Category: Patient Management

Patients with chronic kidney disease (CKD) are at increased risk for hyperkalemia, a serious condition involving elevated plasma potassium levels. Low-potassium diets have been a key management strategy since the 1960s, as declining kidney function limits potassium excretion. Although compensatory mechanisms like colonic secretion help, many patients with CKD still experience postprandial hyperkalemia—potassium spikes after meals—due to impaired renal and cellular responses. Dietary adjustments, such as adding fiber and balancing meals, can help but do not fully address this challenge.

Potassium exchange resins, such as patiromer and sodium zirconium cyclosilicate, effectively manage chronic hyperkalemia by boosting fecal potassium excretion but show limited efficacy in preventing postprandial potassium spikes. Their mechanisms, which bypass kidney-like regulation, may not align with meal-related potassium absorption. While these medications are valuable for chronic management, they do not replace the need for dietary considerations or replicate healthy kidney function. Further research is needed to refine strategies for managing postprandial hyperkalemia in CKD.

Reference: St-Jules DE, Clegg DJ, Palmer BF, Carrero JJ. Can Novel Potassium Binders Liberate People with Chronic Kidney Disease from the Low-Potassium Diet? A Cautionary Tale. Clin J Am Soc Nephrol. 2022;17(3):467-472. doi: 10.2215/CJN.09660721.

In a comprehensive cross-sectional study examining 3,101 US counties, researchers identified significant geographic variations in how social and environmental determinants of health (SEDoH) influence cardio-kidney-metabolic (CKM) syndrome-related mortality. The study utilized geographically weighted models to analyze the impact of various SEDoH, finding that median household income, food insecurity, and high school completion rates were the most significantly associated factors with variations in mortality rates across different regions.

The findings highlight the complexity and the regional differences in the association between SEDoH and CKM-related mortality, suggesting that one-size-fits-all health policy solutions may not be effective. The detailed analysis reveals not only the disparities in mortality rates but also the differentials in the impact of factors like food insecurity, pollution levels, and educational attainment on health outcomes. These insights are crucial for policymakers and healthcare professionals aiming to develop targeted interventions that address the root causes of health disparities and enhance overall public health outcomes in diverse communities across the United States.

Reference: Vieira de Oliveira Salerno PR, Cotton A, Elgudin YE, et al. Social and Environmental Determinants of Health and Cardio-Kidney-Metabolic Syndrome–Related Mortality. JAMA Netw Open. 2024;7(9):e2435783. doi:10.1001/jamanetworkopen.2024.35783

From 2009 to 2019, the percentage of US patients on dialysis choosing peritoneal dialysis (PD) rose from 6.6% to 12.3%. However, about 25% of these patients switch to in-center hemodialysis within two years due to complications like peritonitis and mechanical issues. Advances in managing PD complications, especially infections like peritonitis, have reduced hospitalization rates over the past decade through improved preventive measures. PD-related infections, including exit site infections, remain a key area of focus for ongoing research and updated guidelines.

Catheter-related infections are a leading cause of PD-associated peritonitis, with treatment often requiring antibiotics tailored to culture results, commonly for Staphylococcus aureus. Case studies highlight the challenges in managing recurrent or resistant infections, sometimes necessitating catheter removal. Additionally, noninfectious issues like increased intra-abdominal pressure, hernias, and catheter malfunction are addressed with updated treatment recommendations. Improved PD care practices, including home visits and personalized training, have helped reduce these complications and improve patient outcomes.

Reference: Khan SF. Updates on Infectious and Other Complications in Peritoneal Dialysis: Core Curriculum 2023. Am J Kidney Dis. 202;82(4):481-490. doi: 10.1053/j.ajkd.2023.03.011.

Researchers investigated whether higher phosphorus levels are associated with anemia in individuals with normal kidney function and early chronic kidney disease (CKD). The population-based study was conducted within the Kaiser Permanente Southern California health system from 1998 to 2013, involving individuals aged 18 and older with an estimated glomerular filtration rate >30 mL/min/1.73 m2. The study excluded those with secondary causes of anemia. Researchers analyzed the odds ratio (OR) for moderate anemia (hemoglobin <11 g/dL) and mild anemia (<12 g/dL for females and <13 g/dL for males).

Among 155,974 participants, 4.1% had moderate anemia, and 12.9% had mild anemia. The findings indicated that serum phosphorus levels ≥3.5 mg/dL were associated with both mild and moderate anemia. Specifically, the OR for moderate anemia was 1.16 for every 0.5 mg/dL increase in phosphorus and 1.26 in the highest vs middle phosphorus tertile. The study concludes that higher phosphorus levels are linked to a greater likelihood of anemia in individuals with early CKD and normal kidney function, suggesting phosphorus may serve as a biomarker for anemia and impact hematopoiesis.

Reference: Tran L, Batech M, Rhee CM, et al. Serum phosphorus and association with anemia among a large diverse population with and without chronic kidney disease. Nephrol Dial Transplant. 2016;31(4):636-45. doi: 10.1093/ndt/gfv297.

End-stage renal disease (ESRD) occurs when kidney function is inadequate without transplantation or dialysis. Early referral to nephrology is crucial. Kidney transplantation offers the best outcomes, but most patients undergo dialysis, which requires shared decision-making and vein preservation. Palliative care is an option for those with limited life expectancy. Patients with ESRD should be vaccinated against influenza, tetanus, hepatitis B, HPV, and pneumococcus, and routine cancer screening is discouraged. Blood pressure control, monitoring for protein-energy wasting, and using insulin for diabetes are essential.

The rise in ESRD cases is linked to increasing diabetes and hypertension rates. Early nephrology referral improves outcomes, but many patients lack adequate care before ESRD diagnosis. Kidney transplantation improves survival and quality of life more than dialysis. Shared decision-making is essential for dialysis due to its burdens. Home hemodialysis and peritoneal dialysis are alternatives to center-based hemodialysis. Indications for dialysis include persistent volume overload and refractory metabolic disorders. Conservative kidney management focuses on quality of life. Clinicians must manage ESRD-related complications like anemia, metabolic acidosis, hyperkalemia, and cardiovascular risk.

Reference: Wouk N. End-Stage Renal Disease: Medical Management. Am Fam Physician. 2021;104(5):493-499.

Researchers of this study aimed to identify factors associated with insulin resistance and explore its relationship to chronic kidney disease (CKD) progression, cardiovascular events, and mortality in non-diabetic patients with CKD. Data from 1883 participants of the Chronic Renal Insufficiency Cohort Study without diabetes were analyzed using linear regression for insulin resistance, defined by the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR). Cox proportional hazards models examined the association of HOMA-IR, fasting glucose, hemoglobin A1c (HbA1c), and C-peptide with CKD progression, cardiovascular events, and all-cause mortality.

The study found that novel positive associations with HOMA-IR included serum albumin, uric acid, and hemoglobin A1c. However, after adjustment, HOMA-IR was not associated with CKD progression, cardiovascular events, or all-cause mortality. Notably, a one standard deviation increase in HbA1c was positively associated with cardiovascular events. These findings suggest that while potential determinants of insulin resistance were identified, HOMA-IR did not correlate with adverse renal or cardiovascular outcomes or mortality in non-diabetic patients with CKD.

Reference: Schrauben SJ, Jepson C, Hsu JY, et al. Insulin resistance and chronic kidney disease progression, cardiovascular events, and death: findings from the chronic renal insufficiency cohort study. BMC Nephrol. 2019;20(1):60. doi: 10.1186/s12882-019-1220-6.

Learned helplessness is an early psychological concept with unclear implications for renal nursing, particularly among dialysis patients. The authors aimed to analyze learned helplessness in these patients to improve understanding within renal nursing. Using Rodgers’ evolutionary concept analysis method, a systematic literature search across five databases was conducted. The analysis process involved narrowing relevant articles, extracting data, and identifying attributes, antecedents, consequences, surrogate terms, and related terms.

The study included 22 articles, identifying four attributes of learned helplessness in renal dialysis patients: low self-concept, perceived loss, negative cognitive set, and abandonment of action. Antecedents were sociodemographic characteristics, disease and treatment factors, and psychological factors. Consequences were categorized into psychological problems, physiological issues, quality of life, and health-related behaviors. Surrogate terms were hopelessness and powerlessness, with depression as a related term. The study highlights gaps in awareness and practice challenges related to learned helplessness in dialysis patients and suggests the findings can guide the design of tools and interventions to better incorporate learned helplessness theory into nursing practice.

Reference: Xie C, Li L, Li Y. Learned Helplessness in Renal Dialysis Patients: Concept Analysis with an Evolutionary Approach. Patient Prefer Adherence. 2022;16:2301-2312. doi: 10.2147/PPA.S373134.

Sleep disorders are common in individuals with chronic kidney disease (CKD). A review aimed to assess the effectiveness and adverse events of various interventions for adults and children with CKD, including those with end-stage kidney disease undergoing dialysis or kidney transplantation. The review included 67 studies with 3427 participants, but many studies had incomplete methodological details, leading to uncertain risk of bias. Meta-analyses involved 36 studies with 2239 participants, with follow-up ranging from 0.3 to 52.8 weeks.

The authors found that relaxation techniques and exercise had uncertain effects on sleep quality, with very low certainty evidence. Exercise might reduce depression and fatigue moderately, while acupressure could slightly improve sleep latency and time, though its effects on sleep disturbance were unclear. The evidence for acupressure’s impact on sleep quality compared with sham acupressure was very low. Adverse effects of these therapies were uncertain, and no studies reported treatment effects for children. The overall evidence for improving sleep quality in patients with CKD is sparse, indicating a need for more rigorous future research on sleep interventions in this population.

Reference: Natale P, Ruospo M, Saglimbene VM, Palmer SC, Strippoli GF. Interventions for improving sleep quality in people with chronic kidney disease. Cochrane Database Syst Rev. 2019;5(5):CD012625. doi: 10.1002/14651858.CD012625.pub2.

The current standard for treating end-stage renal disease (ESRD) is kidney transplantation or dialysis when a donor organ isn’t available. The shortage of donor organs and the negative effects of long-term dialysis, such as infections, limited mobility, and increased cancer risk, drive the need for alternative renal replacement technologies. This review assesses two recent innovations: the implantable bioartificial kidney (BAK) and kidney regeneration technology. Both are fully implantable and personalized with patient cells, aiming to replace all kidney functions.

Innovations in kidney replacement technology have focused on creating devices that provide full kidney functionality. The implantable BAK and kidney regeneration technology aim to offer solutions by combining high-efficiency filters with bioreactors or using scaffolding for cellular regeneration. Both technologies address donor shortages and complications from dialysis and immunosuppressants, but they are not yet ready for clinical use. Further research is needed to explore their potential impact on reducing dialysis duration and cancer risk in patients with ESRD.

Reference: Dominy CL, Shamsian EB, Okhawere KE, Korn TG, Meilika K, Badani K. Recent innovations in renal replacement technology and potential applications to transplantation and dialysis patients: a review of current methods. Kidney Res Clin Pract. 2023;42(1):53-62. doi: 10.23876/j.krcp.22.074.

Managing chronic kidney disease (CKD) requires dietary changes to help maintain kidney health. Working with a registered dietitian, patients can develop a meal plan that includes enjoyable foods while managing their condition. The first steps involve reducing salt and sodium intake to control blood pressure, eating the right amount and types of protein to protect the kidneys, and choosing heart-healthy foods to prevent fat buildup in the blood vessels, heart, and kidneys. It’s essential to cook fresh foods, use herbs and spices instead of salt, and monitor sodium levels on food labels.

As kidney function declines, additional dietary adjustments may be needed. Patients should choose foods and drinks with less phosphorus to protect bones and blood vessels and foods with the right amount of potassium to ensure proper nerve and muscle function. High phosphorus levels can weaken bones, while improper potassium levels can cause serious heart problems. Reading food labels, draining canned fruits and vegetables, and avoiding high-potassium salt substitutes are important strategies. Working closely with healthcare providers and dietitians can help patients manage CKD effectively through diet.

Reference: Eating Right for Chronic Kidney Disease. National Institute of Diabetes and Digestive and Kidney Diseases. Published October 2016. Accessed August 1, 2024. https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/eating-nutrition