Chronic Kidney Disease: AANP 2019 Presentation

I recently presented at AANP 2019 in Indianapolis. Here is part of my presentation.

Chronic Kidney Disease: AANP 2019 Presentation

So, I wanted to challenge myself this year and decided that I would submit a proposal for a presentation for the American Association of Nurse Practitioners 2019 Conference in Indianapolis. Here is some info that I shared and hope that it might be useful for others:

CKD or chronic kidney disease is becoming more prevalent in the US. In fact half of the US population between 30 and 64 years of age will develop some degree of CKD during their lifetime. The most common reasons for advanced CKD and in turn, end stage renal disease (ESRD) is hypertension and diabetes. It is vitally important that these two chronic diseases be controlled at all costs in order to prevent renal dysfunction. I attended a session earlier where the presenter stated that the number of patients advancing to ESRD had decreased. However, what he didn't mention was that more patients are dying BEFORE they reach ESRD.

It's recommended referring your chronic kidney disease (CKD) patient to a nephrologist when their estimated glomerular filtration rate (eGFR) reaches 30 or CKD stage 3. (Stage 5 CKD is end-stage renal disease). Though the patient might still remain stable for years to come, by establishing with a nephrologist if there is quick deterioration or other issues, they can easily be addressed.

So the example I used is that you sent your CKD stage 3 patient to nephrology and they progressed to ESRD and started on hemodialysis. So, are you as the PCP done with the patient? They will still need preventive health maintenance screenings, annual exams, immunizations (just as an aside, if the pt is on chronic hemodialysis, immunizations specifically flu and pneumonia will probably be given at the dialysis unit). And unfortunately, your patient can have other non-renal related illnesses or injuries. Plus, and perhaps even more important, the PCP has a long-standing relationship with the patient so a continued relationship is important.

It's very important all meds are renally dosed. Many of us use Epocrates which is a decent reference. However, when you look at some meds and under renal dosing they say “undefined” you might need to look further. I will use either UpToDate or I go directly to the drug manufacturer or consult with a pharmacist.

I also advise patients with CKD/ESRD to notify their nephrology office/provider of any new meds. This is vitally important so that if there is an issue, it can be resolved prior to taking any new meds. It is also important to remember timing of meds if the patient is on dialysis. Is it a medication that will readily dialyze out? For this, you can use an app called Dialysis of Drugs. Its put out by the Renal Pharmacy Consultants and it gets updated every year. There is a cost for the app and its available on the App Store and Google Play.

Avoid nephrotoxins especially NSAIDs. However, anuric dialysis patients can have NSAIDs provided they have no active bleeding or history of GIB from NSAIDs. Of course, they must be renally dosed.

When a patient progresses to CKD stage 4, the nephrologist will probably be discussing dialysis with the patient. There will usually be a discussion about modalities and arrangements will be made to place an access. If the patient is to receive hemodialysis, a fistula or graft is placed in one arm after vein mapping occurs to determine the potentially most successful vessels. Obviously, don’t take BPs in the arm where there is dialysis access. However, it's important that you not take BPs or do lab draws or glucose sticks in a limb where dialysis access is planned. Hopefully, the pt will make you aware of this. Many practices utilize special bracelets for patients to wear to indicate to other healthcare providers that they either have a dialysis access or one is planned.

Of course, avoid contrast if at all possible. If contrast is needed, dose reduction is always ordered so that the smallest amount of contrast is utilized. If you need to order an MRI for a dialysis patient it is vitally important that you notify the dialysis unit if gadolinium is used. Gadolinium can cause nephrogenic systemic fibrosis (NSF) which though rare is very serious. It is similar to scleroderma and causes swelling and tightening of the skin at the joints. The issue is that this doesn’t happen immediately but rather months to years later. If a dialysis patient receives gadolinium it is necessary to dialyze the pt three days in a row as gadolinium does not readily dialyze out.

Last but not least, always use a solid drug reference. Hope you found some of this useful.

10
Up Vote Up Vote ×
traumaRUs

About traumaRUs, MSN, APRN

Trauma Columnist
88 Articles   21,268 Posts

Share this post

Share on other sites
Specializes in Hemodialysis.

I really enjoyed reading this, thanks for posting. Very relevant information as the statistics don't lie! The general public need to be better educated by their PCP when they have diabetes and/or hypertension and that they contribute to renal failure and what it entails.

3
Up Vote Up Vote ×
Specializes in Nephrology, Cardiology, ER, ICU.

Thank you

Agree with your comments also. However, how often do you find in primary care that the pt doesn't think their HTN or DM is "that bad?"

What they don't realize is how important HTN control is for ALL PTs. This is especially true in the African American population. I have several pts in their 20-30's due to HTN alone and what they tell me is "I didn't feel sick so I never went to the doctor."

1
Up Vote Up Vote ×
Specializes in Dialysis.

Thank you for posting this! It's an excellent and often not addressed topic. I work in dialysis, and have Type 1 diabetes myself, which I have very well controlled. Thank goodness no HTN, but I am obese by common definition (any definition, really) and am working on that--I know the realities, with the DM alone, my chances of one day being in the tx chair are good. You are correct, most of these pts don't think that their situation is that bad, or that the HTN or DM caused it. I've been told by multiple pts that it's the water where they live, or multiple UTIs, or pick any other explanation that you can think of. I try to explain to people that in a round about, long distance way that these things may contribute but are not a cause. Many go for contrast studies and are told to come to tx immediately after, and the they will call off that they don't feel good, not realizing that the contrast media needs to be dialyzed out of the body.

Even if a pt has some genetic factors for kidney disease it's imperative that they protect their kidneys.

Bottom line, as a country, we really do stink at making people responsible for their health, and it's cultural as well as the hotel mentality in healthcare. We are not given time or opportunity to appropriately teach sometimes. We should not be reimbursed because care is 'warm and fuzzy', but because people learn and participate in their self care, and begin to have better outcomes. I know it's not a popular view, but it's the elephant in the room that's about to stampede us all! I think NPs are in a good position to lead the way with teaching, informing, and following up with care, and most of all, collaborating with the nephrology team, both MD and clinic staff if able, to provide a complete care regimen for the pt

BTW, thanks for the med reference, I used Epocrates for meds if I question a PCPs med orders to a pt, never thought to use Up to Date

4
Up Vote Up Vote ×
Specializes in Nephrology, Cardiology, ER, ICU.

@Hoosier_RN, MSN you are so right - instead of surveys asking how "warm and fuzzy" care is, surveys should ask more questions about understanding your diagnosis, knowing resources to obtain your meds, how to get to dialysis, etc..

2
Up Vote Up Vote ×
+ Add a Comment