Jenkins, K. et al (2007) Understanding chronic kidney disease 2: referral. Nursing Times; 103: 42, 28–29.
This is the second of a two-part unit on chronic kidney disease. Part 1 examined the risk factors for and diagnosis of the disease. This part explores referral criteria and educating both healthcare professionals and patients.
Karen Jenkins, PGDip HE, RGN, is consultant nurse, East Kent Hospitals NHS Trust; Nicola Thomas, MA, BSc, RGN, is senior lecturer,
St Bartholomew School of Nursing and Midwifery, City University, London; Natasha McIntyre, MSc, PGDip HE, RGN, is nursing research fellow, Derby Hospitals NHS Foundation Trust.
Guidelines for referral
Referral of all patients with CKD would overwhelm renal services and is not necessary – criteria for referral are shown in the table.
National UK guidelines for identification, management and referral of patients with CKD were developed by the Joint Specialty Committee on Renal Medicine (2006). Their purpose is to ensure appropriate and timely referral to renal services. However, these guidelines are lengthy and several local units have simplified the content for ease of use by both primary and secondary care.
The UK guidelines on CKD are being reviewed by the National Collaborating Centre for Chronic Conditions, which is developing NICE guidance for CKD. This is due to be published towards the end of 2008.
The key information that should be included in a renal referral is:
Dipstick result and protein:creatinine ratio if more than trace protein present;
All previous serum creatinine results with dates to assess stability;
Renal ultrasound results or ultrasound requested where this is appropriate;
Haemoglobin (Hb), calcium, phosphate, albumin, bicarbonate cholesterol and HbA1c if the patient has diabetes.
Joint working with renal units, primary care trusts and commissioners for specialist services and patient groups is raising awareness of CKD and removing barriers that have previously stood in the way of providing holistic patient care.
Several renal networks across the UK have been set up with the specific purpose of delivering the renal National Service Framework. Their membership is multidisciplinary with representatives of primary and secondary care, patient groups and commissioners.
Education on early identification
Education is of prime importance and must meet the needs of those who manage long-term conditions in the primary care sector.
Specialist renal services are working with both primary and secondary care to provide local education programmes for those caring for patients at risk of CKD.
As there has been increasing awareness and interest in CKD, especially in its management in the community, a number of support mechanisms have been developed including the CKD Forum. This was set up at the end of 2004 as a support group for renal nurses who were collaborating with primary care teams but has since become a multidisciplinary group. In May 2006, after consultation with the Renal Association and the British Renal Society (BRS), it became a project group of the BRS.
The CKD Forum (BRS, 2007) aims to be a national lead for healthcare professionals in the prevention and management of CKD. This vision will be realised through:
A forum for sharing evidence-based practice to improve outcomes in early CKD;
The provision of leading-edge CKD education for healthcare professionals;
Collaboration with key stakeholders to influence CKD practice and policy;
Web-based educational resources for CKD, collated and developed by the forum.
These resources include clinical guidance and educational resources for patients and staff (see www.britishrenal.org) (BRS, 2007).
There are many challenges ahead in educating people about CKD. Perhaps the most important issues are how to avoid the labelling of people with CKD and how to reduce anxiety when patients are first told that they have kidney disease. Prevention of kidney disease is also crucial. Essentially the principle is the same for renal disease, diabetes and cardiovascular disease – the priority is reducing cardiovascular risk.
Some units are developing local information for patients with CKD but other resources are available, such as the UK National Kidney Federation website, which aims to increase understanding of kidney function (www.kidney.org.uk), and a patient information leaflet published by the Royal College of General Practitioners (2007).
This unit on CKD is to some extent aimed at nurses who are working in primary care, as this is where patients with CKD will receive most of their care. However, many people with CKD will also have another chronic condition that may result in repeated hospital admissions. Examples might include people with diabetes who are admitted with foot problems, or those with hypertension who have been admitted with cardiovascular complications.
In such cases patients may have a serum creatinine (and concurrent eGFR) taken as part of routine blood sampling, and for the first time it may be realised that they have CKD. Similar recommendations for care and management apply for hospital nurses as for primary care nurses. The key points in managing CKD for nurses working in both these settings are:
Once abnormal eGFR (<60) is found, check if this is the first available eGFR result and if not, compare with previous readings;
Check whether eGFR is stable or progressive (>2ml/min/1.73m2 change in six months) and act according to local/national guidance;
If appropriate, explain to the patient that their eGFR result equates to percentage of kidney function (a reading of 30 means 30% kidney function);
Offer advice on smoking, weight, exercise, salt and alcohol intake;
Undertake a dipstick urine test for protein and blood; send urine for PCR if more than trace protein is revealed;
Ensure meticulous control of blood pressure (<130/80mmHg);
Refer to renal services according to local/national guidance – urgently if stage 4 CKD (eGFR<30).
These are the key points to remember in caring for patients with CKD:
Implementing the NSF for Renal Services requires a multiprofessional approach across primary and secondary care;
Education about CKD is essential for both healthcare professionals and patients;
Seek advice from local renal units if you are unsure whether to refer a patient to a specialist renal service;
Use referral and management guidelines;
Refer as early as possible – renal units need at least one year to prepare patients physically and psychologically for dialysis;
Include all key information when referring;
Complete as many investigations as possible and include results with the referral.
Incidence of CKD is increasing and measures need to be taken to care for people who are identified with the disease and require specialist advice and care.
It is essential that primary and secondary care services work together to provide a seamless service for this group. Specialist education for healthcare professionals and people with CKD is essential in order to improve the understanding of the disease itself, causative factors, relevant treatments and management required.
Portfolio Pages can be filed in your professional portfolio as evidence of your learning and professional development. They contain learning activities that correspond to the learning objectives in this unit, presented in a convenient format for you to print out or work through on screen.
British Renal Society (2007) CKD Forum. britishrenal.org/CKD/ckdforum.shtml
Joint Specialty Committee on Renal Medicine (2006) Chronic Kidney Disease in Adults: UK Guidelines for Identification, Management and Referral. renal.org/CKDguide/ckd.html
Royal College of General Practitioners (2007) Chronic Kidney Disease: What It Is – What It Means. London: RCGP.
The full reference list for this part of the unit is available in the Portfolio Pages.