World Kidney Day 2023 – Kidney Health for All
Preparing for the unexpected, supporting the vulnerable!
From the Editors’s Desk!
Nephrology for Nurses!
The NIGHTINGALE presents TEN abstracts on major papers being published on the occasion in the journal MEDICINE, from Elsevier UK
Nephrology for Nurses
(1). RJ. Baker, et al. Renal Transplantation. Renal Transplantation. 2023;51(3):P147-158.
Individuals with kidney failure face a future requiring long-term treatment with either dialysis or renal transplantation. Renal transplantation is the preferred form of renal replacement therapy, and is associated with a better quality of life, and usually increased longevity. Unfortunately, owing to excessive co-morbidities, only 30% of patients who develop end-stage renal failure are fit enough for transplantation. Over 90% of kidney transplants still function after 1 year, and most function for >15 years. Improvements in transplant outcomes are attributable to advances in histocompatibility testing, organ procurement, organ preservation, surgical techniques and perioperative care. Long-term outcomes have shown only minor improvements over the last two decades, although this should be considered in the context of deteriorating organ quality as older deceased donors with increasing co-morbidity are used more often to satisfy the need for donor organs. Living donor activity remains stable, but the use of non-directed altruistic donation and the living donor exchange scheme have reduced the need for higher immunological risk incompatible transplantation. The COVID-19 pandemic has reduced transplant rates globally, although national transplant systems are now recovering.
(2). Lucas B. Epidemiology and causes of chronic kidney disease. Chronic Kidney Disease 2023;51(3):P165-169.
Chronic kidney disease (CKD) is diagnosed when evidence of kidney damage (reduced glomerular filtration rate (GFR) or proteinuria) has been present for >3 months. It is divided into categories depending on GFR and urine albumin:creatinine ratio. CKD is common, affecting 11% of the adult population globally; the prevalence rises sharply with age. Recognition of CKD is important because it is associated with multiple adverse outcomes including increased risk of cardiovascular events, acute kidney injury (AKI) and progression to end-stage kidney disease (ESKD). Risk factors for CKD can be divided into initiating and perpetuating factors, and include genetic factors, ethnicity, socioeconomic factors and age. There are multiple causes of CKD, the most common being diabetes mellitus. Other causes include glomerulonephritis, genetic disorders, drugs, cardiovascular disease, multisystem diseases, urinary tract obstruction, infections and AKI. In order to reduce the burden of CKD, it is essential to recognize which patients are at most risk so they can be diagnosed and treated early to reduce the risk of progression to ESKD. Individuals with newly diagnosed hypertension, cardiovascular disease, diabetes mellitus, multisystem disorders, evidence of urinary obstruction or significant family history should be tested for CKD.
(3). Lightfoot CJ. et al. Non-pharmacological management of chronic kidney disease. Chronic Kidney Disease 2023;51(3):P170-175.
Non-pharmacological management of long-term conditions includes components such as diet, physical activity and lifestyle behaviour modification, and plays an integral role in optimal person-centred care for people living with chronic kidney disease (CKD). However, in order for these approaches to be successful, they require active engagement from the individual. Activating and empowering individuals to take an active role in their own health and healthcare is the focus of person-centred care. Identifying and improving an individual’s level of activation and ability to effectively self-manage their condition can help to tailor interventions which could lead to better health outcomes and improved quality of life. There is a role for the patient : adherence to non-pharmacological therapies is underpinned by patient activation and self-management. Interventions are aimed at improving patient activation and strategies such as education and support, which have the potential to activate and empower people in their health and make effective use of non-pharmacological interventions.
(4). Green D, et al. Pharmacological management of cardio-renal-metabolic disease including new potassium binders. Chronic Kidney Disease 2023;51(3):P176-179.
Management of cardio-renal-metabolic diseases encompasses multiple therapeutic targets including heart failure, progression of chronic kidney disease, proteinuria, hypertension and glycaemic control. Limitations in optimizing pharmacological therapy in this setting are greatest for heart failure with reduced ejection fraction. Here, the concurrent use of all four major drug classes is seen in as few as a third of patients, with worsening renal function and hyperkalaemia being major barriers to optimization. These four main drug classes are discussed here in the context of strategies to optimize their use in heart failure, and also how their use in heart failure may need adjustment for co-morbid factors such as proteinuria, diabetes and hypertension. The drugs discussed are β-adrenoceptor blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists and sodium glucose co-transporter 2 inhibitors. Consideration is also given to the potassium binders sodium zirconium cyclosilicate and patiromer sorbitex calcium. These facilitate the use of therapies otherwise contraindicated by hyperkalaemia. As evident from recent European and US guidance, it is clear that a one-size-fits-all approach to cardio-renal-metabolic drug dosing is unfeasible. Cross-specialty multidisciplinary clinics may optimize polypharmacy delivery to patients with complex multiple long-term conditions
(5). Ola Saad, et al. Urological disorders in children that progress to chronic kidney failure. Chronic Kidney Disease 2023;51(3):P180-183.
Unresolved obstruction of the developing renal tract can lead to irreversible damage to the developing kidneys and accounts for 25% of the chronic kidney failure seen in childhood. Focus is on on congenital and acquired causes of renal tract obstruction, including posterior urethral valves, pelvi-ureteric junction obstruction, prune belly syndrome, neurogenic bladder, renal tract calculi and vesico-ureteric reflux.
(6). Thomas Phillips et al. Renal bone disease. Chronic Kidney Disease 2023;51(3):P184-189.
Sustained loss of kidney function leads to the evolution of progressive secondary hyperparathyroidism associated with a characteristic high-turnover form of metabolic bone disease. The drivers of hyperparathyroidism include the failure of renal bioactivation of vitamin D, phosphate retention and, in some cases, hypocalcaemia. As renal impairment becomes more severe, some patients, particularly under the influence of treatment, and particularly if they have diabetes, evolve in a different direction; here, low-turnover adynamic bone disease develops, associated with relative suppression of the parathyroid glands. Uraemic patients also develop an internal milieu that favours soft tissue calcification involving the peri-articular tissue, skin and vasculature. Arterial calcification is closely associated with arterial stiffening, left ventricular disease and increased cardiovascular morbidity and mortality. Current therapies aim to minimize disturbances of skeletal integrity by maintaining calcium, phosphate, vitamin D and parathyroid hormone concentrations within defined target ranges. It is hoped, but not yet established, that these measures will also result in a reduction of cardiovascular events in this vulnerable population.
(7). Cardiovascular complications of chronic kidney disease. Chronic Kidney Disease 2023;51(3):P190-195.
Chronic kidney disease (CKD) is a risk factor for premature cardiovascular disease (CVD). In patients with kidney failure requiring replacement therapy (KFRT) with dialysis or transplantation, CVD risk is greater, approximately 20 times that of the general population. Conventional cardiovascular risk factors such as diabetes, hypertension, smoking and dyslipidaemia worsen both CKD and CVD. Factors specific to CKD, such as proteinuria, impaired calcium-phosphate homeostasis, anaemia and inflammation, also contribute to cardiovascular risk. Atypical relationships exist between blood pressure, cholesterol and mortality in KFRT. Although CKD accelerates atherosclerosis, sudden cardiac death, rather than myocardial infarction, is the predominant mode of cardiac death in KFRT. Left ventricular disorders are common in this population and are associated with mortality as well as cardiac failure. Clinical trials of interventions to improve cardiovascular outcomes have been disappointing in KFRT, although two new treatments have emerged to reduce cardiovascular risk in earlier stages of CKD: sodium-glucose co-transporter 2 (SGLT-2) inhibitors and the non-steroidal mineralocorticoid receptor antagonist (MRA) finerenone. Tight blood pressure control and lipid-lowering for primary prevention of CVD are beneficial for patients with CKD not on dialysis. Further evidence is required for interventions targeted at sudden death and other non-conventional risk factors in CKD.
(8). Adam Rumjon. Anaemia and chronic kidney disease. Management of End-Stage Kidney Disease 2023;51(3):P196-200.
Anaemia is a common complication of chronic kidney disease. The most important contributory factor is an abnormally low circulating concentration of erythropoietin, which is produced by the kidney peritubular cells. Anaemia of kidney disease is likely to develop once the glomerular filtration rate (GFR) is <60 ml/minute/1.73 m2, and is most evident at lower levels of renal function (estimated GFR <30 ml/minute/1.73 m2). Anaemic patients with a lesser degree of renal function should be screened for other causes. The combination of intravenous iron and recombinant erythropoietin therapy has transformed the management of renal anaemia and drastically reduced the need for repeated blood transfusions, particularly in individuals requiring haemodialysis. The monthly administration of 400 mg iron in haemodialysis patients is associated with fewer cardiovascular events compared with patients given half this dose. Although erythropoietin and iron remain the standard of care, the National Institute for Health and Care Excellence has recently approved the use of roxadustat, which targets the enzyme prolyl hydroxylase.
(9). Oscar Swift. Haemodialysis. Management of End-Stage Kidney Disease 2023;51(3):P201-208.
End-stage kidney disease affects around 1 in 1000 people in the UK, well over a third of whom are treated with haemodialysis. The population undergoing haemodialysis continues to expand, with an increasing prevalence of elderly dependent patients. Despite major advances in technology, long-term clinical outcomes are suboptimal, even in low-risk patients. Poor outcomes are driven by high rates of cardiovascular disease and infection. Current definitions of dialysis adequacy, based on urea clearance, should be broadened to encompass parameters including middle molecule clearance, salt and water balance, and patient-reported outcomes. Haemodiafiltration provides improved middle molecule clearance over haemodialysis, with some evidence of improved survival. There is a trend towards individualizing the haemodialysis dose to meet a person’s needs. Patients with significant residual kidney function may require less dialysis. For others without residual kidney function, more frequent treatments can help to control uraemia and volume status, and improve survival. Home-based treatment can facilitate more frequent treatments without the requirement to travel to a dialysis unit for some patients, although centre-based therapy remains the default for most.
(10). Shailesh Agarwal. Peritoneal dialysis. Management of End-Stage Kidney Disease 2023;51(3): P209-214.
Peritoneal dialysis (PD) is a home-based renal replacement therapy for patients with end-stage kidney disease that allows relative independence from the hospital and benefits for quality of life compared with centre-based dialysis. After the catheter has been placed into the peritoneal cavity, the patient is trained to perform dialysis exchanges during which dialysate is instilled and then drained from the peritoneal cavity. These exchanges can be performed manually (continuous ambulatory PD (CAPD)) or using a machine (automated PD (APD)). During the dialysis exchange, small solutes (e.g. urea, potassium, creatinine) diffuse from the circulation into the dialysate and are removed when the effluent is drained out; ultrafiltration results from the osmotic effect of the dialysate glucose or icodextrin. With CAPD, the standard approach is to perform four exchanges during the 24-hour period using 2 litres of dialysate each time, although the prescription can be varied according to individual requirements. With APD, the dialysis machine performs repeated exchanges overnight, and the patient may have additional daytime exchanges. The most common complications of PD include catheter flow problems, infection at the exit site and peritonitis; other difficulties include solute and water control, as well as the continuing burden to the patient of performing the treatment.