Chronic Kidney Disease Partners In Health - PowerPoint Presentation

Slide1

Chronic Kidney Disease

Partners In Health Chronic care Training For district hospital Nurses in Rwanda 2013

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Session 1: Defining chronic kidney disease

By the end of this Session, participants will be able to:Screen for chronic kidney diseaseDescribe the most common causes of chronic kidney diseaseDescribe the classifications of chronic kidney disease

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Session 1: Defining chronic kidney disease

By the end of this Session, participants will be able to:Screen for chronic kidney diseaseDescribe the most common causes of chronic kidney diseaseDescribe the classifications of chronic kidney disease

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Symptoms of chronic kidney disease (CKD)

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Physical Exam Findings

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Screening for CKD with urine dipstick

The cutoff for proteinuria positive reading is 2+

Urine dipstick result

24-hour urine proteinDipstick result may be suggestive of:

2+

0.5-1.5

gm

Proteinuria

3+

2-5

gm

Nephrotic

-range

4+

7

gm

Nephrotic

-range

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Screening for CKD

All patients with the following diseases should be screened for chronic kidney disease with a urine dipstick:

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Session 1: Defining chronic kidney disease

By the end of this Session, participants will be able to:Screen for chronic kidney diseaseDescribe the most common causes of chronic kidney diseaseDescribe the classifications of chronic kidney disease

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Common Causes of CKD

HypertensionScreen all patients with a blood pressure greater than 160/100

mmHg for proteinuria. Patients with greater than 2+ proteinuria should have their creatinine measured. Patients

younger than 40 who have stage II or greater hypertension should undergo further investigation.

Diabetes

All patients diagnosed with diabetes should have a urine dipstick test performed twice per

year

and serum creatinine checked annually.

HIV

HIV causes renal failure through damage to the glomerulus (part of the kidney that prevents protein from entering urine). This results in HIV-related nephropathy (HIVAN)

Higher rates are associated with more severe HIV disease and it often improves with treatment with ARVs

Screen all HIV patients for proteinuria

Those with

proteinuria

should be started on an ACE inhibitor

Those with chronic renal failure should be started on ARVs regardless of CD4 count.

Screen for

PROTEINURIA

!!

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Epidemiology

Glomerulonephritis

or unknownHypertensionDiabetesOther

AfricaAverage for Nigeria and Senegal

54%

27.4%

11.9%

6.7%

USA

15.4%

24.2%

37.3%

22.9%

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Session 1: Defining chronic kidney disease

By the end of this Session, participants will be able to:Screen for chronic kidney diseaseDescribe the most common causes of chronic kidney diseaseDescribe the classifications of chronic kidney disease

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Stages of Chronic Kidney Disease (CKD)

Degree of dysfunction

Approximate creatinine cutoff for adultsApproximate creatinine cutoff for childrenCKD 1 and 2

Mild dysfunction

< 100 µ

mol

/L

< 1.1 mg/

dL

Normal creatinine for age

CKD 3

Moderate dysfunction

100–199 µ

mol

/L

1.1–2.3 mg/

dL

Normal to < 2x normal creatinine for age

CKD 4 and 5

Severe dysfunction

≥ 200* µ

mol

/L

> 2.3 mg/

dL

≥ 2x normal creatinine for age

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Session 2: Management of CKD in adults

By the end of this Session, participants will be able to:Describe the initial management of CKD 1 and 2Describe the initial and ongoing management of CKD 3, 4, and 5

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Session 2: Management of CKD in adults

By the end of this Session, participants will be able to:Describe the initial management of CKD 1 and 2Describe the initial and ongoing management of CKD 3, 4, and 5

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Overview of CKD Management

IF creatinine < 200 mmol/L: start an ACE inhibitor at a low dose with a goal blood pressure of less than 120/80 mmHg.

AVOID Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, and other kidney toxinsCAUTION with medications that can cause kidney toxicity ( Tenofovir, Gentamicin)CHECK CREATININE

every year through blood test

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Initial Evaluation of CKD Stage 1 & 2

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Initial management of CKD 1-2

Refer to hospital if:dyspnea or other symptoms & signs of volume overloadurinary retention CHECK blood pressureconfusionchest pain

CHECK proteinuriaIf proteinuria is > 3+ rule out nephrotic syndromeCheck HIV status to rule out HIV associated nephropathyFor CKD 1-2 (GFR > 60): Start low dose

ACE-inhibitor (

lisinopril

or

captopril

)

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Session 2: Management of CKD in adults

By the end of this Session, participants will be able to:Describe the initial management of CKD 1 and 2Describe the initial and ongoing management of CKD 3, 4, and 5

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CKD Stage 3, 4, or 5

Patients with moderate to severe CKD (CKD 3, 4, or 5) should be closely evaluated for reversible causes of their disease Patients with CKD 3 (as well as with Stages 1 and 2) are usually asymptomatic and so are identified through screening because they have another disease (such as heart failure).Patients with CKD 4 or 5 will often be symptomatic and initial evaluation will take place in the hospital.

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Initial Evaluation of CKD Stage 3, 4, 5

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Initial management of CKD state 3, 4, 5

REFER TO HOSPITAL if:dyspnea or other symptoms & signs of volume overloadurinary retention confusionchest painBP control: the goal is < 130/80Start iron supplementCKD 3  Can start low dose ACE-inhibitor if creatinine <200

Monitor creatinine closely (2-4 weeks after starting drug, then in 6 months, then yearly)Monitor potassium (K+)CKD 4, 5: avoid ACE-inhibitors, consider furosemide

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On-going care of CKD Stage 3

All adult patients with CKD 3 should receive iron supplementation if their hemoglobin is less than 10 mg/dL. The preferred dose is 200 mg of ferrous sulfate 3 times per day for 30 days. Maintain blood pressures below 130/80 mmHg with an ACE-inhibitor if creatinine less than 2.3 mg/dL or 200 µmol/L

) Furosemide is often a helpful adjuvant therapy for edema.

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CKD Stage 4 or 5

All patients should have their blood pressure controlled if possible. ACE inhibitors should be avoided. High doses of furosemide may be required. When symptoms become a predominant concern, the focus should be on quality of life.

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Normal Creatinine Ranges for Children

AgeCreatinine Range

Newborn27–88 µmol/L (0.3–1.0 mg/dL)Infant or pre-school-aged child

2 months – 4 years

18–35 µ

mol

/L (0.2–0.5 mg/

dL

)

School-aged child

5–10 years

27–62 µ

mol

/L (0.3–0.7 mg/

dL

)

Older child or adolescent

44–88 µ

mol

/L (0.5–1.0 mg/

dL

)

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Session 3: Care of end-stage kidney disease

By the end of this Session, participants will be able to:Describe the most common physical symptoms of end-stage CKDReview treatments for the most common physical symptoms of CKDDescribe the psychological symptoms of CKDDiscuss renal replacement therapy

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Palliative Care

At any stage of CKD, pain, dyspnea, and other distressing symptoms may occur and should be treated. Initiate conversations about goals of palliative care early and continue the discussion throughout. Conversations should include information about symptom control as well as responses to potential psychosocial distress. Explain to patients and families that in the later stages of CKD, many patients will have an increasing need for palliative care, including relief from physical symptoms and psychosocial distress.

In the moments before death, patients will also suffer intractable nausea and vomiting, mental status changes, and seizures as a result of the buildup of urea and other toxins.Palliative Care Role Play:

The first participant will play the role of the nurse. The nurse discusses the symptoms that may develop as the disease progresses, and outlines the palliative care responses that are available.

T

he second participant will play the role of the patient with Stage 4 CKD.

The patient is having pain and anxiety and is concerned about what will happen as the disease gets worse.

The third participant will play the role of a family member.

The family member spends all his/her time comforting the patient, but does not know what else to do to help.

Role Play Feedback

What did the nurse do well? What could the nurse improve next time?

What are the next steps for the patient? What are the next steps for the family member?

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Physical symptom

CauseTreatment

Fatigue and drowsinessDepressionAssess for depression and treat if found.

Fluid overload

Diurese

for fluid overload, if needed.

Anemia, poor nutrition, other organ failure, uremia, insomnia

Nutrition counseling & micronutrient supplementation as needed

Itch

Dry skin

Emollients for dry skin.

Secondary hyperparathyroidism

Hyperphosphatemia

Anemia

Opioids

Antihistamine such as diphenhydramine (can worsen fatigue and delirium).

Steroid.

Palliative Care

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Physical symptom

CauseTreatment

DyspneaPulmonary edemaPleural effusionMetabolic acidosisAnemia

Aspiration

Comorbid CHF, COPD, or other lung pathology

If comfort and quality of life are the only goals of care, not preservation of renal function,

diurese

for symptomatic pulmonary or peripheral edema.

Opioid relieves dyspnea of any cause. Renal dosing

for morphine

Delirium

Metabolic

derangements

Hypoxia/

hypercapnia

Medications

Reduce or eliminate culprit medications, if possible.

Haloperidol

Pain

Bone pain due to 2˚

hyperparathyroidism

Diabetic neuropathy

Polycystic kidney disease

Calciphylaxis

(hemodialysis patients only)

Avoid NSAIDS due to nephrotoxicity and increased risk of bleeding with uremic platelet dysfunction.

Paracetamol

is safe and requires no dose adjustment for renal failure.

Morphine: active metabolite accumulates in CKD 5 and can cause neurotoxicity. Use lower dose and/or longer dosing interval than usual.

Palliative Care

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Physical symptom

CauseTreatment

AnorexiaNausea (see next slide)Diabetic gastroparesisDry mouth

Anti-emetics (see below).

Metoclopramide for

gastroparesis

.

Oral care.

Swelling in legs/arms

Fluid overload

Low oncotic pressure due to proteinuria and malnutrition

Comorbid heart failure

Elevate edematous extremities (although this may exacerbate pulmonary edema).

Elastic wraps as tolerated.

If comfort and quality of life are the only goals of care, not preservation of renal function,

diurese

for symptomatic peripheral edema or

anasarca

. This may require higher than normal furosemide doses.

Dry

mouth

Intravascular volume depletion (can exist even with total body fluid overload).

Instruct family caregivers to keep mouth moist with sips of liquid or sponge.

Palliative Care

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Physical symptom

CauseTreatment

ConstipationMedications including opioids and anticholinergicsIntravascular volume depletionLaxative

Nausea

with or without vomiting

Uremia

Emetogenic

medications

Diabetic

gastroparesis

Reduce or eliminate culprit medications, if possible.

Haloperidol for nausea due to endogenous or exogenous

emetogenic

toxin. Start with low dose.

Metoclopramide for

gastroparesis

.

Cough

Pulmonary edema

Aspiration

Comorbid COPD or other lung pathology

If comfort and quality of life are the only goals of care, not preservation of renal function,

diurese

for symptomatic pulmonary edema.

Opioid relieves cough of any cause. Renal dosing for morphine.

Palliative Care

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Psychological symptom

TreatmentAnxiety

Psychosocial supportsHaloperidolDiazepam (can cause delirium and paradoxical agitation)Feeling sad

Psychosocial supports

Depression

Psychosocial supports

Antidepressant such as fluoxetine or amitriptyline

Common Psychological Symptoms in Advanced CKD

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Renal replacement therapy (Dialysis)

End-stage renal disease (CKD 5) is fatal in a matter of days or weeks. Dialysis offers an effective and immediate solution to otherwise imminent death from renal failure. Dialysis may be performed by filtering the blood through a membrane (hemodialysis), or by filtering the blood across the peritoneum (peritoneal dialysis). Hemodialysis is technically demanding and very expensive.

Peritoneal dialysis is a preferable option in resource-limited settings but there is a risk of peritoneal infection Dialysis of either kind is currently performed in Rwanda only at referral centers.

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Case Study 1

25 year old man complains of rapid weight gain and edema in his legs. What are the next steps in making the diagnosis?Urine dipstick for protein and creatinine (it is important to do both in order to stage the disease). If proteinuria is 2+ and the creatinine is elevated, refer for renal ultrasound. Also, check blood glucose, HIV status, and blood pressure.What medications should he be started on?ACE inhibitor if creatinine <200, lasix for edema. May start other blood pressure medications if the BP is elevated.

Consider starting ferrous sulfate if anemic.

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Case Study 2

28 year old woman with CKD stage 4 presents to NCD clinic for a follow up visit. Her blood pressure is 15/9 and creatinine is 600 µmol/L.What medications should she be started on?Lasix, perhaps doses as high as 200mg BDNifedipine

, hydralazine, isosorbide, atenolol, or other medications to control BP to < 13/8.What medications should be avoided?ACE inhibitors because of the elevated creatinineNSAIDS, and any nephrotoxic medications like

gentamicinWhat symptoms may she have at CKD stage 4 or 5 and what are some treatments?

Nausea, vomiting: treat with metoclopramide

Drowsiness, fatigue: assess for depression and treat with

anafranil

Dyspnea: increase

lasix

dose for comfort if necessary

Itching: diphenhydramine, promethazine, or

chlorpheniramine

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Key Points

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Thank you for your hard work and dedication

to health and human rights!

Matilda

Nikolasi

talks with PIH clinician Joe Lusaka and was the first of many to be served during the new

Dambe

Health Center’s first day on April 25, 2016 in Malawi. She was screened for Hypertension, HIV and Diabetes during this visit through the SHARF (Screening for health and referrals at the facilities) initiative.

(Photo by Nandi

Bwanali

/ Partners In Health)