Chronic Kidney Disease for New Nurse Practitioners

Liz Rohr:

Hey there. It's Liz Rohr RealWorldNP. You are watching NP Practice Made Simple, the weekly video is to help save you time, frustration, and help you learn faster so you can take the best care of your patients. In this week's episode, we're going to be talking about CKD, and oh my goodness, I'm excited. So chronic kidney disease, everything renal can feel very complicated and stressful and overwhelming, and personally, when I was a new grad especially. I used to dread it, but the more I learn about renal, the easier it feels. I mean, maybe that's like a duh thing to say, but hopefully I can part to use some knowledge about chronic kidney disease that will help you feel more comfortable with patients in primary care who have CKD.

So before we jump in, I want to let you know that there is a brand new course coming this fall/winter for chronic disease management. So, the topics we're going to cover our CKD; talk a little bit more about diagnosis, monitoring, assessment, work up, all that stuff, all that beautiful stuff; hypertension medication and management; and diabetes medication and management, including insulin. So, if you want to join us or actually just even learn more about it, head over to realworldnp.com/courses, and you can join the wait list. And when you're on the wait list, you'll get the first email notification with all the details, and then you can decide if you want to sign up. So anyway, would love to help you.

So, let's jump into CKD. So CKD is chronic kidney disease, so the definition is impaired renal function that has lasted for three months or more, also defined as ... I never say this right ... glomerular filtration rate, GFR, of less than 60. I'm going to pause there though and say that the most important thing, if you take nothing else away from this video, CKD is not necessarily a diagnosis by itself. We absolutely always need to know where this is coming from. What is the underlying etiology? What is causing this person to have CKD? We can't just leave it at CKD, right? We need to figure out why.

So, the reason that we need to figure out why is that the main treatments, like ... Let me pause for a second. So most of the new grads that I work with feel very uncomfortable with CKD, because what they see are abnormal renal labs, which if you've worked in the hospital as a nurse, you extra feel the pain of seeing that because feels very stressful, right? And so a lot of new grads that I work with and I talk to and students as well, they look at the abnormal renal labs, BUN GFR, creatinine, see them elevated, and it feels like people have said to me, "It just kind of feels like we're not doing anything for them, and it just keeps kind of going up and up and up, and what are we supposed to do for patients with CKD? It just feels like we're in this waiting game.

So, the two main management principles of chronic kidney disease are to prevent progression, which I'll talk about in a second, and managing the complications that go along with CKD. Now, I'm not going to talk about the complications in this video, but that is going to be inside the CKD course, so if you would like to join us, again, get on that wait list. But that ties into what I said initially, which is that we need to understand the underlying etiology because the primary management is to optimize the underlying causes and to avoid nephrotoxic medication. We're avoiding further damage through treating the underlying cause as well as avoiding things that can cause further damage.

So, that's the initial most important things to know about CKD. One major point I want to make here is that I'm referring to is people who already have CKD diagnosed. So if you see abnormal renal labs and it's the first time you've seen them, you have to differentiate if this is acute or chronic. That's outside of the scope of this video, although it is inside the lab course, and I haven't decided what's going to be involved in the CKD course yet in terms of lab interpretation. There will be lab interpretation involved, but anyway, I digress. You need to know if it's acute or chronic, so I'm kind of primarily talking about patients who already have a known CKD diagnosis in front of you.

Okay, let's recap. So step one, what is the definition? Step two, what is the underlying etiology? Step number three, what are those management principles? Again, it's preventing worsening, preventing further injury through the underlying etiology, as well as avoiding nephrotoxic activities, as well as monitoring and managing those complications. And then the other thing I want to talk about is the role of referral as well as staging, so let's start with staging. So when it comes to CKD, there's stages one through five, so technically GFR less than 60 is the requisite diagnosis, like a criteria for diagnosing CKD. Technically, that's actually stage three. So stages one and two is normal kidney function that is slightly decreased, but it's not to chronic kidney disease yet. So there's stages three, four, and five, which are considered to be chronic kidney disease. There's technically 3A and 3B, but I'm not going to get into that in this video.

So, there's different stages, so once you've seen somebody with CKD, or you see somebody on your patient list or have somebody in front of you, do we know what the underlying cause is? Has somebody investigated this? Again, is this a brand new thing, or is it a chronic thing? What workup has been done so far to determine that etiology? And then the third thing is what is the stage? So is it three, four, or five, 3A and 3B, if you want to get fancy. We'll talk about the fancy in the course, not in this video. Stage three is 30 to 59, so 30 up through 60, so it's less than 60. So it's 30 to 59, your GFR is stage three. Stage four is 15 to 29. Anything less than 15 is stage five, and the that's considered to be end stage renal disease. You will see those patients in primary care, but hopefully that is not the first time you see them with a GFR less than 15, right? Fingers crossed.

So, let's just focus on three and four for now. We'll talk about that in the course with the stage five, but for all intents and purposes, the initial management of CKD. Stages three and four, it's important to know which one they are, and it's generally by looking at the trend over time. Are they hanging out in that three area, or are they pushing the level four, right? Cause they can kind of go up and down a little bit, but you want to see overall where they are at for the most part. So, the next most common question I get for referral to nephrology is when does that happen? When should we refer them, and so couple things I want to say. So anytime we refer somebody, the main two reasons are, number one, diagnostic clarity. Do we understand what's causing these symptoms, or do we need help from a specialist to figure this out with us? And then step two or reason number two is that they need to help us with the ongoing monitoring and management of this patient, because it's outside the scope of primary care.

So the main two reasons to refer to nephrology are, number one, if we are not clear about the underlying cause of CKD. So, you certainly can do this work up in primary care, the initial steps, however, it's really important, especially if you're a newer clinician, to not just order tests, because you found them. It's important to order tests that you feel comfortable interpreting, and if you don't feel comfortable with that, you can look at resources, you can do some continuing education. Lab course, anyone? Or you can consult with a colleague, but please don't go ordering a bunch of tests and stuff that you're not comfortable with interpreting. So you can do that workup yourself if you get some support, and/or you can have them go to nephrology.

The other thing is if they've already had that workup done or you've done it yourself, when do you refer to nephrology? When does somebody have to go to nephrology? As a general statement, anybody at stage four should see nephrology, and that's a couple of reasons. Number one, they help us with the ongoing monitoring and management of complications, as well as things like resistant hypertension, which is pretty common for patients with stage four CKD. Then the other thing is we want to have a conversation about dialysis, unfortunately. So there are people who can stay in stage four forever, however, our job is to assume the worst case scenario and prepare for it. That's our unfortunate job as healthcare providers. I kind of joke with my team that I'm an expert problem solver and like doomsday preparer, because my job. That's my been my whole career so far.

But yeah, so when it comes to stage four CKD, we have to have those conversations, so they definitely need to go. However, when it comes to stage three, again, if you're trying to find diagnostic clarity about the underlying etiologies, is it diabetes? Is it hypertension? Is it an inherent renal problem? Is it medication-related? Hopefully you can do a first pass of like nephrotoxic meds to see if it might have some sort of effect, but they can help with that. But also if you feel uncomfortable, number two, and then number three, there's a whole host of parameters that involve clinical judgment, but things like pregnant patients or hypertension, that's hard to manage even if they're stage three, or if they have CKD at a very young age, like under 40 or under 30 things like that. So I'm not going to go into all those parameters, but using your clinical judgment of is this like a cut and dry situation that I feel really confident that their care is being managed well, right? Are they diabetes? Have we done the workup? What are the assessment parameters?

I guess just very over overarching, one little pearl of practice, if you decide you want to do further investigation with renal stuff, which I highly recommend because it's so fun. It just helps you feel so much more confident when you're like, "Oh, I know what I'm doing." But with renal, the initial workout, I get into this in the lab course like the step by step in how to interpret each of these, but the things you want to think about, there are certain assessment parameters when it comes to renal problems. So part of the workup, again, please consult further resources if you're going to be ordering and investigating these steps, but typically speaking, there's three main tests that we're looking at for renal problems assess their status. We're looking at hypertension too because that's one of the main complications of CKD, but we're looking at how much protein they have in their urine, and we're also looking at are there any other components in their urine that point to a diagnostic cause? That's more for diagnosis, less so for management, but the worse kidney fun function is the more protein they'll have in their urine.

So, there's three tests that go along with that to kind of assess the status and health of the kidney aside from the BUN, GFR, and creatinine, which is urinalysis with microscopy. Not just urine dip, but actual microscopy under the microscope. The next one is a protein creatinine ratio spot test as an initial first pass test to look and see how much protein we have, and not just album into creatinine ratio, which is also known as microalbumin. I have a video for that, if you want to check that out down below. But it's protein to creatinine ratio because it's all the proteins, not just albumin. And then the last one is a renal ultrasound. So again, that's just high level. If you're interested in dipping your toes in, you can kind of look at that, DIY if you want or get support with that with continuing education or support from your colleagues. But anyway, so it depends on the status, but I don't want to overall me with too much information in this video, so I'll leave it at that.

But just as a recap, you really want to see the definition. Are we at CKD stage, stage whatever, right? Figuring out is this CKD? What stage are we at? What is the underlying cause? Do they need to see renal? And are you going to do that work up yourself, or are you going to get support for that? And I guess one other parole of practice just to take with you when it comes to CKD is just doing a med check and looking for nephrotoxic meds. This can be a little bit of a tricky. There's so many meds that can cause that, and so there's a couple of lists that I've found. There's one through AFP, American Family Physician article that I can link to down below, and just kind of utilizing your resources. If you have a med list in front of you, getting comfortable with each patient that you see of is this nephrotoxic or not? Lovely EHR popups can help with this where they'll give you recommendations. If it's a diagnosis of CKD in their chart, "Do you really want to prescribe NSAIDs for this person," et cetera, right?

So, that's it for this video. If you want to join us for that chronic care course that's coming up this fall/winter, we would love to have you. It's realworldnp.com/courses. You can sign up for the wait list, which will have all the information first. First come, first serve there. We would love to have you. So thank you so much for listening and watching, and I will see you again soon. Hang in there.