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Screening for renal disease: the role of the practice nurse

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Peter Ellis, BSc (Hons), MSc, MA, RN, PGCM, PGCE.

Research Projects Manager

In the UK there are an estimated 30 000 individuals currently on renal replacement therapy (RRT) - although it is difficult to get precise figures since not all renal units contribute to the Renal Registry. Forty per cent of these individuals have functioning renal transplants while the others are receiving either haemodialysis or peritoneal dialysis. Each year, 82 people per million of the population are accepted for RRT (Roderick et al, 1998). Data from the Renal Registry (Ansell et al, 1999) shows that, among people aged under 65 receiving dialysis, 80.5% of those with diabetes survive beyond one year compared with 91.4% of non-diabetics. The figures for people aged over 65 are 74.5% and 76.6% respectively.


In the UK there are an estimated 30 000 individuals currently on renal replacement therapy (RRT) - although it is difficult to get precise figures since not all renal units contribute to the Renal Registry. Forty per cent of these individuals have functioning renal transplants while the others are receiving either haemodialysis or peritoneal dialysis. Each year, 82 people per million of the population are accepted for RRT (Roderick et al, 1998). Data from the Renal Registry (Ansell et al, 1999) shows that, among people aged under 65 receiving dialysis, 80.5% of those with diabetes survive beyond one year compared with 91.4% of non-diabetics. The figures for people aged over 65 are 74.5% and 76.6% respectively.



RRT is expensive - up to £30 000 per year to keep alive people on haemodialysis. Transplants cost £10-15 000 in the first year and approximately £2500-3000 subsequently. People with end-stage renal failure (ESRF), who require life-long dialysis, have a poorer quality of life than the general population as well as having a reduced life expectancy. This reduced quality of life is associated directly with the dialysis treatments and the attendant poor body image and also with the co-morbid diseases responsible for, or arising as a result of, kidney failure. For example, about one-third of all patients on dialysis in the UK have diabetes and hence suffer complications such as retinopathy and neuropathy. Complications arising as a result of renal disease include bone disease, anaemia and psychosexual problems.



End-stage renal disease does not develop rapidly in the majority of individuals. Most people who develop ESRF have had progressive, and often undetected, chronic renal failure (CRF) for many years (Ellis and Cairns, 2001). Many of the individuals with ESRF have a long history of chronic diseases that predispose them to the development of renal disease. Unfortunately, the detection of CRF in primary care, as well as in secondary and tertiary care, is ad hoc. Few health-care professionals make systematic efforts at screening for renal disease, despite the fact that, broadly speaking, those individuals at greatest risk of developing renal impairment are well characterised (Box 1).



This lack of screening has the inevitable consequence that many individuals with CRF are referred for nephrological care at an advanced stage of the disease.



Consequences of late referral
Individuals referred at a late stage of their disease spend significantly more time in hospital when they start dialysis than individuals referred earlier. This time reflects the need to create dialysis access, reverse the metabolic effects of kidney failure and treat co-morbid diseases. Time in hospital is used as a proxy measure of morbidity in many studies and demonstrates that individuals referred late for nephrological care spend between 50% (Roubicek et al, 2000) and 600% (Jungers et al, 1993a) more time in hospital at the start of dialysis than individuals who were referred earlier.



There is some evidence that late referral is associated with more deaths (Lamiere and Van Biesen, 1999; Sesso and Belasco, 1996). There is also a strong correlation, however, between death and the use of haemodialysis as the first treatment option and also between death and the use of multiple temporary dialysis lines, which are used more frequently in late referrals (Innes et al, 1992).



People who are referred later have a worse biochemical and physiological status at the start of dialysis. Serum creatinine (a reasonable marker of renal function) is significantly higher - by about 20-30% - in almost all reported cases (Arora et al, 1999; Ellis et al, 1998; Ifudu et al, 1996; Jungers et al, 1993a; Jungers et al, 1993b; Roubicek et al, 2000; Sesso and Belasco, 1996). Individuals with little pre-dialysis nephrological care experience more metabolic acidosis, with significantly lower serum bicarbonate at end stage, than individuals with prior nephrological care (Ifudu et al, 1996; Jungers et al, 1993a; Jungers et al, 1993b). Late referral is also associated with lower levels of serum albumin, which is often considered as a marker of nutritional status and known to correlate well with mortality (Arora et al, 1999; Jungers et al, 1993a; Jungers et al, 1993b; Khan et al, 1995).



Late referrals also experience more severe hypertension (Jungers et al, 1993a; Jungers et al, 1993b; Roubicek et al, 2000; Sesso and Belasco, 1996) and are more likely to have pulmonary oedema, frequently necessitating emergency dialysis (Jungers et al, 1993a; Lamiere and Van Biesen, 1999; Roubicek et al, 2000). The management of anaemia is increasingly important for those with renal disease. Two studies report significantly more anaemia on starting dialysis in late referred individuals (Jungers et al, 1993a; Jungers et al, 1993b). Interestingly, and perhaps unsurprisingly, late referral is also associated with increased depression, frustration and worsening relationships with others (Sesso and Yoshihiro, 1997). See Box 2 for a summary of the consequences of late referral.



Identifying late referrals
In order to help deal with the problems associated with late referral, it is important to have some understanding of why certain individuals experience it. This is not a widely studied question. Two studies have shown that people with polycystic kidney disease are statistically likely to be referred in good time (Jungers et al, 1993b; Khan et al, 1995). This is also true of people with diabetes (Ifudu et al, 1996; Schmidt et al, 1998) and the glomerulonephridites (Khan et al, 1995). People with a diagnosis of renal artery stenosis are more likely to be referred late (Khan et al, 1995) as are people who are labelled as having renal disease of uncertain aetiology (Jungers et al, 1993b) - although this is most likely to be effect rather than cause.



There is little evidence that gender makes a difference to the timing of referral (Jungers et al, 1993b), although more men than women are known to have renal disease. Age does not appear to be an important factor in the timing of referral (Arora et al, 1999; Ellis et al, 1998; Jungers et al, 1993b). There is, however, some evidence from the USA that race (Ifudu et al, 1999) and perhaps income and health insurance status also play an important role (Arora et al, 1999).



Most worrying, however, is the fact that some individuals are known to have renal disease for months or even years before referral to the nephrologist - such evidence includes significantly raised serum creatinines, proteinuria, haematuria and abnormal radiological findings (Jungers et al 1993b; Ellis et al, 1998).



Kissmeyer et al (1999) identified 2693 people aged 50-75 years who had hypertension and/or diabetes from the databases of 12 general practices in north London. The case notes of 2561 of these individuals were audited to see if they had had their blood pressure measured and their urine dip tested for protein within the past 12 months, and plasma creatinine measured in the past 24 months. This study demonstrated that 10.6% of the individuals with hypertension had serum creatinines greater than 125?mol/l (upper limit of normal) as did 12% of those with diabetes. Of the 102 individuals with hypertension who were identified as having renal disease, 27 (26%) were referred to a nephrologist. Of the 48 individuals with diabetes and renal disease, 11 (23%) had been referred. A similar study in south-east London, which included screening of individuals as well as audit data, showed very similar results in a similar population (Ellis and Cairns, 2001).



In an important paper Khan et al (1994) demonstrated that age and co-morbidity were the important factors influencing whether individuals were referred for nephrological care. In an observational study, 69% of people with a low co-morbid risk and renal disease - as demonstrated by a raised serum creatinine - were referred; and only 58% with a medium risk and 21% with a high risk.



The role of the nurse in primary care
The practice nurse has an important role to play in preventing the non-referral and late referral of people with early renal disease (Tones et al, 1990). There is, however, an absence of any universally accepted theoretical framework, philosophy, shared aims or common value system among health educators. This can leave the practice nurse without a clear theory on which to base practice.



Fitzpatrick (1998) states that the roles of the nurse practitioner and the physician are similar. The value of the nurse practitioner is that he or she does not provide medical intervention alone, but also education about disease and disease prevention. This can also be said of the practice nurse. McGrath (1990) and Sparks (1994) focus on the nurse practitioner providing health care on a continuum, both during times of illness and during routine clinics.



The practice nurse can achieve a great deal in the prevention of renal disease. The Health of the Nation (Department of Health, 1992) defines the aim of health education as being ‘to ensure that individuals are able to exercise informed choices when selecting the lifestyle that they adopt’.



Nurses in primary care can play three important roles. First, they can provide screening for individuals who are at high risk of renal disease (Table 1). Second, they can act on the results - often this means ensuring appropriate referral. Third, and perhaps most importantly, they can educate their clients about the importance of screening for the complications of their diseases, handing power back to the patient. Part of this role may involve ensuring information is readily available to the patient, for example by sourcing educational material.



Guidelines from Diabetes UK recommend that individuals with diabetes are screened for renal disease by means of an annual serum creatinine test (Diabetes UK, 2000). This may require that the practice nurse maintains, or at least accesses, the practice database to ensure that all individuals registered who have diabetes receive an annual review. Many practice nurses will undertake at least some of this review, which will include discussion about lifestyle and diet as well as physical and biochemical checks. Urinalysis is also useful in terms of screening for micro-albuminuria - an early indicator of renal impairment.



The British Hypertension Society (Ramsay et al, 1999) provides recommended blood pressure levels, advice on measuring blood pressure and guidance on the pharmacological and non-pharmacological control of blood pressure. It also recommends renal function checks during the regular clinical review of hypertensive individuals. These checks include urinalysis, specifically for protein and blood, as well as a serum creatinine and electrolytes.



Practice nurses should be aware that hypertension may be a manifestation of renal disease and that it may cause or contribute to the progression of renal disease. It is likely that severe hypertension (Fogo et al, 1997), length of time that an individual has had hypertension (Iseki et al, 1997), race (Perneger et al, 1995), family history of renal disease (Bergman et al, 1996) and smoking (Bleyer et al, 2000) all increase the risk of developing renal disease.



Recommendations for practice
It is recommended that practice nurses should become involved in the care and management of people with hypertension and diabetes. Individuals with these diseases require regular review. From the renal perspective, an annual review is sufficient in individuals previously known to be free of renal disease. Such a review should include education about diet, smoking and exercise, as well as information on the potential signs and symptoms of renal disease, such as fluid retention, lethargy, anaemia and changes in urinary habit. The review should also include the collection and analysis of urine and blood samples (Table 2).



Urinalysis, as stated previously, is useful in screening for renal disease. Studies in individuals with hypertension have demonstrated that the presence of low-level proteinuria correlates with increased serum creatinine levels (Pontremoli et al, 1997) and that the presence of micro-albuminuria is associated with an increased rate of decline in creatinine clearance in individuals with hypertension (Ruilope et al, 1996). Similarly, it is widely believed that the presence of micro-albuminuria in individuals with diabetes is predictive of the development of chronic renal disease, especially if left untreated (Bennett, 1989). A positive dip-test should be followed up with a mid-stream-urine sent for microbiology to exclude infection and either a random urine sent for albumin creatinine ratio (simultaneous serum creatinine level needed) or a 24-hour urine collection for protein.



Both poorly controlled hypertension and diabetes play a role in the progression of renal disease and both should be checked as part of the annual review. People with poorly controlled diabetes and/or hypertension should be referred to the GP for better management. Acceptable blood pressure limits are shown in Table 3, while target HbA1c (a measurement of glycosylated haemoglobin that gives a reasonable indication of recent mean glucose control) should be less than or equal to 6.5 (Diabetes UK, 2000). The authors recommend following the British Hypertension Society guidelines (Ramsay et al, 1999) which appear to be supported by emerging evidence for the prevention of cardiovascular disease and in delaying the progression of renal disease.



The characteristics of individuals most at risk of developing renal disease are well known. Screening tests for renal disease are cheap, easy to carry out and often simple to interpret. Nurses in general practice should consider providing screening for high-risk populations, interpret the results of these tests and educate patients about their condition.



Late referral for nephrological care can only be overcome if health-care professionals are educated and equipped to screen for renal disease in appropriate populations. The utility of any screening programme relies heavily on: the application of the correct test; maximum population coverage; rapid and correct interpretation of results and appropriate referral. The continuing failure of health-care policy-makers and many providers to apply themselves to screening and referral of people in high-risk groups for renal disease means that the unnecessarily high levels of morbidity, mortality and spend on RRT will persist into the new millennium.





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