Mary Kean* is a 62-year-old woman who has had hypertension for the last 30 years. She has not taken her medicine routinely because, as she tells her physician, it’s very expensive and she doesn’t feel sick. She also doesn’t adhere to a low-sodium diet. Ms. Kean tires easily and has some edema in her legs, but has no other medical problems.
At her last appointment, Ms. Kean’s physician tells her she is showing signs of kidney disease, including the following abnormal laboratory values: fasting blood glucose of 143 mg/dL with a hemoglobin A1C of 7.2%, serum cholesterol 211 mg/dL with HDL and LDL not within normal limits, and hemoglobin 10.2 g/dL. Urinalysis shows 3+ protein, and she has a glomerular filtration rate (GFR) of 55 mL/min.
The physician wants to schedule Ms. Kean for a kidney biopsy to confirm that the cause of her kidney disease might be uncontrolled hypertension and other comorbidities. He tells her that she doesn’t need dialysis at this time, but should incorporate changes in her medicines, diet, and lifestyle to protect the kidney function she has left.
The nurses caring for Ms. Kean know they need to teach her about her lifestyle changes and re-evaluate her periodically for adherence. She tells the nurses, “I don’t see what high blood pressure has to do with my kidneys.” She doesn’t understand the need for the biopsy, saying, “I worry the doctor thinks I have cancer.”
Nurses frequently encounter patients such as Ms. Kean, who need education to help them protect their failing kidneys. Here is how you can be most effective with these patients. We’ll use Ms. Kean to illustrate key points.
Start off on the right foot
Work with the patient, family, and primary care provider to develop a teaching plan with strategies to stop the progression of kidney damage and prevent complications from kidney disease and its underlying causes such as diabetes and hypertension. Self-management is key for success, so the patient’s active participation is essential.
After completing a complete physical assessment and reviewing the medical record, schedule the patient for a series of educational sessions. Here are some of the topics you’ll want to cover; remember to tie the rationale for interventions to physiological changes.
Causes of kidney deterioration
Instruct patients about the cause of their renal problems. The most common cause is diabetes. For those patients, explain that elevated blood glucose levels damage the small vessels of the kidney and cause proteinuria, a decline in GFR, worsening hypertension, and increased risk of cardiovascular morbidity and mortality.
Ms. Kean: The physician believes her uncontrolled hypertension and other comorbidities such as diabetes and high cholesterol are causing her renal damage. You explain to her that a renal biopsy will give him the information he needs to tailor her treatment. (See What to teach patients about renal biopsy.)
The kidney biopsy confirms that Ms. Kean has stage 2 chronic kidney disease, with mild loss of kidney function. (See Stages of chronic kidney disease.)
Medications
Over time, hypertension causes damage to the small vessels that carry blood to the kidneys. It’s recommended to keep blood pressure below 130/80 mm Hg to prevent kidney complications. If medications are needed to manage hypertension, providers will prescribe ones that are kidney protective, such as angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). These medications help reduce proteinuria.
Other medications used to manage hypertension are beta-blockers and calcium channel blockers. Beta-blockers lower blood pressure by reducing the over-activation of the sympathetic nervous system that is common in patients with chronic kidney disease. Calming the sympathetic nervous system decreases renal vascular resistance, which helps maintain renal blood flow and GFR.
Calcium channel blockers exert important vascular and tubular effects on the kidney, including enhancing GFR, renal blood flow, electrolyte excretion and, ultimately, slowing the progression of chronic renal failure.
Be sure patients understand potential problems with over-the-counter and/or other prescription medicines.
- Nonsteroidal anti-inflammatories such as ibuprofen and naproxen, and cox-2 inhibitors such as celecoxib should be avoided because they can reduce kidney blood flow.
- Many nasal decongestants cause vasoconstriction and high blood pressure, so should be avoided by patients with kidney disease.
- Biguanides, such as metformin, used to control blood glucose, are considered unsafe in patients with renal insufficiency because of lactic acid accumulation, which can be fatal in some patients.
- Patients with kidney disease must not take any of the newer oral diabetes medications known as sodium-glucose cotransporter 2 (SGLT2) inhibitors, such as empagliflozin, canagliflozin, or dapagliflozin, because these drugs rely on normal GFR to remove glucose through the urine.
Ms. Kean: Ms. Kean’s physician prescribes an ACE inhibitor along with a diuretic, which reduces the risk of cardiovascular disease by reducing the volume of extracellular fluid.
You encourage adherence by providing Ms. Kean with a daily pill container to help her remember to take her medications. You also work with her to find options for paying for her medicines.
You suggest that Ms. Kean buy a home blood pressure monitoring device; once she does, you teach her how to use it. You recommend she check her blood pressure at the same time every day and keep a log of the results to bring to her next office visit. You also tell her to call the office immediately if her blood pressure is higher than 160/90 mm Hg.
You review the over-the-counter medicines she should avoid and advise her to consult her physician before taking nonprescription or other prescription medications.
Nutrition
A nutritionist can help patients reach their appropriate weight and make dietary changes to help manage hypertension, diabetes, and high cholesterol. Reinforce the nutritionist’s recommendations, looking for opportunities to include lean protein, whole grains, and fruits and vegetables wherever possible.
Ms. Kean: Because her cholesterol and lipids are not within normal limits, you review with Ms. Kean a list of foods that are high in cholesterol. You teach her to read food labels to help avoid items with high sodium, sugar, and cholesterol. Because she had proteinuria, you tell her to restrict protein to 20% or less of her daily calories. You keep in mind that if her cholesterol and lipid levels can’t be corrected with diet alone, her physician may prescribe a statin medication.
Minerals and hormones
As kidney status declines, the kidneys don’t remove phosphorous from the blood efficiently. Phosphorous and calcium have an inverse relationship, so a higher phosphorous level in the blood corresponds with a lower calcium level. Low calcium triggers the secretion of parathyroid hormone, which corrects the problem by pulling calcium from bones, which can lead to bone loss.
The kidney normally produces the hormone erythropoietin, which stimulates red blood cell production. Erythropoietin production is reduced in kidney disease, leading to anemia. An erythropoietin stimulating agent (ESA) such as epoetin alfa or darbepoetin alfa may be ordered subcutaneously for patients with severe anemia (hemoglobin less than 10%) to replace the missing natural hormone. The frequency and dosage of the ESA will depend on the severity of the anemia.
Ms. Kean: Fortunately her phosphorous and calcium levels are normal. Her physician will monitor the levels closely and order calcium supplements or phosphorous restrictions as necessary. However, Ms. Kean’s hemoglobin is only 9.2 g/dL, so her physician orders subcutaneous epoetin alfa to be given by subcutaneous injection every week.
General well-being
Teach patients with kidney disease to engage in activities that will improve their overall health. For example, exercise has been known to improve overall health, mental outlook, and control blood sugar. Suggest they start a simple exercise program.
Remind patients that radiologic contrast dye, such as intravenous computerized axial tomography scan dye, is nephrotoxic, so they should notify the radiology staff of their kidney disease before having any tests. If the use of contrast is unavoidable, possible strategies include:
- using the lowest possible dose of contrast medium to accomplish the scan
- ordering volume expansion with isotonic sodium chloride solution or sodium bicarbonate before the test
- prescribing oral N-acetylcysteine (a drug with nephro-protective properties) with intravenous isotonic crystalloids to protect the nephrons from damage.
The patient’s serum creatinine level and GFR should be closely monitored after any procedure that includes contrast dye.
Ms. Kean: After consulting with her physician, you suggest Ms. Kean walk 15 minutes three days a week, and then gradually increase the distance to achieve a goal of 2 to 3 hours a week. You recommend she weigh herself weekly, and keep a log of the results. You also advise her to get a pneumonia vaccine and to obtain an annual influenza vaccine, and then explain the potential problems with contrast dye.
A team approach
Nurses assess, diagnose, teach, consult, and reinforce. We help patients make sense of complex diagnoses and support them in managing multifaceted health needs. By working closely with patients, their families, physicians, nurses, nutritionists, and other healthcare providers, you can help prevent or slow further decline in kidney function.
Although the kidney damage Ms. Kean has already experienced is permanent, 1 year later, she is adhering to her medications and diet and has not had any further deterioration in function.
*Name has been changed.
Donna Darcy is clinical assistant professor of nursing at the New York Institute of Technology in Old Westbury, New York. Diane Morris is director of nursing and clinical services at The Rogosin Institute in New York, New York.
Selected references
American Heart Association. Good vs. bad cholesterol. March 23, 2016.
Butt S, Hall P, Nurko S. Diabetic nephropathy. Cleveland Clinic Center for Continuing Education. August 2010.
Hart P, Bakris G. Should beta-blockers be used to control hypertension in people with chronic kidney disease? Semin Nephrol. 2007;27(5):555-64.
Kauric-Klein Z. Improving blood pressure control in end stage renal disease through a supportive educative nursing intervention. Nephrol Nurs J. 2012:39(3): 217-28.
KDIGO. Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2013;3(suppl):1-163.
Mayo Foundation for Medical Education and Research. (2015). Kidney biopsy
National Kidney Center. Causes of chronic kidney disease. 2016.
National Kidney Foundation. What are the stages of chronic kidney disease (CKD)? 2016.
National Kidney Foundation. Nutrition and kidney disease, stages 1-4. 2016.
Taylor C, Lillis CC, Lynn P, et al. (2015). Fundamentals of Nursing: The Art and Science of Person-Centered Care. 8th ed. Philadelphia, PA: Wolters Kluwer.
Wheeler DC, Becker GJ. Summary of KDIGO guideline. What do we really know about management of blood pressure in patients with chronic kidney disease? Kidney Int. 2013;83(3):377-383.
