LOOKING AT LONG-TERM CONDITIONS
Chronic kidney disease: supporting at-risk and diagnosed patients Aysha Mendes discusses the effects of chronic kidney disease and points out the indispensable role that community nurses can play in terms of prevention, diagnosis, treatment and helping patients to live with the disease
© 2015 MA Healthcare Ltd
C
hronic kidney disease (CKD) is common among older people, with 20% of men and 25% of women between the ages of 65 and 74 estimated to have some degree of it (NHS Choices, 2013). In England, 1.8 million people had been diagnosed as of 2012 and a further 1 million were thought to be living with it undiagnosed (Brimelow, 2012). CKD is a blanket term used to describe any abnormality of the kidney, ranging from very slight damage to established kidney failure (National Kidney Federation, 2013). The main function of the kidney is to filter out waste products from the blood before turning them into urine (NHS Choices, 2013). However, kidneys are also responsible for helping to maintain blood pressure, regulate chemical levels which help the heart and muscles function correctly, produce the active form of vitamin D helping to keep bones healthy, and produce erythropoietin which stimulates blood cell production (NHS Choices, 2013). CKD is the kidney’s reduced ability to carry out these functions in the long term (NHS Choices, 2013). Most cases are mild or moderate and do not progress to kidney failure (Tidy, 2014). However, not only does this mean that more people are living with it than are dying with it, and looking to live well, but also, people at any stage of CKD are at increased risk of other complications, particularly diseases of the heart and arteries (NHS Choices, 2014a), as well as depression, anaemia and bone disorders among others (NHS Kidney Care, 2010). Catching the disease at an early stage is essential to reducing its impact on people’s lives, but the challenge is that it tends to remain symptomless until it reaches an advanced stage (NHS Choices, 2013). The reason for this is that people are born with a lot more kidney function than they need to survive and therefore, can tolerate a large reduction in kidney function before any symptoms appear (NHS Choices, 2014b). However, once at an advanced stage, patients usually experience symptoms such as tiredness, swollen ankles, shortness of breath, nausea and blood in the urine (NHS Choices, 2013). Other symptoms of kidney failure may also include weight loss, insomnia, itchy skin, muscle cramps, high blood pressure and erectile dysfunction in men (NHS Choices, 2014b).
Diagnosing CKD In addition to being able to prevent complications and maintain a good quality of life for people with CKD,
British Journal of Community Nursing February 2015 Vol 20, No 2
detecting it and treating it early can slow, or even stop, its progression (Kidney Research UK, 2013). CKD is most often detected through routine blood and urine tests (NHS Choices, 2013). People at high risk of kidney disease should be screened by blood test annually (NHS Choices, 2014c), and it is part of a community nurse’s role to ensure that this is indeed happening. People at high risk of kidney disease include those with (NHS Choices, 2013; 2014d): w Diabetes w High blood pressure (hypertension) w Acute kidney injury (AKI) caused by medications (e.g. lithium, non-steroidal anti-inflammatory drugs (NSAIDs)), kidney stones or enlarged prostate w Vascular disease (any condition of the heart, arteries and veins, e.g. coronary heart disease, stroke) w Heart failure w A family history of CKD w Diseases that affect several parts of the body and may affect the kidneys, e.g. systemic lupus erythematosus w Blood in the urine (haematuria) or protein in the urine (proteinuria) with no known cause.
Preventing CKD The best way for community nurses to help patients avoid CKD is by ensuring that any existing conditions, such as diabetes or hypertension, are carefully managed (Rayner et al, 2012). As with most long-term conditions, lifestyle changes play a tremendous role. Community nurses can therefore also provide patients with appropriate lifestyle advice, as well as any tools, resources and support that can facilitate their uptake of this advice, and the continued effort and engagement to make lasting change (Mendes, 2014a). Some of the changes community nurses can advise and support patients to make are to eat a healthy diet, including fresh fruit and vegetables, less processed, fat-rich and sugar-rich foods, less salt (sodium) and no salt substitutes
Aysha Mendes
Freelance journalist specialising in health, psychology and nursing Email: [email protected]
97
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 19, 2015. For personal use only. No other uses without permission. . All rights re
LOOKING AT LONG-TERM CONDITIONS (potassium), as well as quitting smoking, avoiding excessive amounts of alcohol and medicines that can damage the kidneys, and engaging in regular physical activity (NHS Choices, 2013; Kidney Research UK, 2013; National Institute for Health and Care Excellence (NICE), 2014). Both community nurses and patients, particularly if they are at higher risk of CKD, should also familiarise themselves with some of the signs that can indicate kidney disease, among other problems. Some examples include darkness, redness, odour or foamy appearance of urine, as well as persistent thirst, unexplained tiredness or illness, pruritis, oedema, anaemia and back pain in the renal area, particularly if accompanied by fever (Kidney Research UK, 2013).
current care plan that is appropriate to the stage and progression of their disease, and that it is regularly reviewed in collaboration with them (NICE, 2011). This includes having an advanced care plan for end-of-life care where appropriate (NICE, 2011). Such a process should begin early (Mendes, 2014b). Community nurses have an important and unique role to play in closely monitoring patients’ conditions, informing and coaching them, and providing them with invaluable support and compassion. BJCN Best practice advice and more in-depth guidance related to CKD can be found at http://tinyurl.com/n46gaet (NICE, 2014). Brimelow A (2012) Kidney care ‘needs to improve’. BBC Health, 6 August. http://tinyurl.com/q63cmzf (accessed 16 January 2015) Kidney Research UK (2013) Chronic kidney disease. http://tinyurl.com/ qdn9enq (accessed 16 January 2015) Mendes A (2014a) Change management in diabetes care. Br J Community Nurs 19(11): 559. doi: 10.12968/bjcn.2014.19.11.559 Mendes A (2014b) First priority of care: recognising and communicating the end of life. Journal of Renal Nursing 6(6): 298–9. doi: http://dx.doi.org/10.12968/ jorn.2014.6.6.298 National Institute for Health and Care Excellence (2011) Chronic kidney disease. Quality statement 3: Planning care. http://tinyurl.com/ken83gz (accessed 16 January 2015) National Institute for Health and Care Excellence (2014) Chronic kidney disease. NICE clinical guideline 182. http://tinyurl.com/n46gaet (accessed 16 January 2015) National Kidney Federation (2013) Chronic kidney disease (CKD). http:// tinyurl.com/lccyypu (accessed 16 January 2015) NHS Choices (2013) Chronic kidney disease: introduction. http://tinyurl.com/ n6lz4eg (accessed 16 January 2015) NHS Choices (2014a) National service frameworks and strategies: setting standards in kidney care. http://tinyurl.com/l7cm3fm (accessed 16 January 2015) NHS Choices (2014b) Chronic kidney disease: symptoms. http://tinyurl.com/ c394gs8 (accessed 19 January 2015) NHS Choices (2014c) Health checks for the over-65s. http://tinyurl.com/ mho9crn (accessed 16 January 2015) NHS Choices (2014d) Chronic kidney disease: diagnosis. http://tinyurl.com/ pv5z9qk (accessed 16 January 2015) NHS Choices (2014e) Chronic kidney disease: treatment. http://tinyurl.com/ ndp2l99 (accessed 16 January 2015) NHS Kidney Care (2010) Kidney Disease: Key Facts and Figures. http://tinyurl. com/mlpfbjl (accessed 16 January 2015) Rayner H, Pal R, Dasgupta I (2012) CKD made easy: a guide for general practice. http://tinyurl.com/l9294j6 (accessed 16 January 2015) Tidy C (2014) Chronic kidney disease. http://tinyurl.com/olcogw9 (accessed 16 January 2015) Zalai D, Szeifert L, Novak M (2012) Psychological distress and depression in patients with chronic kidney disease. Semin Dial 25(4): 428–38. doi: 10.1111/j.1525-139X.2012.01100.x
Treatment, education and support In addition to all of the lifestyle changes listed above, treatment of CKD involves taking medication to control blood pressure and lower blood cholesterol levels (NHS Choices, 2014e). In late-stage kidney disease (stage 5), renal replacement therapy or a kidney transplant may be considered, while some patients will prefer to be conservatively managed (Rayner et al, 2012). However, all treatment options should be thoroughly discussed so that patients can make an informed decision that they feel good about and don’t later come to regret, which can occur, for example, when patients who opt for dialysis aren’t aware of the impact this can have on their quality of life (Rayner et al, 2012). Diagnosis and treatment of CKD can come with a tremendous amount of worry and psychological distress, particularly if the disease is not caught early, or when it begins to progress to later stages (Zalai et al, 2012). Community nurses can play a role by having open, honest and sensitive discussions with patients about the facts and uncertainties of their condition as it stands and in the case that it progresses, as well as providing information about the disease and what patients can do to live well with it. Patients may also find referral to additional resources and support services valuable; for example, the British Kidney Patient Association (BKPA). It is important to ensure that patients have an agreed
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© 2015 MA Healthcare Ltd
Community nurses, join in the conversation online
British Journal of Community Nursing February 2015 Vol 20, No 2
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 19, 2015. For personal use only. No other uses without permission. . All rights re
Chronic kidney disease: supporting at-risk and diagnosed patients Aysha Mendes discusses the effects of chronic kidney disease and points out the indispensable role that community nurses can play in terms of prevention, diagnosis, treatment and helping patients to live with the disease
© 2015 MA Healthcare Ltd
C
hronic kidney disease (CKD) is common among older people, with 20% of men and 25% of women between the ages of 65 and 74 estimated to have some degree of it (NHS Choices, 2013). In England, 1.8 million people had been diagnosed as of 2012 and a further 1 million were thought to be living with it undiagnosed (Brimelow, 2012). CKD is a blanket term used to describe any abnormality of the kidney, ranging from very slight damage to established kidney failure (National Kidney Federation, 2013). The main function of the kidney is to filter out waste products from the blood before turning them into urine (NHS Choices, 2013). However, kidneys are also responsible for helping to maintain blood pressure, regulate chemical levels which help the heart and muscles function correctly, produce the active form of vitamin D helping to keep bones healthy, and produce erythropoietin which stimulates blood cell production (NHS Choices, 2013). CKD is the kidney’s reduced ability to carry out these functions in the long term (NHS Choices, 2013). Most cases are mild or moderate and do not progress to kidney failure (Tidy, 2014). However, not only does this mean that more people are living with it than are dying with it, and looking to live well, but also, people at any stage of CKD are at increased risk of other complications, particularly diseases of the heart and arteries (NHS Choices, 2014a), as well as depression, anaemia and bone disorders among others (NHS Kidney Care, 2010). Catching the disease at an early stage is essential to reducing its impact on people’s lives, but the challenge is that it tends to remain symptomless until it reaches an advanced stage (NHS Choices, 2013). The reason for this is that people are born with a lot more kidney function than they need to survive and therefore, can tolerate a large reduction in kidney function before any symptoms appear (NHS Choices, 2014b). However, once at an advanced stage, patients usually experience symptoms such as tiredness, swollen ankles, shortness of breath, nausea and blood in the urine (NHS Choices, 2013). Other symptoms of kidney failure may also include weight loss, insomnia, itchy skin, muscle cramps, high blood pressure and erectile dysfunction in men (NHS Choices, 2014b).
Diagnosing CKD In addition to being able to prevent complications and maintain a good quality of life for people with CKD,
British Journal of Community Nursing February 2015 Vol 20, No 2
detecting it and treating it early can slow, or even stop, its progression (Kidney Research UK, 2013). CKD is most often detected through routine blood and urine tests (NHS Choices, 2013). People at high risk of kidney disease should be screened by blood test annually (NHS Choices, 2014c), and it is part of a community nurse’s role to ensure that this is indeed happening. People at high risk of kidney disease include those with (NHS Choices, 2013; 2014d): w Diabetes w High blood pressure (hypertension) w Acute kidney injury (AKI) caused by medications (e.g. lithium, non-steroidal anti-inflammatory drugs (NSAIDs)), kidney stones or enlarged prostate w Vascular disease (any condition of the heart, arteries and veins, e.g. coronary heart disease, stroke) w Heart failure w A family history of CKD w Diseases that affect several parts of the body and may affect the kidneys, e.g. systemic lupus erythematosus w Blood in the urine (haematuria) or protein in the urine (proteinuria) with no known cause.
Preventing CKD The best way for community nurses to help patients avoid CKD is by ensuring that any existing conditions, such as diabetes or hypertension, are carefully managed (Rayner et al, 2012). As with most long-term conditions, lifestyle changes play a tremendous role. Community nurses can therefore also provide patients with appropriate lifestyle advice, as well as any tools, resources and support that can facilitate their uptake of this advice, and the continued effort and engagement to make lasting change (Mendes, 2014a). Some of the changes community nurses can advise and support patients to make are to eat a healthy diet, including fresh fruit and vegetables, less processed, fat-rich and sugar-rich foods, less salt (sodium) and no salt substitutes
Aysha Mendes
Freelance journalist specialising in health, psychology and nursing Email: [email protected]
97
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 19, 2015. For personal use only. No other uses without permission. . All rights re
LOOKING AT LONG-TERM CONDITIONS (potassium), as well as quitting smoking, avoiding excessive amounts of alcohol and medicines that can damage the kidneys, and engaging in regular physical activity (NHS Choices, 2013; Kidney Research UK, 2013; National Institute for Health and Care Excellence (NICE), 2014). Both community nurses and patients, particularly if they are at higher risk of CKD, should also familiarise themselves with some of the signs that can indicate kidney disease, among other problems. Some examples include darkness, redness, odour or foamy appearance of urine, as well as persistent thirst, unexplained tiredness or illness, pruritis, oedema, anaemia and back pain in the renal area, particularly if accompanied by fever (Kidney Research UK, 2013).
current care plan that is appropriate to the stage and progression of their disease, and that it is regularly reviewed in collaboration with them (NICE, 2011). This includes having an advanced care plan for end-of-life care where appropriate (NICE, 2011). Such a process should begin early (Mendes, 2014b). Community nurses have an important and unique role to play in closely monitoring patients’ conditions, informing and coaching them, and providing them with invaluable support and compassion. BJCN Best practice advice and more in-depth guidance related to CKD can be found at http://tinyurl.com/n46gaet (NICE, 2014). Brimelow A (2012) Kidney care ‘needs to improve’. BBC Health, 6 August. http://tinyurl.com/q63cmzf (accessed 16 January 2015) Kidney Research UK (2013) Chronic kidney disease. http://tinyurl.com/ qdn9enq (accessed 16 January 2015) Mendes A (2014a) Change management in diabetes care. Br J Community Nurs 19(11): 559. doi: 10.12968/bjcn.2014.19.11.559 Mendes A (2014b) First priority of care: recognising and communicating the end of life. Journal of Renal Nursing 6(6): 298–9. doi: http://dx.doi.org/10.12968/ jorn.2014.6.6.298 National Institute for Health and Care Excellence (2011) Chronic kidney disease. Quality statement 3: Planning care. http://tinyurl.com/ken83gz (accessed 16 January 2015) National Institute for Health and Care Excellence (2014) Chronic kidney disease. NICE clinical guideline 182. http://tinyurl.com/n46gaet (accessed 16 January 2015) National Kidney Federation (2013) Chronic kidney disease (CKD). http:// tinyurl.com/lccyypu (accessed 16 January 2015) NHS Choices (2013) Chronic kidney disease: introduction. http://tinyurl.com/ n6lz4eg (accessed 16 January 2015) NHS Choices (2014a) National service frameworks and strategies: setting standards in kidney care. http://tinyurl.com/l7cm3fm (accessed 16 January 2015) NHS Choices (2014b) Chronic kidney disease: symptoms. http://tinyurl.com/ c394gs8 (accessed 19 January 2015) NHS Choices (2014c) Health checks for the over-65s. http://tinyurl.com/ mho9crn (accessed 16 January 2015) NHS Choices (2014d) Chronic kidney disease: diagnosis. http://tinyurl.com/ pv5z9qk (accessed 16 January 2015) NHS Choices (2014e) Chronic kidney disease: treatment. http://tinyurl.com/ ndp2l99 (accessed 16 January 2015) NHS Kidney Care (2010) Kidney Disease: Key Facts and Figures. http://tinyurl. com/mlpfbjl (accessed 16 January 2015) Rayner H, Pal R, Dasgupta I (2012) CKD made easy: a guide for general practice. http://tinyurl.com/l9294j6 (accessed 16 January 2015) Tidy C (2014) Chronic kidney disease. http://tinyurl.com/olcogw9 (accessed 16 January 2015) Zalai D, Szeifert L, Novak M (2012) Psychological distress and depression in patients with chronic kidney disease. Semin Dial 25(4): 428–38. doi: 10.1111/j.1525-139X.2012.01100.x
Treatment, education and support In addition to all of the lifestyle changes listed above, treatment of CKD involves taking medication to control blood pressure and lower blood cholesterol levels (NHS Choices, 2014e). In late-stage kidney disease (stage 5), renal replacement therapy or a kidney transplant may be considered, while some patients will prefer to be conservatively managed (Rayner et al, 2012). However, all treatment options should be thoroughly discussed so that patients can make an informed decision that they feel good about and don’t later come to regret, which can occur, for example, when patients who opt for dialysis aren’t aware of the impact this can have on their quality of life (Rayner et al, 2012). Diagnosis and treatment of CKD can come with a tremendous amount of worry and psychological distress, particularly if the disease is not caught early, or when it begins to progress to later stages (Zalai et al, 2012). Community nurses can play a role by having open, honest and sensitive discussions with patients about the facts and uncertainties of their condition as it stands and in the case that it progresses, as well as providing information about the disease and what patients can do to live well with it. Patients may also find referral to additional resources and support services valuable; for example, the British Kidney Patient Association (BKPA). It is important to ensure that patients have an agreed
BREAKING NEWS: ‘Like’ us on Facebook (www.facebook.com/communitynursing)
Follow us on Twitter (@BJCommunityNurs)
Join our community nurses group on LinkedIn (www.linkedin.com, then search British Journal of Community Nursing)
and stay in contact with us with your views or ideas ([email protected])
www.magonlinelibrary.com/toc/bjcn/current 98
© 2015 MA Healthcare Ltd
Community nurses, join in the conversation online
British Journal of Community Nursing February 2015 Vol 20, No 2
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 19, 2015. For personal use only. No other uses without permission. . All rights re
