older people develop progressive renal impairment, which has the potential to be life-limiting. In older people, decisions about RRT require consideration of multiple health-related and social factors that are less prominent in younger patients (Isles et al 2011). About half of patients over the age of 75 who reach ESRD have at least one comorbidity that significantly affects their quality of life, usually heart failure or ischaemic heart disease. Even among those considered well enough to be taken on to RRT, 50 per cent die within a year of starting (Tamura et al 2012). RRT is therefore not a panacea that can restore older people to health: patient and family expectations should be managed accordingly. The important principle is that patients should always make informed decisions about RRT themselves, with the help of their families and carers, using advice and guidance from specialist staff. Anyone who wishes to be considered for RRT, regardless of age, should be assessed and advised. Modalities of treatment for ESRD RRT is often difficult to undertake in older people. Comorbidities, frailty, 36 December 2013 | Volume 25 | Number 10
functional and cognitive impairment all have a bearing on whether patients would benefit from RRT and, if so, which modality they should choose. Potential transplant recipients need to be sufficiently robust to survive the surgery and to have a life expectancy of about five years after engraftment. The latter point arises because organs for transplantation are in short supply and it is important that they are given to patients who will gain the most benefit. UK transplant units have made a policy of not routinely considering patients aged over 80 for transplant. While haemodialysis can be undertaken at home in certain circumstances, for older patients it is more likely to be done in a dialysis centre where they have the help of specialist nurses. Treatments are undertaken three times a week and last about four hours. Patients are required to make substantial changes to their diet and to restrict their fluid intake significantly. The rigours of this treatment have a significant effect on older people’s quality of life, especially if they have poor cardiac function and cope poorly with the haemodynamic shock of a dialysis session. Nonetheless, it is often surprising how many older people, often in their 90s, cope with haemodialysis and report good quality of life. Dialysis units can also serve as a useful source of social interaction for people who might otherwise lead solitary lives. Health professionals cannot be dogmatic about whom they consider to be unsuitable for treatment. The decision to try haemodialysis rests with the patient. Patients undertake peritoneal dialysis themselves in their homes. Automated machines are used to deliver the dialysate exchanges overnight, every night, and the patient is required to set the machine up at the start of treatment using a pre-programmed cartridge. In older people, peritoneal dialysis has the advantage of being gentler on the cardiovascular system than haemodialysis and it requires less stringent dietary and fluid restrictions. However, the home must be reasonably clean and have space for dialysis stores. Patients must also be able to lift dialysate bags and have sufficient cognitive function and manual dexterity to work the machines. These issues have led to peritoneal dialysis being offered less often to older people than haemodialysis; a situation which many would wish to reverse (Brown et al 2010). A recent innovation has been assisted peritoneal dialysis where patients who cannot undertake dialysis themselves are visited in their homes morning and night by a nurse who initiates and terminates the procedure for them (Oliver et al 2007). The service is limited by cost. Dialysis can have a significant negative effect on quality of life and many older people decide that it is not for them. Active conservative management provides an alternative to RRT and can provide a good quality of life. Indeed, studies have shown that the life expectancy of patients over 80 is little different if NURSING OLDER PEOPLE
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4
Renal replacement therapy
Time out
Low-clearance clinics Making decisions about RRT or conservative management is difficult, particularly for older people who may become bewildered by the amount of information they have to assimilate. Specialist low-clearance clinics are established in all renal units designed specifically to undertake holistic assessment of patient needs. In these clinics patients and their carers are given written and verbal information to make a choice and time to make their decision. People with eGFR less than 20mL/min should be seen in this type of clinic. As RRT is not generally required before eGFR falls below 8mL/min, this gives plenty of time to prepare for the chosen modality, for example, creation of an arteriovenous fistula for haemodialysis or repair of a hernia for peritoneal dialysis, and ensures that patients make decisions before advanced CKD has too great an effect on their cognition (NICE 2008). Once patients decide on a care plan, this is kept under review at each clinic attendance and may change if patients wish. It should be understood that they are not letting anyone down if they switch chosen modality – or even opt to withdraw from RRT altogether. Now do time out 4.
Consider a patient. How do you think they would cope with the different types of renal replacement therapy (RRT)? What factors determine your opinion? If you have a patient on RRT, consider visiting the dialysis unit when they are on treatment. Observe how they cope with the environment, the interaction with other people and the physical process of dialysis itself.
NURSING OLDER PEOPLE
End of life care This is defined as care that helps people with advanced CKD to live as well as possible until they die. It enables the supportive and palliative care needs of patients and families to be identified and met throughout the last phase of life and into bereavement. It includes sharing the expected prognosis with patients and managing the symptoms of uraemia (Russon and Mooney 2010). Patients receiving end of life care include those coming to the end of a conservative management programme and those who have opted to withdraw from RRT because it no longer answers their needs. The prognosis of patients withdrawing from RRT varies according to their residual kidney function, but is usually eight to 11 days (Wong et al 2007). It is more difficult to judge the prognosis of people receiving conservative management because their decline is gradual. Indicators of a prognosis of less than three months include (Wong et al 2007): ■■ eGFR less than 7mL/min. ■■ Intractable symptoms. ■■ Weight loss of more than 10 per cent in six months. ■■ Hypoalbuminaemia (serum albumin less than 24g/L). In CKD, end of life care can and should be planned well in advance with close co-ordination between primary care, palliative care and the renal unit. It is important that a proactive care plan is agreed and documented to ensure continuity. The basis of end of life care is a stepped algorithm (Douglas et al 2009) that is especially configured for the needs of patients with advanced CKD. This is used to escalate intervention according to the patient’s needs. The symptoms commonly encountered in this circumstance and the measures used to ameliorate them are listed in Box 3 (page 38). A framework for end of life care in advanced kidney disease is available (Department of Health 2009), which describes in detail how care should be delivered and how the various agencies should work together optimally. Now do time out 5.
5
Appropriate management
Time out
they have conservative management instead of RRT (Carson et al 2009). Treatment is aimed at reducing the impact of ESRD; notably dietary restriction of protein to reduce uraemic symptoms and to slow progression of CKD, potassium to prevent dangerous hyperkalaemia, and phosphate to reduce blood phosphate which might contribute to pruritus. Symptom control such as antiemetics and anaemia management are also components of this approach. Conservative management is particularly applicable to people leading sedentary lives with comorbidities such as dementia and heart failure, which are likely to make RRT poorly tolerated. Patients on conservative management understand that they may change their minds and have RRT, although it is made clear that initiation of RRT when uraemia is advanced is associated with worse outcomes compared with a properly planned start (Chan et al 2007).
Are you confident that patients with chronic kidney disease in your care are receiving management that is appropriate to their disease stage, their age and their comorbidities? What aspects of their care might be improved?
Conclusion Making a diagnosis of CKD in older people is not straightforward. Insight into the characteristics of the available diagnostic tests is required to identify which people over 75 years of age are at risk. Once December 2013 | Volume 25 | Number 10 37
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Continuing professional development
Symptom
Intervention
Anorexia, nausea and vomiting
Dietary protein restriction can ease symptoms. Regular antiemetics are used at standard doses as required.
Pruritus
Optimise treatment of anaemia and hyperphosphataemia, which can worsen itching. Regular emollients with added antipruritic agents should be applied. Antihistamines and sedatives may be tried.
Fluid overload
Oral furosemide at doses up to 500mg/day. Add metolazone in resistant cases. In terminal phase, opiates should be used to relieve distress.
Restless legs
First, correct anaemia and iron deficiency. Clonazepam, pramipexole or gabapentin are often effective.
Muscle cramps
Quinine can be safely given at standard doses. If necessary, diazepam is a sedating alternative.
Pain
Chronic kidney disease causes accumulation of most opiates, including morphine and diamorphine. This can impair cognition, so fentanyl is the strong analgesic of choice. This can also be used to relieve agitation or distress.
(Lewis 2012)
a diagnosis is established, management of early CKD should be tailored to the individual, in particular avoiding over-aggressive blood pressure control which can be dangerous. In more advanced CKD, carers should be aware of the risk of AKI and take measures to avoid it. At ESRD, older patients expressing an interest in RRT should be assessed by the appropriate specialist team and guided, through education, towards the appropriate care plan.
6
Practice profile
Time out
Box 3 Common symptoms and interventions at end of life in people with chronic kidney disease
Now that you have completed the article you might like to write a practice profile. Guidelines to help you are on page 39.
References Abdel-Kader K, Palevsky P (2009) Acute kidney injury in the elderly. Clinics in Geriatric Medicine. 25, 3, 331-358.
Department of Health (2009) End of Life Care in Advanced Kidney Disease: a Framework for Implementation. DH, London.
Bejan-Angoulvant T, Saadatian-Elahi M, Wright J et al (2010) Treatment of hypertension in patients 80 years and older: the lower the better? A meta-analysis of randomized controlled trials. Journal of Hypertension. 28, 7, 1366-1372.
Douglas C, Murtagh F, Chambers E et al (2009) Symptom management for the adult patient dying with advanced chronic kidney disease: a review of the literature and development of evidence-based guidelines by a United Kingdom Expert Consensus Group. Palliative Medicine. 23, 2, 103-110.
Brown E, Johansson l, Farrington K et al (2010) Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients. Nephrology, Dialysis, Transplantation. 25, 11, 3755-3763. Carson R, Juszczak M, Davenport A et al (2009) Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clinical Journal of the American Society of Nephrology. 4, 10, 1611-1619. Chan M, Dall A, Fletcher K et al (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis. American Journal of Medicine. 120, 12, 1063-1070. Chandna S, Da Silva-Gane M, Marshall C et al (2011) Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrology, Dialysis, Transplantation. 26, 5, 1608-1614. Davison A, Cameron S, Grünfeld J-P et al (Eds) (2005) Oxford Textbook of Clinical Nephrology. Third edition. Oxford University Press, Oxford.
Hillege H, Fidler V, Diercks G et al (2002) Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population. Circulation. 106, 14, 1777-1782. Isles C, Robertson S, Almond A et al (2011) The challenges of renal replacement therapy and renal palliative care in the elderly. Journal of the Royal College of Physicians of Edinburgh. 41, 3, 238-243. Johnson E, Thorp M, Platt R et al (2008) Predicting the risk of dialysis and transplant among patients with CKD: a retrospective cohort study. American Journal of Kidney Diseases. 52, 4, 653-660. Kidney Disease Improving Global Outcomes (2013) KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. tinyurl.com/m4hbcgm (Last accessed: November 11 2013.) Lewis R (2012) Understanding Chronic Kidney Disease: a Guide for the Non-Specialist. M & K Publishing, Keswick.
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Murray M, Kroenke K (2001) Polypharmacy and medication adherence: small steps on a long road. Journal of General Internal Medicine. 16, 2, 137-139.
Oliver M, Quinn R, Richardson E et al (2007) Home care assistance and the utilization of peritoneal dialysis. Kidney International. 71, 7, 673-678.
National Confidential Enquiry into Patient Outcome and Death (2009) Adding Insult to Injury: A Review of the Care of Patients who Died in Hospital with a Primary Diagnosis of Acute Kidney Injury (Acute Renal Failure). NCEPOD, London.
Renal Association UK Renal Registry (2012) 15th Annual Report. December 2012. www.renalreg.com/Reports/2012.html (Last accessed: November 11 2013.)
National Institute for Health and Care Excellence (2008) Chronic Kidney Disease: Early Identification and Management of Chronic Kidney Disease in Adults in Primary and Secondary Care. Clinical guideline 73. NICE, London. National Institute for Health and Care Excellence (2013a) About the Quality and Outcomes Framework (QOF). www.nice.org.uk/ aboutnice/qof/qof.jsp (Last accessed: October 30 2013.) National Institute for Health and Care Excellence (2013b) Acute Kidney Injury. Prevention, Detection and Management of Acute Kidney Injury up to the Point of Renal Replacement Therapy. Clinical guideline 169. http://guidance.nice.org.uk/CG169/ NICEGuidance/pdf/English (Last accessed: November 11 2013.) O’Hare A, Choi A, Bertenthal D et al (2007) Age affects outcomes in chronic kidney disease. Journal of the American Society of Nephrology. 18, 10, 2758-2765.
Russon L, Mooney A (2010) Palliative and end-of-life care in advanced renal failure. Clinical Medicine. 10, 3, 279-281. Tamura M, Tan J, O’Hare A (2012) Optimizing renal replacement therapy in older adults: a framework for making individualized decisions. Kidney International. 82, 3, 261-269. UK Renal Association (2010) Anaemia of CKD. www.renal.org/clinical/guidelinessection/ AnaemiaInCKD.aspx (Last accessed: November 11 2013.) Weiner D, Tighiouart H, Amin M et al (2004) Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies. Journal of the American Society of Nephrology. 15, 5, 1307-1315. Weiner D, Tabatabai S, Tighiouart H et al (2006) Cardiovascular outcomes and all-cause mortality: exploring the interaction between CKD and cardiovascular disease. American Journal of Kidney Diseases. 48, 3, 392-401. Wong C, McCarthy M, Howse M et al (2007) Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Renal Failure. 29, 6, 653-659.
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