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Renal Care in the Community Lynette Knuth. RN, BSc, PG cert Crit care, PGDip NS. 2014 Masters candidate Chronic Kidney Disease – Stage 4 Nurse Specialist - 0.5 fte Clinical Nurse Specialist – 0.1 fte Dialysis Nurse (PD and HD) – 0.3 fte 30 May 2014

• Past, present and future of the Anaemia protocol • CKD stage 4: management • Advanced care planning: end of life care

Past, present and future! Our anaemia protocol • Anaemia protocol started around 2004 • Roche employed nurses to coordinate the protocol – move it into • Temporary positions • To ensure primary physicians can manage renal anaemia • These nurses were passionate and proud. • Very good at their jobs and wanted to keep their jobs* • Taranaki was the first protocol • Presented at many Australasian conferences. • After having the protocol within the primary sector for 8 years, Roche pulled funding for their positions. • These nurses went into "Save our jobs" mode • DHBs didn't listen, they still lost their jobs…

SO……. What's happening now • Fair enough, by rights after 10 years of having this protocol out… we shouldn't need them • The whole purpose of the anaemia coordinator was to get the protocol out and usable • Make it fully managed by GPs • Why • Saves the patient admissions to hospital • No blood transfusions – no antibodies when comes to Tx • Saves $1200/night/patient in hospital – tax payers money • Good revenue for GPs • Easy protocol

• Across the country, anaemia jobs have been disestablished • CKD nurse to organise • Special authorities for all renal anaemia patients • Iron infusions for CKD patients

Erythropoietin (EPO) Administration

• Start EPO in the dose of 4000 units subcutaneously once a week
• Monitor Hb, iron status, renal function, albumin, and BP (blood pressure) monthly
• If Ferritin > 500 microg/L then check CRP and Reticulocyte count
• Adjust EPO dose as below

• Hb < 110 g/l:

• Increase EPO dose by 1 step

• Hb 110 – 120 g/l:

• No change in EPO dose

• Hb > 120 g/l:

• Reduce EPO by one step

• • STOP EPO and restart at lower step when Hb is <120 Weekly Dose
Weekly frequency
1000 units equivalent
2,000 units x fortnightly
2000 units
2,000 units x once a week
3000 units
3,000 units x once a week
4000 units
4,000 units x once a week
5000 units
5,000 units x once a week
6000 units
6,000 units x once a week
8000iu units
4,000 units x twice a week
10000 units
10,000 units x once a week
12000 units
6,000 units x twice a week
Parts of the protocol often not read • The general practitioner will consult with the renal physician, (Dr A Williams), if there are any difficulties in achieving target haemoglobins, or for any other queries related to this protocol. • Oral Iron Administration
NB: If BP > 160/100 do not give EPO – ****refer to renal
NB: ****Refer to Physician**** if:
• Hb increase is > 10g/L in the past month • Hb increase is < 3 g/L in the past month and is below target range • Hb < 80 g/L and patient is on EPO • Hb increase above target range despite previous dose decrease • CRP > 50 Chronic Kidney Disease (CKD) www.kidneys.co.nz Who should usually be referred to a nephrologist? • eGFR <30mL/min/1.73m2* • Persistent significant albuminuria (urine ACR >30mg/mmol) • A consistent decline in eGFR from a baseline <60mL/min/1.73m2 >5mL/min/1.73m2 (a decline over a six-month period which is confirmed on at least three separate readings) • Glomerular haematuria with macroalbuminuria • CKD and hypertension that is hard to get to target despite • At least three anti-hypertensives • Diabetes with eGFR <45mL/min/1.73m2** Prognosis of CKD by GFR and albuminuria category Albuminuria Stage Microalbuminuria Macroalbuminuria (Urine ACR mg/mmol) (Urine ACR mg/mmol) (Urine ACR mg/mmol) Female: < 3.5 structural or pathophysiological abnormalities present < 15 or on dialysis Progression risk Causes of new patients 2012 • Cease smoking • Weight management • Physical activity • Good nutrition • Alcohol intake • Blood pressure management • Proteinuria management • CVD Risk • Blood glucose management • Up to 80% of our dialysis population could have been • Incentre Haemodialysis patients can cost up to if not more than $100,000/per year/patient • Peritoneal dialysis patients can cost up to $50,000 • Big drive for community dialysis and pre-emptive transplantation… Continuum of development, progression and complications CKD Management of CKD Patients • First we need to prevent CKD… Diabetes, obesity, heart • Main aim of management: • Prevent Complications
Prolong period before needing dialysis
Positive end of life
• Anaemia – Iron stores first - then EPO • BP management • Bone health • Kidney monitoring • Symptom management • Cognitive testing • Advanced care planning Bone health and Kidney Failure • Phosphate - Increases • Calcium - Decreases • PTH - Increases • Alk Phos – Increases • What does Calcium carbonate work on? • What does Calcitriol work on? • What does Aluminium work on? • What does increased alk phos indicate? • Phosphate absorbed by food • Dairy/Meat/Eggs • Excreted mainly by kidneys, some by the bowel • Calcium increased by PTH activation of vitamin D • Excreted mainly by bowel, little by kidney, reabsorbed by kidneys. • Released in response to low extracellular concentrations of free Ca+ • Stimulates production of inactivated vitamin D • Mobilization of Calcium from bone • Suppresses calcium loss in urine • Inactivated Vitamin D – 25 Dihydroxylvitamin D • Converted by liver • Mobilised to kidney convert it to useable form • 1,25 dihydroxycalciferol – increases Ca+ absorption in intestine. Bone health and kidney problems Simply • Phosphate is not excreted via kidneys • Serum phos rises • Unable to activate Vitamin D • Absorption of Ca+ is decreased • Serum Ca+ decreases • PTH hyper secreted, in an effort to increase intestinal absorption Complications of poor bone health • Alk Phos rises = Damage to bone structure. CKD-MBD • Brittle Bones • Deformation • "Chalk" vessels • Calciphylaxis Years of poor bone health Bone Health Medications • Phosphate Binders – Calcium carbonate and aluminium taken with every meal – Ca Carb - CHEWED!! – excrete phosphate through bowels • Calcitriol – (Rocaltrol) Activated Vitamin D to increase Calcium and suppress secretion of PTH. New Initiatives - TDHB Cognitive Testing Cognitive Testing • Up to 70% of HD patients have chronic cognitive impairment - Moderate to Severe • Unrecognized cognitive impairment • Functional status of older patients that start dialysis is maintained in only 13% of these patients • Cognitive and functional impairment is associated with increased risk of death amongst dialysis patients Why do cognitive testing • Failure to train patients onto home dialysis • Prevent early death within 6 months of starting dialysis • Gives an understanding how these patients will train • To early to tell results • Pre-dialysis cognitive testing • Addenbrooke's tests • Survival calculations at pre-dialysis modality session • ANZdata calc • Haemodialysis calc • On dialysis, every 12 months (Only HD patients at this point) • Test for deterioration – 30% of our patients have deteriorated Advance Care Planning End of life care • What is Advanced Care Planning? • Process – capable (Mentally competent) adult engages in a plan about health care decisions, in the event that they become incapable (Legally incompetent) to personally direct his/her own health care • Kind of care the person would want or not want if he/she unable to make a decision • Process of exploring Qs that often go unasked • What give life meaning • Are there circumstances • Loss physical functioning • Loss mental awareness ACP – Role of health worker • Health care workers should initiate ACP conversations – Having those difficult conversations. • Health care worker should encourage ACP. Not just for those people facing life threatening conditions etc. • Health care workers can and should be a support and resource to people doing ACP. • Health care workers should know how to assist an adult person who wants to complete an ACP. Ethical and Legal obligations • Appropriate training to communicate effectively during ACP discussions and to understand the legal and ethic issues involved. • Basic level one training is free on line – easy ? 1.5 hours of professional development • www.advancedcareplanning.org.nz • No one should be pressured – adults right to refuse • Consent to treatment must be obtained from a capable adult • The fact that a person has an ACP and/or advanced directive – NOT relevant as long as the person is capable of making his or her own decisions about care. • The person: Fosters personal resolution, help to reduce anxiety about what lies ahead. • Confidence that wishes are known and will be followed • Patients loved ones: Benefit of knowing what choices the patient would have made • Look back with the knowledge that they were able to honour their family members wishes • The health care worker: integrating ACP into routine clinical encounters enables them to help pts families etc to prepare for the kinds of decisions they may face in future. • Pre – course work • Level one basic online training – print out certificates, bring with you to the course • When registered – ACP people send out pre-course workbook • Complete your own ACP • Full course – 10 participants only • 2.5 day course – full on! • To complete the course, its compulsory to be there the whole time. • Compulsory to participate – ROLE PLAY • Role-play – You – 1 actor – one video player and the facilitator • 4 others watching Post course expectations • Post course expectations • Structure support group • Identify patients who would benefit from ACP • Initiate discussion and provide resources • Help patients to document their preferences • Keep a reflective log of the conversations • At ONE MONTH – need to have completed 10 conversations and let the facilitators know. • I sent in my reflective log to prove I had at least 10 • They send a certificate • No anaemia nurse coordinators • Physician to physician contact • 1st prevent CKD • 2nd prevent complications of CKD • 3rd Management of CKD • Cognitive assessment of patients • Importance of advance care planning • Alosco, M. L., Spitznagel, M. B., Raz, N., Cohen, R., Sweet, L. H., Colbert, L. H., . . Gunstad, J. (2013). Executive dysfunction is independently associated with reduced functional independence in heart failure. J Clin Nurs. doi: 10.1111/jocn.12214 • Hayes, T. L., Larimer, N., Adami, A., & Kaye, J. A. (2009). Medication adherence in healthy elders: small cognitive changes make a big difference. J Aging Health, 21(4), 567-580. doi: • Johnson DW, Atai E, Chan M, Phoon KS, Scott C, Toussaint ND, et al. KHA- CARI Guideline: Early chronic kidney disease: detection, prevention and management. Nephrology 2013; 18: 340-350 • KHA-CARI Guidelines www.cari.org.au and the New Zealand Primary Care Handbook 2012 Revised October 2013 • Kidney health NZ. (2013) Chronic Kidney disease (CKD) Management in general practice. Summary guide • Thiruchselvam, T., Naglie, G., Moineddin, R., Charles, J., Orlando, L., Jaglal, S., . . Tierney, M. C. (2012). Risk factors for medication nonadherence in older adults with cognitive impairment who live alone. Int J Geriatr Psychiatry, 27(12), 1275-1282. doi: 10.1002/gps.3778

Source: http://www.nzirh.org.nz/wp-content/uploads/2013/03/GPs.pdf

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ARTICLE IN PRESS Medical Engineering & Physics xxx (2006) xxx–xxx Photoacoustic monitoring of the absorption of isotonic saline solution by human mucus F.L. Dumas , F.R. Marciano , L.V.F. Oliveira , P.R. Barja , D. Acosta-Avalos a Instituto de Pesquisa e Desenvolvimento (IP&D), Universidade do Vale do Paraiba, Av. Shishima Hifumi 2911, CEP 12244-000, S˜ao Jos´e dos Campos, SP, Brazil