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The nephrology nurse's role in improved care of patients with chronic kidney disease.

For nearly 3 decades, Medicare has provided funding for the care of end stage renal disease (ESRD) patients. As a result, extensive resources are committed to tracking the prevalence and incidence of ESRD in the United States (National Institutes of Health, USRDS, 2001a) and to improving clinical outcomes of patients with ESRD (Health Care Financing Administration, 2000). More recently, however, policy makers and health care professionals have paid greater attention to the public health concerns surrounding earlier stages of chronic kidney disease (CKD). For example, the United States Department of Health and Human Services has issued the Healthy People 2010, an agenda for improving the health of Americans (U.S. Department of Health and Human Services, 2000). The document contains a chapter dealing with CKD and sets forth the goal to reduce new cases of CKD and its complications, along with disability, death, and economic costs. The National Institutes of Health (2001a) has initiated the National Kidney Disease Education Program (NKDEP). The National Kidney Foundation (NKF, 2001) has launched the Kidney Early Evaluation Program (KEEP) and has sponsored the development of clinical practice guidelines for CKD (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative [NKFK/DOQI], 2002). These efforts and others are designed to achieve earlier diagnosis of kidney disease, reduce complications of kidney impairment, and attain better success in avoiding or delaying the need for dialysis and transplantation.

Several authors have advocated the use of multidisciplinary patient care teams to provide the most effective and efficient care for patients with CKD (Grady, Casde, & Sibley, 1996; Self et al., 1999). This article will review selected aspects of CKD management, describe the contributions of nephrology nurses practicing within a multidisciplinary CKD clinic, and discuss national CKD initiatives and educational materials that will assist nephrology nurses in caring for CKD patients.

While there are an estimated 375,000 ESRD patients in the United States (National Institutes of Health, 2001b), this population pales when compared to estimates of the prevalence of CKD. Data from the National Health and Nutrition Examination Survey (NHANES III) suggest that there are over 6 million individuals who have serum creatinine values of 1.5 mg/dL or greater (Jones et al., 1998). The NKF estimates that over 20 million adults in the U.S. may have CKD. This very large population presents an enormous challenge to health care providers while providing an opportunity for positive clinical interventions designed to prevent and reduce complications associated with CKD, including anemia, hypertension, cardiovascular disease, neuropathy, nutritional disorders, bone and mineral abnormalities, complications of diabetes, and diminished quality of life.

Recent studies indicate that the care of at-risk patients as well as patients with CKD and related diseases is suboptimal. For example, data from NHANES III indicated that while approximately 75% of persons with hypertension and elevated serum creatinine concentrations were treated with antihypertensive medications, only 11% reached optimal blood pressure goals (Coresh et al., 2001). Data from NHANES III also demonstrated that approximately one third of all persons with diabetes mellitus were undiagnosed (Harris et al., 1998), and a substantial portion of treated patients did not achieve recommended blood glucose control (Shorr et al., 2000).

Studies from a large health maintenance organization in New Mexico and from outpatient clinics in the Greater Boston area confirmed that many patients with CKD are not referred to nephrology specialty services until renal disease is quite advanced (Kausz et al., 2001; Kazmi et al., 2001; Nissenson et al., 2001). In these studies, the authors noted that many patients do not receive optimal evaluation of their kidney disease and related complications and do not receive widely recommended treatments with such medications as recombinant human erythropoietin (r-HuEPO, epoetin alfa), iron, phosphate binders, vitamin D, and angiotensin-converting enzyme inhibitors. Late referral of CKD patients to nephrology-related specialists is associated with greater mortality, reduced rate of transplant, lower serum albumin and calcium concentrations, reduced placement of arteriovenous fistulae, more acidosis, more severe anemia, and more untreated secondary hyperparathyroidism (Goransson & Bergrem, 2001; Stoves, Bartlett, & Newstead, 2001).

Estimation of Kidney Function

Measurement of serum creatinine, a metabolite of muscle metabolism, is often used for assessing kidney function. Creatinine is a small molecular weight compound that is filtered by the glomerulus and, to a lesser extent, secreted by renal tubular cells. It is not reabsorbed by the tubules. Therefore, measuring the serum creatinine concentration provides an indirect measurement of kidney excretory function. However, the endogenous production of creatinine varies with age, gender, and muscle mass. Therefore, because the concentration of creatinine in the blood is influenced by patient variables, it is an inexact measurement of kidney function. This laboratory measurement should not be used alone to establish the presence or absence of kidney failure. Equations based on the serum creatinine concentration ([S.sub.cr]) are widely used to calculate creatinine clearance ([Cl.sub.cr]) and serve as an indicator of glomerular filtration rate (GFR). The normal GFR in young, healthy adults is > 90 mL/min. Glomerular filtration may gradually decline as a normal part of the aging process. Because of the difficulty in directly measuring the GFR with inconvenient and expensive clearance studies with inulin or radionuclides such as [sup.125]I-labeled iothalamate, most clinicians use the more easily estimated [Cl.sub.cr] as an indicator of GFR. Creatinine clearance closely approximates GFR when the kidneys are healthy. With moderate to advanced renal disease, the [Cl.sub.cr] often overestimate mates true GFR. Like the GFR, a normal [Cl.sub.cr] is considered to be [greater than or equal to] 90 mL/min.

The most widely used equation to estimate [Cl.sub.cr] for adults is the Cockcroft-Gault equation (Cockcroft & Gault, 1976):

[Cl.sub.cr] (mL/min)= (140-age) x weight (kg) 72 x [S.sub.cr] x (0.85 female)

Example: A 68-year old African-American female weighs 62 kg. Her [S.sub.cr] concentration is 2.5 mg/dL, serum urea nitrogen concentration is 35 mg/dL, and serum albumin concentration is 4.0 gm/dL. What is her estimated [Cl.sub.cr]?

[Cl.sub.cr] (mL/min) = (140-68) x 62 x 0.85 72 x 2.5 = 21.1 mL/min

A useful online calculator for creatinine clearance can be found at www.medmath.com.

More recently, the Modification of Diet in Renal Disease (MDRD) Study equation (Levey et al., 1999) has gained popularity for estimation of GFR in adults:

GFR (mL/min/1.73[m.sup.2]) = 170 x [([S.sub.cr] (mg/dL)).sup.-0.999] x [(age).sup.-0.176] x (0.762 if female) x (1.180 if black) x [(SUN).sup.-0.170] x [(alb).sup.+0.318]

SUN = serum urea nitrogen concentration; alb = serum albumin concentration

The MDRD Study equation is more accurate than the Cockcroft-Gault equation as an estimate of GFR (Levey et al., 1999), however, its mathematical complexity is cumbersome. The use of the MDRD equation in the above example would calculate a [Cl.sub.cr] of 24.7 mL/min. Clinicians may wish to use a computerized version of this equation such as the one available at http://calc.med. edu/.

Classification of Chronic Kidney Disease

The recently released NKF-K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease propose a five-stage classification system for kidney disease progression as outlined in Table 1 (NKF, 2002).

Efforts should be directed at screening and identifying patients who have Stage 1 or Stage 2 kidney disease. At-risk individuals include those with a family history of kidney disease; those with predisposing chronic diseases such as diabetes or hypertension; the elderly; and ethnic minorities such as Native American, Hispanic, and African-American groups. The goal of therapy is to prevent or slow the progression of CKD through optimal intervention strategies and patient education. Patients in Stages 3 and 4 should be referred to a nephrologist, preferably working within a multidisciplinary team, for management of specific kidney-related complications. At this time, patients should also be prepared in advance for the eventuality of dialysis or transplantation.

Early referral to a CKD clinic provides greater opportunity to address issues of blood pressure control, anemia management, nutrition, bone and mineral disorders, neuropathy, and maintenance of quality of life. The multidisciplinary CKD clinic holds the promise of being an efficient and effective approach to care for patients with CKD. Experiences with two clinics in Canada suggest that patients have fewer urgent dialysis starts, more training in the outpatient setting, fewer days spent in the hospital immediately following the initiation of dialysis, and better dialysis access (Levin et al., 1997). These clinics have also led to overall cost savings. CKD clinics already in existence in Canada and the United States are using the skills and knowledge of physicians, nurses, nurse practitioners, pharmacists, physician's assistants, dietitians, social workers, and case managers. While the CKD clinic provides specialized services to patients with kidney disease, it is also designed to be in partnership with the patient's primary care provider.

National Initiatives and Resources

Many organizations have launched initiatives designed to improve the care of the CKD patient population. In addition, resources of value to the CKD clinic are now becoming available.

The National Institutes of Health NKDEP program is intended to incorporate the goals for kidney disease as stated within the federal government's public health agenda, Healthy People 2010.

The NKF KEEP program is a 1-day health screening program designed to identify individuals who are at risk for developing CKD, inform them of their risks, and encourage these individuals to seek further evaluation and follow up. Screenings include blood pressure check, blood sugar and hemoglobin evaluation, [S.sub.cr], and [Cl.sub.cr]. Urinalyses for hematuria, microalbuminuria, and pyuria are also performed. Currently 6,000 individuals have been screened. The KEEP initiative continues to evolve, and a new version, KEEP 3.0, a longitudinal cohort study, is being initiated at 15 clinical sites.

Various professional associations have launched national initiatives to educate health care providers and patients about CKD. The Renal Physicians Association (RPA) has embarked on an educational manuscript, "Appropriate Patient Preparation for Renal Replacement Therapy." It will be available in the summer of 2002. This paper is intended to educate nephrologists about CKD, its identification and therapeutic options to delay deterioration of renal function, and to help prepare their patients for renal replacement therapy or transplantation. Additionally, the NKF, through its K/DOQI initiative, has contributed clinical practice guidelines for CKD, dialysis adequacy, anemia, vascular access, and nutrition. These initiatives by the RPA and NKF are leading the way in CKD guidelines for health care professionals.

Pharmaceutical companies have also supported the development of CKD resources. Space limitations do not permit a comprehensive presentation of all such resources, however, a few examples are reviewed.

The BE ACTIVE[R] program (Ortho Biotech Products, L.P.) was launched in 1999 as a resource primarily for health care providers. This is a multifaceted educational program with targeted goals stressing the importance of multidisciplinary collaborative care for CKD patients. The BE ACTIVE program targets an eight-step patient management approach focusing on blood pressure management, anemia control, ESRD treatment options, cardiovascular disease, vitamin D, metabolic acidosis, dietary intervention, iron management, and a team approach to diabetes care. This eight-step approach, cultivated in the nephrology community, serves as a call to action for nephrologists and primary care physicians for early identification and management of CKD patients for improved patient outcomes.

Another example of a resource for health care providers is Renal Advances[R] (Amgen Inc.). This program targets nephrologists, primary care physicians, and physician extenders. The Renal Advances RAMP (Renal Anemia Management Period) initiative focuses on the need for proactive and aggressive management of anemia within the context of CKD and its related comorbidities (Besarab & Levin, 2000).

Patient and family-focused resources are also available. One example is The Life Options Rehabilitation Program (Medical Education Institute) that targets patients and deals with education. Originally developed for ESRD patients, this program is now adding resources for CKD. It stresses teamwork in patient adjustment and rehabilitation to CKD as well as continued education about the patient's primary diseases.

"Kidney Care: Finding Your Strength" (Ortho Biotech Products, L.P.) is another patient and family-targeted educational program designed to raise awareness about CKD, conditions that can lead to CKD, and side effects of CKD such as anemia. The goal of the program is to ensure that people who have CKD or are at risk for developing CKD understand the importance of proper kidney care. The program conveys the importance of patients playing an active role in the health of their kidneys and empowers individuals to take steps on their own behalf toward a more healthy life.

"Stay in Touch" (Baxter Healthcare) is a program for individuals with CKD and their families. This program is designed to help patients learn about and cope with kidney disease. Participants receive a series of educational mailings on important topics such as:

1. What Kidneys Do

2. Causes of Kidney Disease

3. How Patients Can Monitor Their Condition

4. How Patients Can Maintain Their Health

5. Treatment Options

6. Questions Patients Can Ask Their Health Care Providers

Health care providers receive quarterly reports on their patients' progress.

Federal, professional, and corporate initiatives such as these are now taking root and bearing fruit. Nephrologists' increased awareness of the CKD population has resulted in development of CKD clinics within larger private practices. These clinics are using nurses in the care of these patients. As the comprehensive approach to the care of CKD patients is a work-in-progress, we can expect continued maturation of national programs and resources as outcomes data are evaluated.

The Nurse's Contribution to the Care of the CKD Patient

The role of the nephrology nurse is associated with the care of patients with ESRD receiving dialysis. Hemodialysis nurses, peritoneal dialysis nurses, transplant nurses, pediatric nephrology nurses, and acute dialysis nurses all represent nephrology nursing. Now, with the growing CKD patient population, nephrology nurses have the opportunity to identify and intervene early and make valuable contributions to the health care of these patients.

The American Nephrology Nurses' Association (ANNA), in its Standards and Guidelines of Clinical Practice for Nephrology Nursing, includes a section on disease management that focuses on patient education prior to ESRD. While ANNA recognizes the importance of preparing patients for renal replacement therapy, the majority of the 12,000 members are involved in outpatient hemodialysis. The clinical special interest groups (SIGs) within the association include hemodialysis, peritoneal dialysis, transplant, pediatric, and advanced practice. These established SIGs represent the 375,000 ESRD patients receiving dialysis or who have received a transplant. With the new focus on the larger CKD population with earlier stages of kidney disease, a chronic kidney disease SIG would provide an opportunity for nephrology nurses to share experiences from varied practice environments. CKD clinics have been established in private practice, managed care practices, and university settings. A cohesive definition of the role of the nephrology nurse in a CKD clinic would benefit nurses entering this practice domain.

The lack of awareness of the scope of the CKD problem has cost valuable time. Not only has the size of the CKD population been underestimated, but the need for early identification and intervention has been ignored, resulting in patients beginning dialysis with anemia, bone disease, left ventricular hypertrophy, and other comorbidities that should have been addressed years earlier. Early identification and intervention not only improves the outcomes of patients receiving dialysis, but also improves their status as transplant candidates. With the current cadaveric transplant waiting list exceeding 4 years in many transplant centers, the need to slow disease progression and improve the health of those beginning dialysis is now more important than ever.

Recognizing the immense benefits of early intervention on the progression and sequelae of CKD, individual nephrology practices have initiated CKD programs. While the actual number of CKD programs is unknown, many nephrology professionals are sharing their experiences and program designs. These programs differ greatly from practice to practice, but all appreciate the benefits of early patient identification and intervention.

The Healthy Start program at Ochsner Clinic in New Orleans is perhaps the best-known CKD program. The goal of this multidisciplinary program is to intervene early in the course of CKD in order to improve patient outcomes and slow the progression of the disease. This program has also demonstrated the economic benefits of early intervention as demonstrated by the decrease in hospital costs for those patients in the Healthy Start group (Self et al., 1999).

The CKD program at Western New England Renal and Transplant Associates was initiated over a year ago. The nephrologists and nurse practitioners collaborated to develop guidelines, a charting format, and a self-care manual. Classes on modality selection are held twice a month for patients and family members. Clinical parameters addressed include anemia, bone disease, blood pressure, hypercholesterolemia, nutrition, acidosis, and palliative care issues. The nephrology team follows over 150 CKD patients (S. Petroff, personal communication, Dec. 11, 2001).

In Boston, a renal disease management program within a managed care setting follows over 500 CKD patients. The multidisciplinary team consists of primary care physicians, nephrologists, nephrology nurses, and a nutritionist. This unique relationship with the primary care physicians and nephrology professionals promotes early referral where interventions to slow the progression of the disease can have an impact on the morbidity and mortality associated with CKD. In addition to addressing the comorbidities associated with CKD, this program provides educational opportunities to patients and their families (J.B. Wolfrum, personal communication, Dec. 10, 2001).

In 1996, the Division of Nephrology at Virginia Commonwealth University/Medical College of Virginia Hospitals (VCU/MCV) made a commitment to the development of a CKD patient education program. The multidisciplinary team includes nephrologists, a nurse practitioner, transplant coordinator, licensed clinical social worker, nutritionist, and a doctor of pharmacy. An instructional designer, pursing her doctorate in education, designed the performance-based program. The program consists of eight 1-hour classes that run repeatedly. These classes are held every week during the hour prior to clinic. Patients and families are welcome to attend any or all of the classes, regardless of whether they have a clinic appointment. The participants receive a patient guide with information pertinent to each class topic. Class topics include kidney function, dialysis options, transplantation, financial /adjustment issues, nutrition/diet, medications, blood pressure, and support/rehabilitation.

The goals of all CKD programs include:

1. Early selection of treatment modality.

2. Timely placement of appropriate access.

3. Early referral to transplant clinic.

4. Improved psychosocial, physical, and rehabilitative outcomes.

5. Improved functional status and quality of life.

6. Easier transition to dialysis or transplantation.

7. Decreased need for urgent dialysis.

8. Slowed progression of CKD.

9. Reduced hospitalizations.

10. Improved adherence to treatment.

11. Early control of blood pressure, proteinuria, anemia, hyperparathyroidism, and hypercholesterolemia.

12. Saved health care dollars.

In a study of the VCU/MCV program, 16 patients who had educational intervention were compared to 16 who had no intervention. The results indicated that patients who have pre-dialysis education are better prepared for dialysis as indicated by a significantly higher rate of permanent dialysis access, elective start, and compliance with the treatment prescription. This analysis reflects similar results of Canadian studies that compared patients with and without educational intervention (Levin et al., 1997).

Components of a successful CKD program include:

1. Physician support and education to enhance screening and early referral.

2. A designated nurse coordinator.

3. Commitment of the multidisciplinary team.

4. A patient referral system.

5. Positive patient experience.

6. Early treatment of comorbidities (i.e., anemia, diabetes, hypertension, bone disease, nutrition).

7. Improved patient outcomes.

With these program components in place, there is improved likelihood of early screening for and identification of CKD, early referral to a nephrologist, early intervention, and early treatment of related complications such as anemia, hypertension, cardiovascular disease, and complications of diabetes.

CKD programs are not all alike. One size does not fit all. Different health care environments may have different resources and different needs. However, there are many resources already developed that can be shared and tailored to the needs of specific programs.

The time requirement associated with a CKD program is the most intense in the planning and early initiation phase. Many organizations have patient education materials available at no cost and are developing databases to follow patient labs and interventions. Many programs have developed their own tracking systems to follow patient-specific issues associated with CKD. These programs become a routine part of the work week and save time in the long-run by avoiding "crisis intervention."

Lack of timely referral of patients is a common problem. Collaboration with primary care physicians, diabetic nurse educators, and other health care professionals who have access to this patient population is crucial. Marketing a successful program to other health professionals as well as at-risk patients and families will improve referral.

Recognizing the global benefits of CKD programs, nephrology nurses have an opportunity to expand their scope of practice and to impact the long-term outcomes of this patient population. Nurses are pivotal in the success of these programs. The physician directs the care and the nurse coordinates the care. This collaborative model has proven effective in the management of this complicated patient population.

The nurse-patient relationship is unique in that nurses spend the most time with patients. This allows the nurse to better understand the educational, psychosocial, and economic issues surrounding the patient's ability to adhere to the treatment plan. As a result, the nurse is best suited to coordinate the care.

Patient education has traditionally been the nurse's responsibility. The CKD patient needs an understanding of the functions of the kidneys, signs and symptoms of kidney failure, causes of kidney failure, and strategies to slow the progression of kidney disease. Preparing the patient for the successful transition from CKD to ESRD involves an understanding of the treatment options and the associated surgery. These educational interventions need to be introduced when they will provide maximum benefit.

Laboratory and medication review is another important aspect of a CKD program. The successful diagnosis and treatment of anemia, hypertension, uncontrolled blood glucose, renal bone disease, acidosis, hyperlipidemia, and worsening renal function should be carefully monitored. Collaboration with the physician allows the nurse to coordinate the treatment plan and obtain the necessary nutritional and social work consultations as they relate to the implementation of the plan.

Whether a CKD program is coordinated by an advanced practice nurse or a BSN-prepared registered nurse depends on the circumstances of the medical practice. The case manager model can be adapted to fit a CKD program and can be effective in collaboration with an interested and knowledgeable physician. This complicated patient population requires more time than most physicians can spare, making knowledgeable nephrology nurses a valuable asset in a CKD program. CKD programs may not be limited to nephrology practices, but might also have a role in primary care practices. The opportunity to bring nephrology nurses' expertise to other medical specialties and practices should not be ignored. With the shortage of nephrologists and over 20 million individuals with CKD, creative strategies to provide appropriate care to this population should be explored.

Nephrology nurses have the opportunity to define their role in a CKD program. The NKF-K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease should assist the multidisciplinary team in developing a program that will successfully address the issues associated with CKD. No program can be effective without collaboration between a committed nurse and physician, a designated coordinator, and a knowledgeable multidisciplinary team.

Conclusion

Improved care of patients with CKD has become a priority. Many federal, professional, and corporate programs have been initiated to improve identification and intervention of CKD. One important aspect is the development of the multidisciplinary CKD clinic. Nephrology nurses working within these clinics are well suited to bring their unique skills to improved patient care outcomes. As part of the team approach to caring for patients with CKD, nurses play a crucial role in improving the quality of life of these patients, including monitoring patients for comorbid conditions, providing patient education, appropriate planning for the later stages of CKD, and providing ongoing patient and family support. Early identification and intervention of CKD are likely to improve quality of life while decreasing morbidity and mortality in these patients.
Table 1

NKF Classification System for Kidney Disease Progression

Stage   GFR (mL/min/1.73[m.sup.2])   Description

1       [greater than or equal to]   Kidney damage with normal or
        90                           [up arrow] GFR

2       60-89                        Kidney damage with mild
                                     [down arrow] GFR

3       30-59                        Moderate [down arrow] GFR

4       15-29                        Severe [down arrow] GFR

5       <15 or dialysis              Kidney failure


Acknowledgments: This work was supported by an educational financial grant from Ortho Biotech Products, L.P. The content and opinions expressed in this publication are those of the authors alone and do not necessarily reflect the opinions of the American Nephrology Nurses' Association (ANNA) or the publisher.

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Ann Compton, MSN, FNP-C, CNN, is a Nurse Practitioner in the Division of Nephrology, Virginia Commonwealth University/Medical College of Virginia, Richmond, VA. She has been a nephrology nurse since 1976, and follows over 350 chronic kidney disease and end stage renal disease patients.

Robert Provenzano, MD, is Chief, Department of Nephrology and Associate Clinical Professor of Medicine, Wayne State University School of Medicine. He also serves as the Treasurer of the Renal Physicians Association.

Curtis A. Johnson, PharmD, is Professor of Pharmacy and Medicine (Nephrology) at the University of Wisconsin-Madison, and is a principal in Nephrology Pharmacy Associates, Inc. He is a member of the RPA/National Patient Safety Foundation/Forum of ESRD Networks' Task Force on Patient Safety, and is a member of CMS' ESRD Clinical Performance Measures Quality Improvement Committee.
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Author:Compton, Ann; Provenzano, Robert; Johnson, Curtis A.
Publication:Nephrology Nursing Journal
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Date:Aug 1, 2002
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