Symptom experience in non-dialysis-dependent chronic kidney disease: A qualitative descriptive study.

BACKGROUND: Studies indicate that symptoms attributable to impaired kidney function are important determinants of quality of life and functional status in patients with chronic kidney disease (CKD). Accordingly, symptom assessment and subsequent control are prerequisites of high-quality care in this patient population. Whilst symptom burden in patients with advanced CKD managed without dialysis has been likened to that of palliative care cancer populations, there is little information about the nature and range of symptoms in earlier stages of the CKD trajectory. This paper reports the findings of the preliminary phase of a study aimed at exploring the symptom experience in patients with CKD stages 4 and 5. METHODS: Eighteen semi-structured patient interviews were conducted, using an interview schedule developed specifically to guide discussion. Data were analysed using thematic analysis to identify symptom categories and thematic patterns across the patient experiences. RESULTS: Patients reported a wide range of symptoms, with over 50 different categories and sub-categories emerging from the interview data. Symptom categories could be broadly classified into physical symptoms, such as 'Altered taste perception', 'Sleep disturbance' and 'Fatigue', and psychological symptoms, such as 'Forgetfulness', 'Poor concentration' and 'A sensation of gradually slowing down'. Of note, when questioned further, patients indicated that they would not usually report their symptoms to clinicians. CONCLUSIONS: This study suggests that patients with CKD stages 4 and 5 may have a high symptom burden. The finding that patients did not routinely report their symptoms emphasises a need for clinicians to incorporate symptom assessment into routine clinical consultations.

CE: continuing education article. Prevention of infection in patients with chronic kidney disease part 1: application of infection control principles to the renal care environment.

This first paper, in a three-part CE series on the prevention of infection in patients with chronic kidney disease, focuses on infection susceptibility in this patient population and the application of infection control principles to the renal care environment. The second and third papers in this series will focus on specific aspects of infection control including the prevention and management of blood-borne virus and other healthcare-associated infections.

CE: Continuing Education Article: MANAGEMENT OF ANAEMIA IN CHRONIC KIDNEY DISEASE.

SUMMARY Anaemia is an almost universal issue that develops in the later stages of chronic kidney disease (CKD) primarily due to a lack of erythropoietin (EPO) and the depressed EPO response in bone marrow. This can have a profound effect on the patient's lifestyle and quality of life. Knowledge of both the psychosocial and clinical areas of CKD is imperative for healthcare professionals so that they can be at the forefront of improvements of CKD patient care.

An evidence-based approach to anaemia management in predialysis chronic kidney disease.

The use of Evidence-based practice (EBP) is a decision-making process, which integrates the best available research, clinician expertise, and client characteristics, integrating quality patient care in terms of clinical outcomes and cost-effectiveness. This paper describes the application of EBP to an outpatient intravenous (IV) iron clinic for patients with predialysis chronic kidney disease (CKD). There has been an increasing focus on managing anaemia in patients with predialysis CKD. Along with the use of erythropoiesis stimulating agents, there has been an emerging interest in the use of IV iron preparations to treat anaemia in this patient population. Using EBP, we introduced a single dose preparation Ferinject to replace our original IV iron protocol using Venofer. As a test dose of Ferinject is not required, it is extremely appropriate for use in busy nurse-led IV iron clinics. Based upon the evidence generated from our initial trial of using Ferinject, and our clinical experience of using this preparation, we have now converted our IV iron protocol to Ferinject. Although the evaluation of Ferinject in our predialysis population is ongoing, we are continuing to observe the benefits of using this preparation, both in terms of patient outcome and cost-effectiveness. We consider that the use of Ferinject has reduced waiting time and waiting list pressure, and also reduced material and hospital transport costs, which are significant due to the large geographical area covered by our CKD service.

Management of co-morbid diseases in a patient with established renal failure.

This follows on from an article relating to chronic kidney disease (CKD) and co-morbidities. Not only do these co-morbid diseases cause problems to patients with CKD, they continue to impact upon them when they develop established renal failure (ERF). Various co-morbid conditions can affect the patient including diabetes, hypertension, anaemia and cardiovascular issues. As nephrology nurses we play a fundamental role in patient education, monitoring and management of these factors.

The efficacy of a single dose of intravenous ferric carboxymaltose (Ferinject) on anaemia in a pre-dialysis population of chronic kidney disease patients.

Anaemia due to chronic kidney disease (CKD) is common and may be managed with erythropoiesis stimulating agents and/or iron preparations. Iron preparations may be administered orally, intravenously or by intramuscular injection. Oral preparations pose a significant tablet burden on patients who are often taking multiple medications and may have undesirable gastrointestinal side effects. The existing intravenous preparation Venofer requires multiple doses of drug (typically 100-200 mg) at multiple clinic visits. The preparation Cosmofer may be given as a single dose, but this requires four to six hours to administer. For these reasons, their use in pre-dialysis patients remains limited in practice. The new intravenous iron preparation Ferric Carboxymaltose (Ferinject) may be given as a single dose of up to 1000 mg (but not exceeding 15 mg/kg/week) as an infusion over 6-15 minutes. This offers a significant advance in the management of these patients. We describe our initial experience with using this drug in a non-dialysis patient population with chronic kidney disease.

Intravenous iron in chronic kidney disease: haemoglobin change shortly after treatment of patients neither on dialysis nor on erythropoietin.

Anaemia is a common in chronic kidney disease. Although erythropoietin and iron supplementation are established treatments, knowledge on the use of IV iron alone in patients not on dialysis or erythropoietin is incomplete. The responses of 82 patients referred to the renal anaemia service with haemoglobin of 11.5 g/dl or less were assessed 1 week after completing four once weekly doses of 200 mg of venofer. No patients were on dialysis or erythropoietin. The haemoglobin rise 1 week after treatment was 0.53 g/dl. Ferritin levels improved from 110.8 to 410.2 ng/l and transferrin saturation from 17.7 to 27.3%. Ferritin levels remained below our target range (200-500 ng/l) in 7.7% while 25.6% had levels above this. Ferritin levels remained less than 800 ng/l in nearly all patients. Intravenous iron is cost effective and should be considered for use in patients with renal anaemia. Patients with CKD stage 5 appeared to respond less well.

Pre-dialysis education and patient choice.

The discussion was initiated by a paper on the influence of a pre-dialysis education programme on the mode of renal replacement therapy by Goovaerts et al (NDT 2005). Barriers to the uptake of self-care treatment modalities, including late referral, limited availability of treatment options, reimbursement, support from staff and families, the requirement for a helper and the length of the training programmes for home haemodialysis (HD) were discussed by 21 participants from 12 countries. The 'take-home' messages from the discussion were that to optimise the uptake of self-care modalities, renal units should try to ensure the all patients who are able to choose are fully informed before starting dialysis, even if they are referred to the unit very late. Offering a wide range of treatment options to new patients, and allowing (or encouraging) home HD without a helper, may also increase the number of patients who start and stay on a self-care modality. It should be possible to provide an acceptable level of training, without compromising on safety, within 3 weeks if the patient is confident with needling.