Management of Patients with Chronic Kidney Diseases – A Systematic Review of Literature

Introduction

            Kidneys function so as to keep the metabolic balance in the human body. According to (Norton et al., 2017) kidneys helps in maintenance of stable concentrations of inorganic anions through the control of blood composition and volume. In addition, they maintain stable acid-base balance and waste removal for excretion through the urethra and bladder. Also, kidneys play vital metabolic and endocrine functions. Kidneys produce rennin that helps in maintenance of erythropoietin and vascular volume. Other functions of kidneys include gluconeogenesis, metabolism of endogenous substances like insulin and drugs and conversion of 25-hydroxyvitamin D to active vitamin D.

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            The research over the past decade has helped in creation of awareness on the great risk factor of chronic kidney disease for cardiovascular diseases. According to (Segall, Nistor, & Covic, 2014) the prevalence of cardiovascular diseases among patients with chronic kidney disease in the United States, reached an astonishing 68% compared to 6% among those without the disease. In end stage renal disease that is common among dialysis dependent patients, the risk of cardiovascular mortality is estimated at 10-20 times higher than in age and gender matched patients.  The remarkable mortality and risk of cardiovascular diseases among patients with chronic kidney disease (CKD) requires effective management of such patients.

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            This paper offers a literature review on the management of patients with chronic kidney disease. The literature search involved the use of keywords to locate scholarly materials from PubMed, Google scholar and university library database. The references of the articles included in this review were also examined to determine the authenticity of the sources.

Results

CKD Management Interventions

According to (Tawfic & Bellingham, 2015) chronic kidney disease has become a worldwide healthcare problem. (Murphree & Thelen, 2010) points that about 13% of adult population suffers from chronic kidney disease (CKD). The knowledge of the therapeutic interventions for chronic kidney disease is important for reduction of morbidity among the patients. Chronic kidney is defined as decline in glomerular filtration rate to less than 60mL/min/1.73m2 or kidney damage of at least three months (Murphree & Thelen, 2010). The disease is common and has high morbidity rates among the patients.  The common sings of kidney damage are proteinuria, persistent glomerulonephritis or structural damage resulting from polycystic kidney disease.  

Regardless of the cause of the disease, the main objective of treatment of CKD is the prevention of occurrence of cardiovascular events, which are responsible for high morbidity rates among the patients. Among the management strategies that were common in the literature, most involved the management of diet, avoiding acute kidney injury, diabetes and pain management.

Management of Diet

The major role of nutrition and food is complex and does not only dwell on the combination of nutrients that the food provides. According to (Campbell & Carrero, 2016) food determines who we are, controlling our health and diseases. The most important aspect of food is quality rather than quantity. The authors further points in their study the increasing public health recommendations for prevention of chronic diseases through good dietary patterns.

The focus of primary prevention of chronic diseases have evolved and shifted its focus on single-nutrient to dietary patterns and whole foods. (Campbell & Carrero, 2016) notes that traditional dietary management of chronic kidney diseases have often focused on the quantity within the diet of protein, energy and restriction of single macronutrient, with recommendation of plant-based patterns. The little focus on quality of diet for CKD patients makes quality of such patients suboptimal. According to the authors, this can be attributed to many factors, which includes restriction on consumption of phosphorus, potassium and sodium and social and financial barriers.

In their study that involved over half a million U.S community dwellers (Campbell & Carrero, 2016) found that individuals who consistently adhered to quality dietary patterns experienced less composite outcomes. The authors noted that the composition of the desirable diet patters included whole grains, legumes, vegetables and high volumes of fruits. The undesirable diet patterns included taking of processed foods that were high in sodium and sugars, red meat and saturated fats.

The management of diet for patients with chronic kidney disease is a complex task (Murphree & Thelen, 2010). According to the authors, it is recommended that as CKD progress, there is need for medical nutrition therapy from a qualified dietician. The authors recommend reduction of excessive protein and sodium intake among the patients with CKD. They argue that protein from the animal source have the potential to increase the renal blood flow rate and glomerular filtration rate (GFR). For sodium intake, the authors argue that reducing sodium intake offers the potential of improving blood pressure control; it lowers the albumin levels in urine and increases the efficacy of RAAS bloggers that manage albuminuria and hypertension.

Management of Diabetes

            Although there is little evidence that a tighter control of CKD compared to poor control slows the progress of CKD. However, (Murphree & Thelen, 2010) points that keeping good blood glucose control lowers albuminuria among patients with diabetes and this reduces the risks that are associated with the declining CFR among the CKD and diabetic patients. Moreover, (Hahr & Molitch, 2015) asserts that diabetes mellitus is the common cause of kidney failure and CKD. According to the authors, those patients who suffer from stage 4-5 CKD and those undergoing dialysis have delayed gastric emptying. This may significantly affect blood sugar levels. Given that patients with CKD are more likely to suffer from CKD, the management of diabetes provides a good intervention for the management of CKD.

Avoiding Acute Kidney Injury

            Acute kidney failure refers to the loss of kidney function, which is defined by increase in serum creatinine <0.3 mg/dL, reduction in urine output by about 0.5 mL/kg/hr for more than six hours or a 50 or more percentage increase in serum creatinine (Murphree & Thelen, 2010). Patients who suffer from CKD are highly susceptible to nephrotoxic medications, which predispose them to acute kidney injury. Kidney injuries have the potential of accelerating progression of CKD. In addition to provision of education to CKD patients on way of lowering acute kidney injuries, such patients must be advised to avoid medications such as β-lactam antibiotics, no steroidal anti-inflammatory drugs (NSAIDs), quinolones and sulfonamides. Moreover, the intravascular administration of iodinated agents must be administered by physicians with caution.

Pain Management

            The most significant element that influences the quality of life of patients with CKD is pain (Zyga et al., 2015). CKD patients undergo pain during the hospital dialysis process. According to the authors, self-efficacy in pain and quality of life can play a significant role in CKD and treatment outcomes. According to (Tawfic & Bellingham, 2015) postoperative pain management issues could include one or a combination of dose adjustment, prevention of further renal damage, the presence of chronic pain and the use of peripheral nerve blocks. The authors further categorize pain management into the various stages of CKD.

            Patients with CKD in stage one have normal renal function but with a structural abnormality diagnosed incidentally during radiological examination, such as presence of kidney cysts. Posttraumatic and postoperative pain management with this group of patients should include neuraxial or peripheral nerve blockade. In stage 2, CKD patients suffer from mild impairment of renal function. The sufficient level of renal functions CKD stage two demands no adjustment for pain medications. CKD in 3rd and 4th stages should be managed through regional techniques as they can be effective in reducing exposure to analgesics.

Conclusion

Based on the findings above, it can be concluded that management of patients with chronic kidney disease involves limited interventions that include control of diabetes, pain management, avoidance of acute kidney injury and management of diet. The focus of the therapeutic interventions is the management of underlying complications and illnesses of chronic kidney disease. It is advisable that CKD is prevented before its offset through radiological screening and quality diet.

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