A deep dive into renal disease

Posted 23 Sept 2022

Faculty members at the inaugural meeting of specialist nurses working in the closely linked specialties of heart failure, renal disease and diabetes (hFRenDs) presented a ‘deep dive’ into their respective specialties: this article focuses on the management of renal disease

 

Chronic kidney disease (CKD) affects more than 2.6 million people in the UK.1 Kidney disease occurs on a continuum from impairment to total failure. Stages of CKD are classified according to estimated glomerular filtration rate (eGFR) and urinary albumin:creatinine ratio (uACR) and annual testing is required for people at risk of CKD or for those with an existing CKD diagnosis.2,3 While dipstick tests are helpful, uACR monitoring for risk should comprise laboratory analysis, using an early morning sample, and the result must be confirmed.2,3 CKD stage 5 disease requires monitoring every 1–2 months.2 Monitoring is required for at least 3 years after an episode of acute kidney injury (AKI), or longer following stage 3/severe AKI.2

Key risk factors for CKD include:2,3

  • Type 1 diabetes or type 2 diabetes (T2D)
  • Hypertension
  • Previous AKI
  • CVD (ischemic heart disease, coronary heart disease, peripheral arterial disease)
  • Structural renal tract disease
  • Multisystem disease with potential renal involvement
  • Gout
  • Family history or hereditary renal disease
  • Incidental detection of haematuria or proteinuria
  • Use of potentially nephrotoxic medication (e.g. non-steroidal anti-inflammatory drugs, lithium)

The Kidney Failure Risk Equation has been validated and accurately predicts the 2- and 5-year probability of treatment for kidney failure (people with CKD stages 3–5).4 The tool aims to reduce the number of patients being referred at later stages of disease.

Working together across cardiovascular and renal medicine (CRM) specialties remains essential because individuals with multimorbidity will have numerous appointments across services, which can have a detrimental impact on their quality of life. Approximately 35.4% will receive haemodialysis, which can require attendance at clinic three times each week. Just 5.6% will receive peritoneal dialysis, with low numbers due to physician preference or as a consequence of urgent referral for dialysis (usually given in the form of haemodialysis). A small proportion of people will have home haemodialysis (2.0%). Increasing numbers of people are receiving transplants (57%), with live (and unrelated) donor transplants becoming more common. Conservative management or supportive care may be offered where a person decides against renal replacement therapy (RRT) – dialysis or transplantation.

RENAL REPLACEMENT THERAPY

Haemodialysis is effective, providing maximal solute clearance, it is readily available and treatment times are relatively short. However, in-centre haemodialysis is resource intensive and can cause fluid compartment shifts, which may affect the heart. Anticoagulation and good vascular access is needed. Peritoneal dialysis requires minimal equipment and training, and haemodynamic compromise is minimised. Disadvantages of peritoneal dialysis include slower treatment times and less efficient solute removal with the potential for respiratory compromise and peritonitis infection. This treatment is only viable for approximately 5 years. Kidney transplant permits a return to normal life and avoids dialysis-related complications, although there are risks associated with surgery and tissue rejection risk necessitates life-long antirejection medication.

HYPERTENSION

CKD and hypertension are intrinsically linked. Hypertension is both a cause and symptom of CKD. It damages the glomerular basement membrane leading to excess renin production, which stimulates the renin-angiotensin pathway and drives blood pressure further upward, causing additional injury to the basement membrane. Good blood pressure management is recognised as a way of slowing CKD progression, especially in people with diabetes. Blood pressure targets are 130/80 mmHg in non-diabetic individuals and 120/70 mmHg for people with T2D.5 NICE recommends angiotensin receptor blockers (ARBs) or ACE inhibitors for people with uACR >30 mg/mmol.2 SGLT2i therapies should be considered for people with uACR >30mg/mmol and eGFR >15mL/min/1.73 m2.6 People with CKD who are treated with renin-angiotensin system antagonists need to have their serum potassium regularly checked.2 Non-potassium sparing diuretics are typically used, with doses titrated to relatively high levels as kidney function progressively deteriorates.2 Once CKD advances to stage 5, RRT will commence, diuretic use is usually discontinued and antihypertensive dosing will likely be reduced.2

CARDIOVASCULAR RISK

Half of all patients with CKD stage 4/5 have cardiovascular disease (CVD). The risk of developing CVD exceeds the risk of progressing to end-stage CKD, with atherosclerotic cardiovascular disease (ASCVD; due to hypertension, insulin resistance, T2D and dyslipidaemia) being the main driver of cardiovascular risk.7 Hyperglycaemia accelerates the progression of both CKD and CVD, and increasing albuminuria and proteinuria are significant risk factors for CVD progression in people with/without T2DM.7 Vascular calcification related to hyperphosphatemia exacerbates the risk for CVD in people with CKD and inflammatory processes cause oxidative stress through accumulation of advanced glycation end products, which contribute to CVD development.7 Changes in fluid shifts in CKD and during haemodialysis contribute to the development of left ventricular hypertension.7

ANAEMIA

Anaemia is a shared issue with HF. Management of renal anaemia is a specialist nurse role. Individuals with anaemia and eGFR <60 mL/min/1.73m2 should be assessed to examine whether it is secondary to their CKD.8 As renal function decreases, production of erythropoietin from the kidneys declines alongside erythrocyte formation in the bone marrow. Treatment generally comprises erythropoiesis stimulating agents (ESAs) and coexisting iron and Vitamin B12 deficiency may require supplementation.8 Red blood cells and associated iron will be lost during dialysis. Haemoglobin target levels of 100–120 g/L are recommended to avoid clotting issues at higher levels. Individuals with CKD require regular screening for haemoglobin, ferritin and percentage transferrin saturation.8

Collaborative working with DSNs is critical for optimal management of CKD. Nearly one-third of CKD stage 5 cases requiring RRT will be due to T2D, primarily as a result of glomerular basement membrane damage. HbA1c must be monitored and accuracy can be impaired in advanced CKD due to increased turnover of red blood cells. People with T2D require regular eGFR and uACR monitoring to check for developing CKD. People undergoing dialysis can miss meals, which is an issue for those with T2D and hypoglycaemia can occur due to blood glucose removal and medication (e.g. insulin) may need adjustment during RRT. Peritoneal dialysis requires careful selection of appropriate dialysate and close blood glucose monitoring as most dialysates are glucose based. Metformin remains the first-line therapy for most people with T2D, provided their eGFR >30 mL/min/1.73 m2.

PHARMACOTHERAPY

SGLT2is or glucagon like peptide-1 receptor agonists (GLP-1RAs) have shown value in managing T2D in people with CKD, including slowing of CKD progression to end stage kidney disease (ESKD), cardiovascular death and hospitalisation.9 Haemodialysis is associated with long sedentary periods, making foot care and monitoring particularly important on renal units. People with Type 1 diabetes can now receive a combined kidney/pancreas transplant, but post-transplant diabetes mellitus (PTDM) is a common complication of solid organ transplantation, affecting 10–20% of patients.10 Calcineurin inhibitors (tacrolimus, sirolimus) decrease insulin release from pancreatic beta cells.10 Early prevention through lifestyle modification is advocated and those undergoing transplantation should be made aware of the risks. Insulin therapy is typically used, post-transplant, and people taking metformin should pause treatment in line with ‘Sick Day’ recommendations when there is a risk of hypovolaemia.10

ACUTE KIDNEY INJURY

AKI carries an increased risk of CKD development and increased mortality,11 but is poorly recognised and managed in clinical practice. It is usually caused by ineffective kidney perfusion, direct renal trauma or related disorders of the urinary system.11 Accurate fluid monitoring is crucial for prevention of AKI progression.11 Oral rehydration should be encouraged for those receiving iodine-based contract media and ACEi or ARB treatment may be ceased when eGFR drops <40 mL/min/1.73 m2.11 Serum creatinine monitoring is vital when AKI risk is high. The Think Kidneys project has developed ‘Sick Day’ guidance for people at risk of AKI during periods of intercurrent illness.

The ANN Renal Services Transformation Programme (RSTP) is working with service users and MDT stakeholders to improve quality and consistency of renal care across the country. The programme is using clinical networks, integrated care and renal teams to monitor outcomes and spread best practice in line with Getting It Right First Time (GIRFT) recommendations.1248

 

RENAL FAILURE RESOURCES FOR PATIENTS AND CLINICAL STAFF

See also Nurses call for closer links across specialties, A deep dive into diabetes and A deep dive into heart failure

References

 

1. Public Health England. Chronic Kidney Disease Prevalence Model; 2014. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/612303/ChronickidneydiseaseCKDprevalencemodelbriefing.pdf

2. NICE NG203. Chronic kidney disease: assessment and management. https://www.nice.org.uk/guidance/ng203.

3. Kidney Disease: Improving Global Outcomes (KDIGO) Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International Supplements . 2013;3:1-150.

4. Prasad B, Osman M, Jafari M, et al. Kidney Failure Risk Equation and Cost of Care in Patients with Chronic Kidney Disease. Clin J Am Soc Nephrol 2022;17(1):17-26. doi:10.2215/CJN.06770521

5. Carriazo S, Sarafidis P, Ferro CJ, Ortiz A. Blood pressure targets in CKD 2021: the never-ending guidelines debacle. Clin Kidney J 2022;15(5):845-851. doi:10.1093/ckj/sfac014

6. UK Kidney Association Working Group. UK Kidney Association Clinical Practice Guideline: Sodium-Glucose Co-Transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease; 2021. https://ukkidney.org/sites/renal.org/files/UKKA%20guideline_SGLT2i%20in%20adults%20with%20kidney%20disease%20v1%2018.10.21.pdf

7. Jankowski J, Floege J, Fliser D, Böhm M, Marx N. Cardiovascular Disease in Chronic Kidney Disease: Pathophysiological Insights and Therapeutic Options. Circulation. 2021;143(11):1157-1172. doi:10.1161/CIRCULATIONAHA.120.050686

8. Thomas N. Renal Nursing: Care and Management of People with Kidney Disease. 5th ed. (Thomas Nicola, ed.). Wiley-Blackwell; 2019.

9. Triozzi JL, Parker Gregg L, Virani SS, Navaneethan SD. Management of type 2 diabetes in chronic kidney disease. BMJ Open Diabetes Res Care 2021;9(1). doi:10.1136/bmjdrc-2021-002300

10. Hecking M, Sharif A, Eller K, Jenssen T. Management of post-transplant diabetes: immunosuppression, early prevention, and novel antidiabetics. Transpl Int. 2021;34(1):27-48. doi:10.1111/tri.13783

11. Dainton M. Acute Kidney Injury. 5th ed. (Thomas Nicola, ed.). Wiley-Blackwell; 2019.

12. Lipkin G, McKane W. Renal Medicine. Getting It Right First Time Review; 2021. https://ukkidney.org/sites/renal.org/files/Renal%20Medicine%20Sept21k.pdf

 

 

 

 

 

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