Irish Practice Nurses Association Annual Conference Tullamore Court Hotel OCTOBER 6 th 2012 Susan McKenna Renal Clinical Nurse Specialist Cavan General Hospital
Renal patient population ACUTE RENAL FAILURE Chronic Kidney Disease (CKD) End Stage Renal Disease (ESRD) Conservative management of ESRD Transplant patient
Risk Factors for CKD The most common causes of ESRD are: Diabetes Hypertension Vascular nephropathies Glomerulonephritis Obstructive nephropathy / reflux nephropathy Polycystic kidney disease NSAIDS, Antibiotics, Lithium, dyes Autoimmune diseases CKD is prevalent in diabetology and cardiology practices Reviewed by Parmar. BMJ 2002; 325:85-89
Measuring renal function 24 hour collection Creatinine - < 130 Urea - < 7.5 Modified Diet in Renal Disease (MDRD) scr, age, sex, albumin, race estimated Glomerular Filtration Rate mls/min egfr tables egfr on all biochemistry
Stages of CKD CKD CARE ESRD End Stage Renal Disease Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 >90 (& kidney damage) 60-89 30-59 15-29 <15 egfr* (ml/min/1.73m 2 ) (or dialysis) *It can be helpful to think of egfr (ml/min/1.73m 2 ) as an approximation of % kidney function Adapted from F Drüeke, WCN Presentation 2005
Serum creatinine is not a good measure of egfr AGE GENDER BODY WT. MUSCLE MASS RACE SCr 120uMol/ L = 120 umol/l egfr 30mls/min 130 mls/min
egfr Calculator
On line egfr Calculator
egfr on Lab result
Nephrotic Syndrome - ESRD
IGA Nephropathy Dialysis
Conservative mgt - Death
ANCA+ Vasculitis - Recovered
Increasing event rate >60 45-59 30-44 15-29 <15 >60 45-59 30-44 15-29 <15 >60 45-59 30-44 15-29 <15 Rates per 100 person years Rates per 100 person years Rates per 100 person years Prognosis Declines with Progressing CKD Hospitalisation CV Events Death 150 40 15 100 50 30 20 10 10 5 0 0 0 egfr (ml/min/1.73m 2 ) Decreasing egfr egfr (ml/min/1.73m 2 ) egfr (ml/min/1.73m 2 ) Adapted from Go et al. NEJM 2004; 351:1296-1305
What is Chronic Kidney disease? egfr of < 60mls / Min for a period of 3 months or more - With or without evidence of kidney damage OR Evidence of kidney damage - With or without reduced egfr For 3 months or more - Proteinuria - Heamaturia - Pathological abnormalities - Anatomical abnormalities
Implications for patient care Awareness of egfr Awareness of age related renal impairment Patient demographics Renal Replacement Therapy (RRT) options Awareness of referral guidelines (Irish Nephrology Society Nephrology.ie) Primary care management
Anatomy and physiology of kidney
Removal of metabolic wastes Urea end product of protein metabolism Creatinine Muscle activity / energy Potassium Excreted by the kidneys As GFR decreases plasma Urea and Creatinine increase Urea and Creatinine alone not good indicators of renal impairment Not sustainable with life
Implications for Patient care Monitoring of blood levels Dietary interventions Patient education Patient adherence Renal replacement therapy choices
Regulate body fluids 180 L / 24 hours filtered through kidney 1,500mls output Dehydration V fluid overload Regulation of fluid balance 1. Osmoreceptors 2. Antidiuretic Hormone 3. Nephron
Implications for patient care Fluid restrictions Intake and output records Urine collections Low salt diet Patient education Patient adherence
Proteinuria Normally not present in any detectable amount 30mg/ per day Damage renal tubules Microalbuminuria Albumin Creatinine Ratio Macroalbuminuria - + Sub nephrotic - + + Nephrotic - + + +
Implications for patient care Urinalysis Spot urine Albumin Creatinine Ratio Diabetic patients Medications Blood pressure Nephrotic syndrome Patient education
Acid Base Balance The kidneys play the primary role in maintaining long term control of Acid-Base balance The kidney does this by selecting which ions to retain and which to excrete The kidneys adjust the body s Acid-Base balance
Implications for Patient care Clinical history Metabolic acidosis? Blood Co2 levels Bicarbonate Dialysis
Removal of drugs / toxins Renal impairment affects the pharmcokinetics of drugs - egfr < 30mls/min - Drug dosage may need to be adjusted - Systemic blood levels Removal of toxins - Dyes - Heavy metals - Herbicides or pesticides
Implications for patient care An awareness of medication management Monitor blood levels Patient education Avoid NSAIDS, K+ sparing diuretics, aminoglycosides Polypharmacy Management of tests
Regulation of blood Pressure Renin Effects of hypertension on the body BP < 130/80 (Non Diabetic) BP <130/80 or lower (Diabetic)
Implications for patient care Ace inhibitors, ARB Nephroprotective effect Betablockers Calcium channel blockers Diuretics Low salt diet Weight loss Exercise Smoking cessation
Renal anaemia Function of Red Blood Cell 1. Oxygen transportation 2. Acid base buffering Regulation of RBC s 1. Circulating Oxygen 2. Erythropoietin (EPO) main stimulus Maturation factors 1. B12 and Folate 2. Iron Ferritin, TSAT
Renal anaemia + Iron EPO given S/C Hb standard 11 12 g/dl Ferritin > 200 Transferritin saturation > 20% Intravenous Iron
Implications for patient care EPO Mircera, Neorecormon, Aranesp IV iron Venofer, Ferinject B12 & Folate Monitor response follow up bloods during the correction phase and maintenance phase Explore other reasons for blood loss No blood transfusions
Renal Bone Disease Normal strict blood calcium & phosphate control Calcitriol & PTH Calcium (2.1 2.6mmol/L) Phosphate (.8 1.5mmol/L) Vitamin D Kidneys fail to activate Vitamin D Excessive PTH secretion Bone disease renal osteodystrophy Calcification
Implications for patient care Monitoring of blood levels Phosphate binders One Alpha Paricalcitol Patient education Diet Dialysis Parathyroidectomy
Management of CKD in Primary Care Use egfr to measure renal function Dip stick urinealysis for proteinuria Laboratory urinealysis for Albumin Creatinine Ratio Maintain register of at risk patients Use INS referral guidelines Ongoing education Patient self management Smoking cessation
Polycystic Kidney
Hypertension / Arteriolosclerosis
Cancer of the Kidney
Chronic glomerulonephritis
Diabetic glomerulosclerosis
Quality Outcome Framework
Acknowledgements CKD network Roche Ltd. UK CKD Guidelines kidney.org.uk Irish Nephrology Society nephrology.ie Irish Kidney Association ika.ie i.tunes/apple.com/ie/app/clearance-gfrcalculator