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Health Assessment & Self- Care in Kidney SM Gatmiri, MD, Nephrologist, Imam Khomeini Hospital, NSEP, NRC, TUMS, October 2014 In The Name of God

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Health care includes : 1- Treatment for current illness, 2- Preventive care to lessen future health decline.

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Issues in effective preventive care. -Which to recommend? -Which to discourage? Conditions, Tests & Interventions

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Principles on priorities

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Identifying those conditions that cause largest burden. A small number of modifiable factors probably underlies a large number of outcomes.

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Labeling Effect -Positive: All the screening tests were normal -Negative: Screening test is abnormal and more testing is necessary

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False-positive tests cause worry even after NL follow- up tests. Such situations might promote a sense of vulnerability instead of health. Examples: HCVAb+, PSA &

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HTN (Accounts for 35% of MI and strokes, 49% of episodes of heart failure, and 24% of premature deaths), DM, Smoking, Crash, Breast cancer, Lung cancers, Prostate cancer, Violence, & are issues in effective preventive care

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Examples The optimal interval for screening for HTN is not known. The 2007 US Preventive Services Task Force (USPSTF) guidelines recommend screening -Every 2 years for SBP

Stage 1: NL GFR (>90 mL/min/1.73 m2) & persistent albuminuria (1.8% of the total US adult population). Stage 2: GFR 60 to 89 mL/min/1.73 m2 & persistent albuminuria (3.2 %). Stage 3: GFR 30 & 59 mL/min/1.73 m2 (7.7 %). Stage 4: GFR 15 & 29 mL/min/1.73 m2 (0.35 %). Stage 5: GFR of

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SCREENING FOR CKD The NKF-K/DOQI, recommend that all individuals should be assessed for developing CKD.

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Targeting Screening for CKD DM, CVD, HTN, HLP, obesity, metabolic syndrome, smoking, HIV, HBV, HCV infection, Malignancy, Family history of CKD, Age >60 years, Treatment with potentially nephrotoxic drugs

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Testing can be done with 1-U/A 2-First morning or a random "spot" urine for alb or protein & Cr assessment & 3-Serum Cr for GFR determination.

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Ultrasonography in particular risk factors, such as ADPKD &

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GFR=(Ux. V)/Px

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MDRD These equations were validated in studies of white patients with nondiabetic CKD.

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Equation which GFR can be calculated using Cystatin C = [100/Cystatin C (mg/L) ]-14

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Excretion of Uremic Toxins

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Kidney International, Vol. 63, Supplement 84 (2003), pp. S6S10

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Excretion of Volume Overload

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Evaluation of Overload, HTN, Pulmonary Edema, Prominent JVP, Generalized Edema

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Balance in Acid Base system

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Tackypnea, Kusmul Breathing, ABG, VBG, Bone Disorder, Muscles wasting,

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Balance in Electrolytes

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Hypo & Hypernatremia Hypo & Hyperkalemia Edema HTN Hypo & Hypercalcemia &

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Trigger of Hematopoesis

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Hb, Hct, Serum Iron, TIBC, Ferritin

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Effect on Vit D & Bone Metabolism

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Ca, P, PTH, Vit D level, (25 OH & Calcitriol), Bone Densitometry, Radiography &

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Patient-Professional Partnership Self-care in Kidney diseases.

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Self-efficacy training for ESRD Journal of Advanced Nursing Volume 43, Issue 4 pages 370375, August 2003

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This RCT examine the effectiveness of self-efficacy training on fluid intake in ESRD.

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In 62 ESRD patients -Experimental group (n = 31) received 12 sessions of structured self-efficacy training (based on Bandura's theory and included an educational component, performance mastery, experience sharing, and stress management) -Control group (n = 31) received routine care.

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Programme focused on: CRF, HD, medications, complications, nutrition, drinking, control of thirst, stress management & participants learned to relax muscles through music, interviewes, weight gain &... & if the goals were achieved, praise and recognition rewards were given.

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Analysis of the sample Table 1 lists the clinical and demographical characteristics of patients who completed the study (n = 62).

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There were no statistically significant differences in gender, age, education levels, current use of medication, length of dialysis, symptoms, biochemical data, Kt/V, types of dialyser used and number of chronic diseases between the groups (P > 005).

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Body weight change was significantly different between 2 groups (t = 403, P = 001).

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Mean weight change between groups Descriptive statistics of mean body weight gains for the experimental and control groups at baseline, 1, 3 and 6 months following the self-efficacy training are presented in.

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The impact of self- management support (SMS) on the progression of CKD A prospective randomized controlled trial Nephrol. Dial. Transplant. (2011) 26 (11): 3560-3566. doi: 10.1093/ndt/gfr047 First published online: March 17, 2011

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Methods 54 CKD (Stages IIIV) patients; 27 were randomized into an SMS group and the 27 into a non-SMS group. SMS comprised -health information, -patient education, -telephone-based support and -aid of a support group.

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The primary end points were -absolute eGFR alteration and -of hospitalization events. The secondary end points were -an eGFR decrease of up to 50%, -ESRD demanding RRT, -all cause mortality or a -composite secondary end point.

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Results Absolute eGFR at the end of the study was significantly higher in SMS patients (29.11 20.61 versus 15.72 10.67 mL/min; P < 0.05).

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Fewer hospitalization events for SMS patients [5 (18.50%) versus 12 (44.47%); P < 0.05]. One patient (3.7%) in the SMS group and 9 (33.3%) in the non-SMS group had an eGFR reduction of >50% (P < 0.05).

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Survival analysis of the composite secondary end points of ESRD that required RRT and all-cause mortality revealed no differences between the two groups.

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Prevalence and associations of limited health literacy (HL) in CKD A systematic review Nephrol. Dial. Transplant. (2013) 28 (1): 129-137. doi: 10.1093/ndt/gfs371 First published online: December 4, 2012

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7 databases were searched. 82 studies were identified & of which 6 met the inclusion criteria. The total number of people in all studies was 1405. 5 studies were in dialysis or transplant populations, and all were from the USA.

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The review identified associations between limited HL and socio- economic factors (lower education, lower income), and certain process and outcome measures (lower likelihood of referral for transplant, higher mortality).

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Conclusions Limited HL is common among people with CKD and independently associated with socio-economic factors and health outcomes. It may represent an important determinant of inequality in CKD.

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