Support in the Care of the Nephrology Patient - Essay Example

Renal diseases attract attention of the researchers since beginning of scientific era in health care. After Richard Bright and his contemporaries thescientific horizons became wider. Medicine has got effective technologies of diagnostics and treatment, e.g. renal transplantation and haemodialysis. But technical facilities cannot replace human factor. Nephrology patients need psychological support, diet advising, and high quality care. Because renal diseases could restrict patient's abilities for self-care and worse his/her life quality than multidisciplinary approach should be used in all nephrology units. There was stated that "Management of renal disease requires a multi-professional team including many other professionals in addition to doctors/nurses. This is often poorly appreciated by those commissioning renal services, leading to shortages of key staff." (CPG, 2003) Kidneys play an essential role for life. Excretion of toxic products of metabolism, the maintenance of water-electrolyte balance, secretion of rennin and erythropoetin - these functions could be impaired in the cases of the severe renal diseases. Until the late 1950s the diagnosis of established renal failure was a synonym of death sentence. Nowadays advanced medical technologies could extend the lives of the patients and improve their life quality. Older patients having multiple pathologies could be treated effectively. Sick infants and children got chance for life. The epidemiology of renal diseases is characterised with the prevalence of chronic forms. This fact can be explained by the prolongation of patients' lives and by the association between chronic renal diseases and other nosologies, e.g. cardiovascular diseases or diabetes mellitus. By the official data (DOH, 2005) there are more than 2,500,000 people in England who suffers with chronic kidney diseases. Frankel, Brown & Wingfield (2005) assessed the prevalence of chronic kidney disease as 0.2-0.5% of general population. In 2003 the prevalence of chronic renal diseases among the adult population of the United States was 11% (Coresh et al., 2003). Correspondingly the number of patients who will approach end-stage kidney disease is very high - actually, it is equal to number of sufferers with chronic kidney problems. The incidence and prevalence of terminal stages of kidney diseases continues to grow worldwide. Accordingly to research data (Moeller, Gioberge & Brown, 2002) there were 1,500,000 people receiving renal replacement therapy. Among them the absolute majority (about 69%) received haemodialysis, 23% had transplanted kidney and 9% received peritoneal dialysis. That is interestingly that the highest incidence and prevalence rates are observed in the United States of America and Japan, i.e. in the countries with the highest technological and economical potential. Generally, a number of people receiving specialised nephrological care depend on the various factors including demographic characteristics, responsiveness of health care systems, government funding, reacceptance of treatment, and accessibility of care. Thus in the industrialised countries the number of people who achieve the terminal stages is increased. This circumstance require urgent actions of health care services, particularly in the development of effective system of palliative care and ensuring that patients will get adequate pain relief and other appropriate treatment and they spend the last days of their lives with dignity. The National Service Framework (NSF) for Renal Services recommended the measures, which should be implemented in three main domains, including early medical interventions in the cases of chronic kidney disease, reducing the incidence of acute renal failure and extending good palliative care practice to patients with terminal stages of chronic renal failure. There were also developed sets of standards and identified the markers of good practice which "will help the NHS and its partners manage demand, increase fairness of access, and improve choice and quality in dialysis and kidney transplant services" (NHS, 2004). The complexity of practical experience including using continuous haemosorption, peritoneal dialysis, haemodialysis, and renal transplant require the optimum clinically appraised and evidence based strategies. Not only nurses but also many other specialists participate in the provision of the optimal conditions for nephrological patients. By the opinion of Mendelssohn (2005) late referral to the nephrologists is associated with many adverse outcomes, e.g. rapid onset of end-stage renal disease, progression of co-morbid conditions such as anaemia and cardiovascular disease and so on. Other problems related to inappropriate terms of the referral include worsened intravenous access for dialysis, increased use of centre-based haemodialysis, increased hospital utilization, increased cost and poorer survival rate. Multidisciplinary team-based care was implemented into medical practice in the early 1990s. But there are still exist barriers to more pervasive usage of this model of care. Firstly some specialists still cannot accept the advantages of new model of care. On the other hand, medical legislation and local policy sometimes do not provide adequate funding to support the infrastructure, space and salaries of multidisciplinary teams. This is paradoxical situation because many researchers (Curtis et al., 2005; Hudson, 2004; Goldstein et al., 2004) proved that multidisciplinary team-based care is cost-effective and very promising approach. Thus there was shown that with implementing multidisciplinary team-based care the onset of terminal stages of renal insufficiency was delayed, the use of arterial-venous fistulae and cost-effective home-based dialysis modalities was increased, and the lethality in the specialized units was decreased. Goldstein and coauthors (2004) stated that multidisciplinary team-based pre-dialysis care is associated with better clinical outcomes after the start of dialysis therapy. By the opinion of Ravani P. et al. (2003), the multidisciplinary approach to management of chronic renal diseases is more effective than just timely referral to nephrologists, particularly, in improving patient survival on dialysis. Multidisciplinary team includes not only physicians (e.g. nephrologists, endocrinologists, etc) but also nursing staff, occupational therapists, renal dieticians, physiotherapists, social workers, pharmacists, health care support workers and auxiliary staff. They all work in the different fields but for common purpose - to improve health of their patients. Thus nurses of specialized items provide manipulations and medical interventions prior to, during and post transplantation of kidneys, maintain fluid and electrolytes balance. Other their responsibilities includes control on the diet, psychological and educational support of patients and their families (Compton, Provenzano & Johnson, 2002). During the past several years renal nurses obtained new roles, e.g. they could work as pre-dialysis nurses, vascular access nurses, anaemia co-ordinators, transplant nurse practitioners and outreach nurses (NHS, 2004). Youngman (2004) underlined the role of new post of renal diabetes nurse in the multidisciplinary team-based nephrological care. The National Renal Workforce Planning Group identified that healthcare assistants should work within the multidisciplinary team in skilled roles, usually within a discreet area of practice (NHS, 2002). The reassessment of the renal workforce required implementing new clinical and support roles. There are two groups of specialists providing administrative support and the transportation of patients with kidney diseases - clinical support workers, and technicians. Perryman & Harwood (2004) in their case study highlighted the role of the physiotherapist and importance of providing multidisciplinary care for haemodialysis patients. They consider that nurses are often in positions to identify patients, who are in need of or could benefit from a physiotherapy consultation. In this case, the collaboration between nurse and physiotherapist could be highly successful for pain-relief and returning patient to his/her previous level of functioning. NHS experts (2004) urged that education of patients with progressive renal failure could significantly improve their knowledge of that disease and of renal replacement therapy. Participants of such pre-dialysis educational programs had improved psychosocial outcomes and required shorter hospital admission. Nevertheless some researches did not give evidence of the preferences of multidisciplinary approach to the management of chronic renal diseases. For example, Harris LE. et al. (1998) did not find any differences in the outcomes of treatment between the routine and multidisciplinary case management in patients with chronic renal insufficiency. Renal function, health services use, and mortality in the first five years after new approach was enrolled. The annual direct costs of the intervention were significantly higher than usually and there were no significant distinct in the use of renal sparing or selected potentially nephrotoxic drugs. Authors considered that intensive, multidisciplinary case-management intervention had no effect on the outcomes of care among primary-care patients with established chronic renal insufficiency. They wrote that these "expensive and intrusive interventions, despite representing state-of-the-art care, should be tested prospectively before being widely introduced into practice" (ibid, p. 546). But it seems that such negative attitude to the multidisciplinary approach has only anecdotal character. Renal dieticians are involved in the nutritional care of all patients with renal diseases, including pre-dialysis, dialysis and post-transplantation stages (King, 2003). The Renal Nutrition Group of the British Dietetic Association developed evidence based "renal dietetic standards". Similar guidance was implemented into the practice by the Paediatric Renal Interest Nutrition Group. The role of renal dietician is not restricted only for control on the diet of nephrological patients but it's the most important function. Thus, recently conducted randomised controlled trials approved that dietary protein restriction can reduce the risk of renal failure or death in non-diabetic renal disease and improves clinical symptoms of nephropathy in insulin-dependent diabetes mellitus (Fouque et al., 2005; Kugler et al., 2005). There are also following requirements to the daily diet of the patients with renal insufficiency: it should be low in phosphate, potassium, sodium and protein, and high in fibre. The volume of water for drinking is restricted also. But unfortunately many patients many patients had difficulties when following diet recommendations and fluid restrictions. For increasing the adherence to diet and fluid intake control the multidisciplinary approach could be critical (Kugler et al., 2005). Nowadays the role of renal dieticians is encompassed because they took more responsibilities and advanced their practice into new areas such as prescribing. Generally, the participation of the dieticians as part of the multidisciplinary team is beneficial for optimising time management and cost preserving. Many kidney centres have incorporated transplant pharmacists into the multidisciplinary transplant clinical team (Martin & Zavala, 2004). The transplant pharmacists participate both in clinical and research activities of the multidisciplinary team. The requirements for workforces in multidisciplinary team-based nephrological care are flexible and depend on the needs in highly specialised care, e.g. renal replacement therapy. Nevertheless there is the gap between the current and desirable staffing (see Table 1 of the Appendix). Further development of the approach of multidisciplinary team based care will allow eradicating this disproportion. References: 1. BDA (2005) Specialist Groups of the BDA. Accessed at the web-site: on 20/06/2005. 2. Compton A, Provenzano R. & Johnson CA. (2002) The nephrology nurse's role in improved care of patients with chronic kidney disease. Nephrol Nurs J. Vol. 29, No. 4 pp. 331-336. 3. CPG (2003) Renal Disease in Scotland. Edinburgh. Scottish Parliament. Accessed at the web-site: on 20/06/2005. 4. Curtis BM. et al. (2005) The short- and long-term impact of multi-disciplinary clinics in addition to standard nephrology care on patient outcomes. Nephrology, Dialysis, Transplantation. Vol. 20, No. 1 pp. 147-154 5. DOH (2004) The evidence base for the National Service Framework for Renal Services Modules One and Two: Dialysis and Transplantation. Accessed at the web-site: on 19/06/2005. 6. Fouque D. et al. Low protein diets for chronic renal failure in non-diabetic adults The Cochrane Database of Systematic Reviews 2005 Issue 2 7. Frankel A., Brown E. & Wingfield D. (2005) Management of chronic kidney disease. British Medical Journal Vol. 330 pp. 1039-1040 8. Goldstein M. (2004) Multidisciplinary predialysis care and morbidity and mortality of patients on dialysis. American Journal of Kidney Diseases. Vol. 44, No. 4 pp. 706-714. 9. Harris LE. et al. (1998) Effects of multidisciplinary case management in patients with chronic renal insufficiency. American Journal of Medicine Vol. 105, No. 6 pp. 464-71. 10. Hudson M. (2004) Multidisciplinary collaboration (MDC): what was it and where did it go Nephrology News Issues. Vol. 18 No. 6 p. 48. 11. King K. (2003) Multidisciplinary contributions to rehabilitation: a National Kidney Foundation survey of the dialysis health care team. Advanced Renal Replacement Therapy. Vol. 10, No. 1 pp. 78-83. 12. Kugler C. et al. (2005) Nonadherence with diet and fluid restrictions among adults having hemodialysis. Journal of Nursing Scholarship. Vol. 37, No. 1 pp. 25-29. 13. Martin J.E. & Zavala E.Y. (2004) The expanding role of the transplant pharmacist in the multidisciplinary practice of transplantation. Clinical Transplantation, Vol. 18, No. s12, pp. 50-54 14. Mendelssohn DC. (2005) Coping with the CKD epidemic: the promise of multidisciplinary team-based care. Nephrology, Dialysis, Transplantation. Vol. 20, No. 1 pp. 10-12. 15. National Renal Workforce Planning Group (2002) The Renal Team: A Multi-Professional Renal Workforce Plan for Adults and Children with Renal Disease. Accessed at the web-site: on 20/06/2005. 16. Perryman B. & Harwood L. (2004) The role of physiotherapy in a hemodialysis unit. Nephrology Nursing Journal. Vol. 31, No. pp. 215-216. 17. Ravani P. et al. (2003) Multidisciplinary chronic kidney disease management improves survival on dialysis. Journal of Nephrology Vol. 16, No. 6 pp. 870-877. 18. Youngman S. (2004) The developing role of the renal diabetes nurse. EDTNA ERCA Journal. Vol. 30, No. 3 pp. 169-172. Appendix: Table 1. Current and recommended specialist renal staff to patient on renal replacement therapy ratios (NRWPF, 2002) Read More