Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 13:

Diabetic Nephropathy and End-Stage Renal Disease

Belinda P. Childs, ARNP, MN, CDE, BC-ADM1

1Childs is a diabetes nurse specialist at Great Plains Diabetes in Wichita, KS.

Diabetes is the leading cause of end-stage renal disease (ESRD). It is estimated that 20–40% of individuals with diabetes will develop diabetic kidney disease.1 From 2005 and continuing through 2011, however, improvement in blood glucose control, management of the blood pressure, and use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) have contributed to the noted declining incidence of chronic kidney disease (CKD) in individuals with diabetes.2 The most recent National Health and Nutrition Examination Survey data indicate that more than 20 million Americans have CKD.3

Minorities are disproportionately affected by kidney disease. African Americans are nearly four times more likely, and Native Americans are 1.4 times more likely than non-Hispanic white Americans to develop ESRD.3,4

The treatment of CKD is a leading contributor to the overall cost of diabetes. Medicare expenditures for patients with CKD and diabetes in 2010 was $22.1 billion, including Plan D costs. These costs account for 27.1% of all Medicare diabetes dollars and are up from 12% in 2000.

The terms microalbuminuria (30–299 mg/24 h) and macroalbuminuria (>300 mg/24 h) are no longer used as it is now recognized that albuminuria occurs along a continuum. Albuminuria is now defined as a urine albumin-to-creatinine ratio (UACR) of >30 mg/g creatinine.4

This chapter reviews the pathogenesis, risk factors, prevention, treatment strategies, and nursing strategies related to the prevention and treatment of renal disease associated with diabetes.

PATHOGENESIS OF DIABETIC NEPHROPATHY

Studies have suggested that diabetic nephropathy is related primarily to the metabolic changes associated with diabetes.

• Renal changes initially are absent in people with diabetes who have kidney biopsies at diagnosis.

• Renal changes occur in all types of diabetes.

• Renal damage occurs in animal models regardless of whether they have spontaneous or induced diabetes.

• In animal models, a reversal of diabetes through intensive insulin therapy or transplantation prevents renal disease and may reverse early histological changes.5

The onset of diabetes seems to lead to hemodynamic changes in the renal circulation that leads to increased renal plasma flow, glomerular capillary hyperperfusion, and increased glomerular pressure gradient. These hemodynamic changes are hypothesized to cause functional and structural damage to the glomeruli, which results in defects in glomerular capillary permeability, proteinuria, mesangium changes, and glomerulosclerosis.2 The natural progression of diabetic nephropathy and some of the contributing factors are shown in Figure 13.1.

Figure 13.1—Natural course of renal disease in diabetes

Figure 13.1—Natural course of renal disease in diabetes.

Source: Adapted from Nelson et al.6

RISK FACTORS FOR DIABETIC NEPHROPATHY

Risk factors that contribute to the development of renal disease include duration of diabetes, familial and genetic factors, hypertension, hyperglycemia, plasma prorenin activity, and lipid levels.2,6 One of the most important risk factors for the development of diabetic nephropathy is duration of diabetes; however, in type 1 diabetes (T1D), only 30–50% of patients develop diabetic nephropathy. Therefore, factors other than diabetes itself appear to affect the development of diabetic nephropathy.

Familial and Genetic Factors

Whether someone has T1D or type 2 diabetes (T2D), genetics plays a role in the severity and progression of diabetic nephropathy. If a person has a first-degree relative with diabetic nephropathy, they have a higher likelihood of developing diabetic nephropathy. In patients with T1D, if one sibling has diabetes and nephropathy, then it is more likely that another sibling also will have nephropathy.2 Another important contributing factor is race. African Americans and Native Americans have a three- to sixfold greater risk than non-Hispanic whites of developing renal disease.

Hypertension

Hypertension may be a result of nephropathy, but it also is associated with progression and pathogenesis. Both systolic and diastolic hypertension accelerate the progression of diabetic kidney disease. Aggressive management of blood pressure, frequently with combinations of antihypertensive medications, can decrease the rate of fall of the glomerular filtration rate (GFR).

Hyperglycemia

In the Diabetes Control and Complications Trial (DCCT), intensive therapy focused on attaining a glycated hemoglobin A1c (A1C) level as close to normal range (~7%) as possible reduced the occurrence of microalbuminuria (urinary albumin excretion ≥40 mg/24 h) by 39% and albuminuria (urinary albumin excretion ≥300 mg/24 h) by 54% in the combined cohort.7 Many of the individuals who participated in the DCCT also agreed to long-term follow-up in the Epidemiology of Diabetes Interventions and Complications (EDIC) study. On the basis of recent EDIC study findings, those who originally were randomized to the intensive insulin group had a “memory” effect with continued delay in onset and progression of increased urinary albumin excretion and estimated glomerular filtration rate (eGFR).8 Optimal diabetes control in the primary prevention group (those with retinopathy at baseline) in the U.K. Prospective Diabetes Study (UKPDS) demonstrated a reduction in the rate of progression of renal function end points.4,9

Prorenin and Hyperlipidemia

The roles of prorenin and lipids in the development and progression of nephropathy are less clear. Prorenin is the precursor to renin, and an increase in plasma prorenin has been associated with the microvascular complications of diabetes. Several small studies have suggested that a higher cholesterol level promotes the progression of renal disease.

Pregnancy

Pregnancy, regardless of whether a woman has diabetes, is associated with a transient rise in GFR and a moderate increase in urinary protein excretion (see Chapter 25, Polypharmacy). Women with preexisting diabetes may experience an increase in proteinuria from the first to third trimester, but this usually returns to normal after delivery. A pregnancy complicated by diabetes does not appear to adversely affect early diabetic renal disease; however, a greater risk of progression may occur in those with hypertension or more severe renal disease.2,6

DIAGNOSIS AND RENAL FUNCTION TESTS

Diagnostic tests focus on early detection of kidney disease. The American Diabetes Association (the Association) recommends at least annual assessments of urinary albumin (e.g., spot UACR and eGFR) in patients with T1D with a duration of >5 years, in all patients with T2D, and in all patients with comorbid hypertension.4

Analysis of the UACR is the most commonly recommended screening method.4 The other two alternatives, 24-h collection and a timed specimen, rarely are used for screening. Normal albumin excretion by spot collection is defined as <30 mg/g creatinine (see Table 13.1).4

Table 13.1—Definitions in Abnormalities in Albumin Excretion

Category

Spot collection (mg/g creatinine)

Normal

<30

Albuminuria

≥30

Historically ratios between 30 and 299 mg/24 h were considered microalbuminuria and >300 mg/24 h was macroalbuminuria or clinical albuminuria.

Source: From the American Diabetes Association.4

Because of variability in urinary albumin excretion, at least two of three tests performed within a 6-month period should show elevated levels before a patient is designated as having albuminuria. Exercise within the preceding 24 h, infection, fever, congestive heart failure, vasculitis, other inflammatory processes (such as acute rheumatoid arthritis), and marked hyperglycemia and hypertension may elevate urinary albumin levels above baseline. If any of these factors were present at the time the urine sample was collected, the test should be repeated.

Creatinine clearance had been the most widely used direct method of estimating GFR, but it now is rarely used. This creatinine value is measured based on a carefully timed urine collection, usually over 24 h. It is critical to note an accurate timeframe even if a full 24 h has not passed. A complete sample is imperative. Partial loss of a urine sample or a discrepancy in actual time collected will invalidate the test.10 Nephrologists may order a 24-h collection for albumin.

Serum creatinine is an indirect measure of GFR. It is now recommended that the serum creatinine be used to estimate GFR and to stage chronic kidney disease. The Levey modification of the Cockcroft and Gault method also can be used to calculate eGFR, which uses serum creatinine, patient age, and weight. Online calculators for eGFR are available.4,11 Clinical laboratories now include eGFR in addition to serum creatinine on standard reports.

Practical Point

A patient with nephropathy may also have diabetic eye disease. The presence of albuminuria in all age-groups has been associated with an increased risk for retinopathy. With renal disease, yearly screening for retinal disease becomes essential.

PREVENTION AND TREATMENT

Preventing and delaying the progression of diabetic nephropathy can be achieved with management of the factors known to influence the development and progression of the disease. Table 13.2 contains an outline of treatment approaches divided into primary, secondary, and tertiary prevention strategies.

Table 13.2—Strategies to Prevent or Delay the Progression of Diabetic Nephropathy

Prevention

Goal

Primary prevention

Goal: Prevent diabetic nephropathy.

Optimize glycemic control: A1C <7%.

Blood pressure control: <140/90 mmHg.

Secondary prevention

Goal: Prevent or delay the progression of albuminuria.

Control of blood pressure: <140/90 mmHg

Limit dietary protein: ≤0.8–1.0 g/kg body wt/day (10% of daily calories).

Medical intervention: Initiate ACE inhibitor or ARB treatment if increased albumin-to-creatinine ratio and hypertension.

Tertiary prevention

Goal: Prevent or delay the progression of overt diabetic nephropathy and improve clinical outcomes (tertiary care reduces morbidity and mortality by delaying time to dialysis or transplantation).

Strategies: As above for secondary prevention.

ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker.

Source: Adapted from the American Diabetes Association and DeFronzo.2,4,14

The ADA does not recommend using ACE inhibitors or ARBs for primary prevention (i.e., normal blood pressure and normal UACR <30 mg/g creatinine), but it does recommend these treatments for people with albuminuria (UACR >30 mg/g creatinine) that has been verified with a confirmatory test and hypertension (confirmed office blood pressure >140/90 mmHg).4 ACE inhibitors and ARBs should not be used in combination.2

Blood Pressure Reduction

Hypertension is known to be the single most important factor in the progression of established renal disease. Both systolic and diastolic hypertension accelerate the progression of the disease.5

According to the Association’s Standards of Medical Care in Diabetes, blood pressure should be evaluated at each medical visit.4 Elevated blood pressure should be confirmed on a separate day. If it is >120/80 mmHg, the primary goal should be to lower blood pressure with lifestyle modifications, such as weight loss (if appropriate); dietary alterations, include lowering sodium, potassium, and alcohol intake; and increased physical activity. If blood pressure is >140/90 mmHg and UACR >30 mg/g creatinine, and there are no contraindications for use, then an ACE inhibitor or ARB should be initiated. Patients with hypertension but without albuminuria may be treated with any drug class shown to reduce cardiovascular events in people with diabetes (ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers). Target blood pressure readings for most patients with diabetes and hypertension are <140/90 mmHg, whereas lower goals, such as 130/80 mmHg, may be appropriate for individuals at high risk of cardiovascular disease if theses goals can be achieved without undue treatment burden.2 Electrolytes should be monitored periodically in those on ACE inhibitors, ARBs, and diuretics particularly in those with renal insufficiency.

Education and Self-Management

The patient with hypertension should self-monitor their blood pressure. Self-monitoring of blood pressure enhances education efforts and allows the patient and health-care team to work together to detect, treat, and evaluate the risk for renal complications. Reviewing patients’ technique and regularly checking blood pressure monitoring devices can help ensure accurate readings.

Dietary Protein Restriction

For people with non–dialysis-dependent diabetic kidney disease, the Association’s 2017 Guidelines specify that dietary protein intake should be ~0.8–1.0 g/kg/day (the recommended daily allowance) because lower or higher levels do not improve glycemic measures, cardiovascular risk measures, or the course of the decline of the GFR.4 Most Americans consume more protein than is recommended. Helping individuals to recognize appropriate protein portions may be needed. A dietitian should be consulted for any patient with moderate to severe nephropathy.

To consume an adequate number of calories, the patient may need to increase intake of other macronutrients. As renal disease progresses, appetite frequently diminishes, and patients may have to be encouraged to eat adequate calories with enough protein. For patients on dialysis, higher levels of dietary protein intake should be considered.

CHRONIC RENAL DISEASE

Chronic renal disease is defined in two ways:10

1. Kidney damage for ≥3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifested by either—

a. pathological abnormalities; or

b. markers of kidney damage, including abnormalities in the composition of the blood or urine or abnormal imaging tests.

2. GFR <60 mL/min/1.73 m2 for ≥3 months, with or without kidney damage.10,12

The stages of chronic kidney disease are given in Table 13.3.

Table 13.3—Stages of Chronic Kidney Disease

Stage

Description

GFR (mL/min/1.73 m2)

1

Kidney damage* with normal or increased eGFR

≥90

2

Kidney damage* with mildly decreased eGFR

60–89

3

Moderately decreased eGFR

30–59

4

Severely decreased eGFR

15–29

5

Kidney failure

<15 or dialysis

*Kidney damage is defined as UACR persistently ≥30 mg/g Cr or other abnormalities on pathological, urine, blood, or imaging tests. Adapted from Mallappallil et al.2

CLINICAL PRESENTATION AND ASSESSMENT

Individuals are asymptomatic throughout the early stages of diabetic nephropathy. Clinical manifestations of diabetic nephropathy are evident when GFR is 20–35% of normal, and patients become nephrotic with a urinary protein excretion of >4 g/day.13 The clinical management of diabetes with nephrotic syndrome presents a great challenge. The management of blood glucose becomes more difficult as loss of renal function diminishes renal catabolism of insulin. Proteinuria is generally 4–8 g/day, but urinary protein loss can reach 20–30 g/day. Fluid retention is often massive, resulting in weight gain, peripheral edema, congestive heart failure, and pulmonary edema as uremia progresses. Fatigue and shortness of breath result in a reduction of daily activities. Hypertension may become uncontrolled, secondary to fluid volume overload. Uremia becomes evident because of the accumulation of metabolic wastes and toxins.

At equivalent levels of renal failure, patients with diabetes may appear more ill than those without diabetes. Underlying diabetes-induced neurological abnormalities, such as gastroparesis, can exacerbate uremia-induced nausea and vomiting.

A nephrologist should be consulted if there is uncertainty regarding the cause of the kidney disease, such as significant proteinuria with a normal or elevated eGFR, rapid decline in the eGFR, active urine sediment, or the absence of retinopathy. Consider referral if there is difficult management issues (resistant hypertension management, for anemia management, for secondary hyperparathyroidism, metabolic bone disease, or electrolyte disturbances, and advanced kidney disease, at minimum, by progression to stage 4 kidney disease (eGFR < 30 mL/min/1.73 m2.4

OTHER CONSIDERATIONS IN NEPHROPATHY PROGRESSION

Hypoglycemia

Patients with renal disease are at higher risk for hypoglycemia because most diabetes medications are metabolized in the kidney. It may be necessary to reduce the dosages of some antihyperglycemic medications and avoid the use of others. Of the oral agents, the sulfonylureas have the greatest risk for inducing and prolonging hypoglycemia, and glyburide should be avoided. Glimepiride and the meglitinides are least likely to lead to hypoglycemia. Even with these medications, lower dosages will likely be necessary, GLP-1 analogs are not recommended once the serum creatinine is >2 mg/dl or the eGFR is <30 mg/minute. DPP-4 inhibitors should be reduced as it is excreted in the urine. Sodium glucose co-transporter 2 inhibitors are contraindicated with renal disease. Metformin may be an alternative medication to be used even in the presence of renal disease.

Despite prior concerns that metformin could lead to lactic acidosis if used in the presence of renal disease, current data indicate this risk is very low. The Association’s Standards of Care suggest that metformin can be used if the eGFR is >45 mL/min/1.73 m2 at a maximum dose of 1,000 mg/day. Risks/benefits should be assessed in those whose eGFR falls <45. The usual maximum dose of metformin is 2,000 mg/day until a decline in eGFR is noted. Metformin should not be initiated as a new antihyperglycemic agent if the eGFR is <45mL/min/1.73m2. Metformin should be discontinued if the eGFR is <30 mL/min/1.73 m2; in any situation that would increase the risk of lactic acidosis, such as hypoxia, sepsis, or hypotension; or any time that the eGFR could worsen, such as with radiocontrast dyes if the eGFR is <60 mL/min/1.73 m2.4

The kidneys catabolize one-fourth to one-third of injected insulin. As kidney function declines, exogenous insulin acts longer and in an unpredictable manner.14 Studies have concluded that the kidney can make and release glucose. On the basis of recent evidence, it would seem that the release of glucose by the kidney might play a role in the regulation of glucose homeostasis. The lack of this production and release also may be a contributing factor in hypoglycemia associated with kidney disease.13,15 Use of insulin analogs, intensive insulin therapy, and hypoglycemia awareness training may all aid in the reduction of severe hypoglycemia in the patient with renal impairment.

Additional Complications

Management and rehabilitation of patients with ESRD are further complicated by the fact that >95% of patients with diabetic nephropathy have some degree of retinopathy, with 50% being blind or having significant vision loss (renal-retinal syndrome). If either renal or retinal disease has been diagnosed, it is important to screen for disease in the other system. Metabolic bone disease may be an additional complication, as is anemia, and albuminuria is a prognostic indicator of cardiovascular disease in T2D.

Practical Point

Patients who present with frequent and unexplained hypoglycemia should have their renal status assessed.

Other Threats to the Kidney

Urinary Tract Infections

Urinary tract infections (UTIs) are more common in older adults and in those with autonomic neuropathy affecting the bladder. UTIs are often asymptomatic or the patient may complain of unexplained hyperglycemia, incontinence, and vague symptoms, such as fullness in the suprapubic area. Chronic infections can lead to pyelonephritis. There is debate regarding the importance of asymptomatic bacteremia and the necessity of treatment. Patient education on the symptoms of UTI is important.

Neurogenic Bladder

Neurogenic bladder is more common in individuals with diabetes and may predispose individuals to UTIs. Symptoms such as frequent voiding, nocturia, incontinence, and recurrent UTIs may occur sporadically or may be considered a result of age or prostatic hypertrophy. If diagnosed, the nurse can teach Credé’s manual voiding maneuvers, which should be performed every 8 h. This is often sufficient to prevent the postvoid residual. If not, parasympathetic agents may be tried. If pharmacologic therapy proves unsuccessful, intermittent straight catheterization should be performed two to three times daily.

Dye Studies

Intravenous pyelography and other dye studies can pose a risk for patients with diabetes, who are at increased risk for acute renal failure after any radiocontrast. Many times, an alternative diagnostic study can be performed. If contrast media are necessary, a minimum amount of dye should be used and adequate hydration with half-normal or normal saline should be ensured before the dye study. Serum creatinine tests should be checked after the contrast study.

Nephrotoxic Drugs

If nephrotoxic drugs (e.g., amphotericin B; aminoglycosides, such as gentamicin; acyclovir; nonsteroidal anti-inflammatory drugs [NSAIDs]) must be used, monitor serum creatinine levels and drug levels and reduce the dosage of the drug administered to patients with impaired renal function. Recommend acetaminophen rather than NSAIDs because these agents reduce prostaglandins and can damage the kidney.

Medication Dosages

Because the presence of renal disease can increase the half-life of most medications, new medications should be started at one-half the recommended dosage, and other current medications should be reviewed for possible changes in dosage.

Practical Point

In caring for patients with renal disease, consider the following:

• Identify UTIs early and treat aggressively

• Avoid nephrotoxic medications

• Avoid NSAIDs

• Avoid contrast dyes

SPECIAL CONSIDERATIONS IN ESRD

Anemia

Anemia caused by ESRD is the result of a decrease in the production of erythropoietin. Because erythropoietin stimulates the production of red blood cells, the anemia often leads to fatigue and decreased activity. The anemia of kidney disease is often managed with regular injections of erythropoietin.

When assessing patients with renal disease and anemia, patient symptoms may not correlate with capillary blood glucose values or with A1C. Thus, it is important to be aware of how anemia can affect tests for glycemic control. With low hemoglobin and low hematocrit levels, some of the commonly used tests are affected and may produce inaccurate results. A1C can give a falsely low value. Sometimes, a fructosamine test can be used to assess glycemic control. Because the fructosamine test is affected by the low albumin and protein levels often are seen in patients with ESRD, this test may not give an accurate assessment of glycemic control.

Additionally, capillary blood glucose tests can be affected by a low hematocrit level and therefore also may be altered by anemia. Capillary blood glucose results are most accurate when the hematocrit level is between 30% and 50%. Some glucose meters, however, have a documented accuracy with hematocrit ranges of 25–60%.16 If the patient’s symptoms do not correlate with his or her capillary blood glucose levels, the nurse should compare the glucose meter value with a laboratory reference value.

Provided the difficulties concomitant with ESRD and anemia in testing blood glucose values, thorough and careful testing is advised in these patients. Evaluating which meter is less dependent on hematocrit will be important in assisting these patients. If a renal patient is reporting symptoms of hypoglycemia but obtaining normal or high capillary blood glucose levels, it would be prudent to obtain a blood glucose level by the reference laboratory with a simultaneous glucose meter reading.

Fluid Volume Excess

Fluid volume excess can result from oliguria or anuria. Because of the thirst associated with ESRD, the patient tends to drink in excess and crave sodium, further contributing to the volume excess. The variation in hydration also can affect blood glucose levels. Edema may be a problem associated with the decreased serum osmolality. The nurse needs to assist the patient in identifying ways to relieve this thirst, such as with ice chips, mouth swabs, and sugar-free hard candies as appropriate. These patients are often on fluid restrictions, especially if they have not yet begun dialysis or are on hemodialysis, so a registered dietitian should be consulted. The nurse should reinforce these fluid restrictions and make it clear that foods that are liquids when at room temperature (e.g., gelatin, pudding) are also fluids and therefore subject to these same restrictions. In patients who crave sodium, identifying foods that have alternative flavors without sodium, such as lemon, is an option.

Symptoms of electrolyte imbalance include weakness, muscle twitching, nausea, fatigue, headache, and heart palpitations. Other symptoms may include edema, alterations in electrocardiograms and chemistry panels, and positional blood pressure changes. Patients need to be cautioned about standing too quickly. This will reduce the potential of falling as a result of orthostatic hypotension and muscle weakness. Family members may need to be encouraged to support the patient when standing.

Dietary Changes

Protein restriction may be used in ESRD. As the disease progresses, patients often experience anorexia, nausea, and vomiting. In addition, foods containing potassium, sodium, and phosphorus often are restricted on the renal diet. Given the multiple comorbidities of diabetes, it is not uncommon for a patient to try to manage a meal plan that is low in fat, has consistent carbohydrate content, and is low in potassium, sodium, and phosphorus. The challenges this poses can lead to confusion, anger, and feelings of deprivation. Malnutrition can occur because of reduced appetite and dietary restrictions. The nurse should encourage a consultation with a dietitian and make every effort to offer additional food choices if the patient does not eat while in the hospital or in the dialysis unit. During dialysis sessions, dietary restrictions are modified, allowing the patient to enjoy a wider range of foods.

COORDINATION OF CARE

The patient with diabetic nephropathy presents a challenge for nursing. Renal disease requires a complex medical program of care. When renal disease is coupled with diabetes, the interaction of medical and nursing management issues demands a higher level of nursing care and expertise. Research has demonstrated that excellent diabetes management must be maintained to retard renal deterioration, but with renal disease, diabetes self-management and the patient’s ability to achieve glucose goals become increasingly difficult. Foremost, the role of the nurse is to assist the patient in dealing with the complexity of the renal care regimen. A nurse will encounter many of these intricate aspects, including dietary issues and their effects on glucose levels; prevention and treatment of hypoglycemia, including the use of glucagon; issues regarding alterations in activity and increased fatigue associated with anemia and uremia, skin dryness, and pruritus; and mental health conditions, such as depression. The patient will be interacting with the health-care system at many levels: dietitians, renal and dialysis specialists, diabetes specialists and nurse educators, mental health providers, pharmacists, and social workers. As is evident, these many levels of interaction only increase the potential for miscommunication and faulty care coordination. The nurse is the ideal patient advocate to coordinate and facilitate care.

The renal patient has increased physical care needs. Table 13.4 identifies these needs and suggests nursing actions to meet them.

Table 13.4—Physical Care Needs for the Renal Patient with Diabetes

Physical needs

Nursing actions

Monitor fluid and electrolyte balance

1. Weigh patient for fluid retention and measure urinary output and fluid intake.

2. Assess for signs of fluid overload and congestive heart failure.

3. Assess blood pressure and orthostatic changes.

Maintain adequate nutrition status

1. Evaluate food intake and dietary adherence.

2. Collaborate with the dietitian and provide reinforcement on education regarding sodium, potassium, and protein restriction.

3. Assess weight changes and alterations in lab values and notify a doctor if necessary.

4. Educate patient in eating smaller, more frequent meals to reduce nausea and maintain blood glucose level.

Maintain skin integrity

1. Maintain hygiene to prevent infection.

2. Relieve dryness and pruritus by choosing alcohol-free creams and nondrying soaps.

Prevent constipation

1. Use stool softeners and fiber products.

2. Discourage use of over-the-counter remedies that may cause electrolyte imbalances.

Maintain target glucose levels

1. Help patient to identify times of the day when hypoglycemia is most likely to occur.

2. Discuss appropriate treatment for hypoglycemia: oral medications and glucagon by injection.

3. Discuss changes in glucose levels with continuous ambulatory peritoneal dialysis fluid changes or before and after dialysis.

4. Encourage patient to keep a glucose log to assist in insulin adjustment decisions.

Encourage safe level of activity

1. Assess patient’s gait, balance, range of motion, muscle strength, and condition of feet.

2. As tolerated, encourage activity to prevent bone demineralization and assist with glucose control.

Increase understanding of complex regimen of care

1. Help patient to express treatment concerns and fears; refer to mental health professionals as appropriate.

2. Assess treatment schedule to avoid unnecessary fatigue and to better coordinate with diabetes management program.

3. Review alterations in diabetes therapy caused by changes in kidney status.

Source: Adapted from Nettina.17Behavioral Considerations

Rates of depression, anxiety, and stress may be higher among patients with ESRD than among the general population. These psychological reactions may occur in response to the losses associated with diabetes and renal disease (e.g., loss of physical capacities and loss of control from the complications associated with diabetes). A variety of health-care professionals, including mental health professionals, need to be involved in helping patients and families adjust to their losses and to select treatment options. In addition, the involvement of these professionals will make the task of learning a new, often complex treatment regimen more successful.18

CHOOSING A TREATMENT OPTION FOR ESRD

Treatments for ESRD are aimed at replacing the work of the kidneys. Several new treatment options are available for renal replacement therapy. People with diabetes who receive transplants or dialysis experience higher morbidity and mortality than patients without diabetes because of coexisting complications, such as coronary artery disease, retinopathy, and neuropathy. Providing education and information on each treatment option allows the patient and family to make an informed choice and enhances the chances of a positive outcome. Benefits and risks of each treatment option should be reviewed with patients and family members for a comparison of options in treating uremia. Direct contact with other patients who are receiving different forms of therapy for ESRD may be valuable in providing education, emotional support, and hope.

Dialysis or renal transplantation usually occurs earlier in patients with diabetes than in those who do not have diabetes. Typically, renal replacement therapy will begin when serum creatinine is >6 mg/dL or creatinine clearance is <20 mL/min, but more important, it should begin before the development of severe uremic symptoms, such as uremic pericarditis, unresponsive hypertension, muscle deterioration, worsening lethargy, nausea, and vomiting.14

Planning for treatment should begin early, usually when the serum creatinine level reaches 3 mg/dL (265 µmol/L). Early involvement with a nephrologist, which usually is recommended when eGFR is <30 mL/min/1.73 m2, is also important to optimize medical therapy as well as help the patient begin the adjustment process. Patients with renal disease may assume that they are participating in a program in which the goal is to preserve kidney function as long as possible. Late referrals for treatment, which will require hasty decisions regarding type of dialysis or being put on a list for kidney transplantation, frequently result in sentiments of anger and betrayal at the primary care provider for not conveying the seriousness of the kidney disease. If transplantation is under consideration, planning includes tissue typing of family members or other living unrelated donors for possible kidney donation, being placed on a cadaver waiting list, and creating vascular access for dialysis.

Candidate Selection

Circumstances may be present that limit the patient’s choice of treatment. For example, individuals with cardiovascular disease or vascular access problems might be less suitable candidates for hemodialysis. Likewise, individuals unable to tolerate fluid in the peritoneal cavity or those prone to infections would not be appropriate candidates for peritoneal dialysis.

Behavioral Considerations Within the Health-Care Team

Health-care providers may experience a range of emotions and may need the help of a team member to express or deal with their feelings about what the patient and family are going through and how they are coping.

TREATMENT OPTIONS FOR ESRD

If treatment is not initiated for ESRD, death ensues. Survival is reduced in patients with diabetes compared with those without diabetes. Nearly one-half of all patients with diabetes who begin dialysis die within 2 years. For renal transplant patients with diabetes, the survival rate is much better than that of dialysis-treated patients, primarily because those patients who have kidney or kidney and pancreas transplants have fewer comorbidities.

No Treatment

A patient has the right to choose not to begin dialysis. The patient and family should consider the no-treatment option only after the patient is dialyzed and is not uremic because uremia can affect the mental status. Some patients could be considered incompetent because of uremia. Nurses should encourage the patients and families to discuss the decision not only with their physicians but also with clergy, psychologists, social workers, health-care teams, and other family members. It is important to evaluate the patient for potentially undiagnosed or untreated depression. Planning supportive care (e.g., home care, hospice care) is necessary for the patient who chooses to forgo or discontinue renal replacement therapy.

Hemodialysis

Hemodialysis is the most commonly used kidney-replacement therapy for people with ESRD in the U.S. The use of maintenance hemodialysis requires vascular access, which may be more difficult in the patient with diabetes because of systemic atherosclerosis. A synthetic graft may be used in the patient with diabetes.

Hemodialysis can be performed at a dialysis center or at home. Three types of hemodialysis can occur in the home. Conventional home dialysis is usually done three to four times a week. A new home therapy is now available that is performed five to seven times per week using a newer machine designed for shorter treatments of 2 h each. Nocturnal home hemodialysis consists of a long, slow treatment overnight, usually six nights a week. Training for the individual and the support team or family usually occurs over a 2- to 4-week period.19

Factors that can alter glucose levels for the patient receiving hemodialysis treatment include the glucose concentration in the dialysate bath, appetite alteration on days with dialysis and days without dialysis, decreased activity on dialysis days, and emotional stress. The following questions are useful in eliciting information regarding causes of blood glucose variability in patients with diabetes who are receiving hemodialysis treatment:

• Tell me about your glucose pattern on the days you are having dialysis?

• Tell me about your glucose pattern on other days?

• Tell me when and how much you eat on days you are having dialysis?

• Tell me about your eating pattern on other days?

• Tell me about your activity pattern on days you are having dialysis?

• Tell me about your activity pattern on other days?

Altered hematocrit levels can alter the accuracy of some glucose meters (see the section, “Anemia”). Sometimes a change in the type of glucose meter used may be warranted to avoid erroneous measurements of blood glucose values. Meter manufacturers provide specifications of hematocrit ranges for their meters. The health-care provider should be aware of this potential cause of variability.

Peritoneal Dialysis

Peritoneal dialysis has rapidly grown in popularity because of its advantages of rapid patient training and reduced cardiovascular stress. The use of the mechanical cyclers, called continuous cyclic peritoneal dialysis (CCPD), has simplified the process. Both CCPD and continuous ambulatory peritoneal dialysis carry the risks of peritonitis and gradual decrease in peritoneal surface area. Insulin, antibiotics, and other medications can be added to the dialysate. The amount of insulin required may vary based on the glucose concentration of the dialysate. Typically, regular insulin is added to the dialysate.

Patients requiring insulin can administer regular insulin directly into the dialysate before it is instilled into the peritoneal cavity. This reduces the need for injections because the insulin can be added to the dialysate and represents a more physiological way to deliver insulin because it is absorbed continuously by the hepatic system, much like insulin produced by β-cells.

Factors that can affect glucose regulation for patients on peritoneal dialysis include the concentration of the dialysate solution, method(s) of insulin delivery (e.g., intraperitoneal, subcutaneous, or both), and infection (peritonitis). Carefully written instructions need to be provided. Self-monitoring of blood glucose is essential. Adjustments in the amount of insulin added to the dialysate should be based on glucose monitoring. A pattern approach should be used. The patient should be encouraged to keep accurate records, noting the glucose concentration of the dialysate used, calories and carbohydrates eaten, insulin added to dialysate, and insulin injected. Although regular insulin is preferred in the dialysate, fast-acting insulin can be supplemented for meals and as a correction dose.

Kidney Transplantation

After kidney transplantation, most individuals with diabetes will require a higher insulin dose because the immunosuppressive medications (i.e., steroids) have a hyperglycemic effect, the newly functioning kidney catabolizes the insulin, and the patient’s appetite often is increased with resolution of the uremia because of the effect of the steroids. Patients should be aware that an unexplained and sustained rise in blood glucose may signal a problem with the transplanted kidney. Infection can increase blood glucose. Prolonged hypoglycemia may signify a reduction in kidney function and a potential rejection episode. If a rejection episode does occur, the medication to prevent the rejection likely will substantially increase blood glucose levels and, consequently, the insulin dose.

Simultaneous Kidney AND Pancreas Transplantation

Kidney and pancreas transplantation restores both glucose metabolism and kidney function. Criteria for patient selection vary at each transplant center but typically include the diagnosis of T1D; evidence of secondary complications, such as moderate or severe neuropathy; metabolic instability; and adequate financial resources and insurance coverage. The complications of kidney and pancreas transplantation are cardiac incompetence; arterial or venous thrombosis; anastomotic leaks and bleeding; and side effects, including immunosuppression, pancreatitis, and metabolic acidosis related to exocrine pancreatic function.

Renal transplant function is easier to measure than pancreas function. A rise in serum creatinine is a primary indicator of kidney rejection. A decrease in serum amylase or urinary amylase production can signal a jeopardized pancreas. Hyperglycemia occurs late in pancreas rejection. Signs of rejection can be detected earlier in the kidney and treatment can be initiated, thus providing some protection for the pancreas.

SUMMARY

Optimal control of blood glucose and blood pressure are the keys to the prevention of nephropathy. Early detection using the annual albumin-to-creatinine ratio will identify those who are at risk, and aggressive treatment may delay the progression of the disease. The nurse plays a vital role in prevention and detection as well as education about the seriousness of the condition. If the patient has developed ESRD, it is imperative that the nurse provide support to the patient and family when they are making a decision regarding treatment options.

Future Nursing Research

Qualitative research is needed to develop a better understanding of how the diagnosis of ESRD affects individuals with diabetes and their families. Additional research issues may address the area of behavior-changing requirements that are related specifically to the lifestyle modification necessary for adapting to a diagnosis of diabetic nephropathy.

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