NR 507 Assignment Recorded Disease Process Presentation Peer Review

Thank you for your response and all of your kind words in regard to my presentation. I hope that my presentation allowed for a better understanding of renal disease and how as nurse practitioners we can provide the best care possible for these patients. I am so pleased with the questions you asked and was able to do some further research into this disease and gain some helpful knowledge because of them. Both questions you asked are addressed below.

Regarding this question, if a patient is told they will need dialysis, but they refuse, they have an approximate survival time of six months. What would you do to change the patient’s mind about dialysis?

For patients who are instructed to use dialysis for a treatment method, this can be scary and life changing. For patients that refuse at the initial instruction of dialysis it is essential to educate and ensure that he or she has an understanding of the outcome if refusal continues. One initial response, as was mentioned in the case you presented to me, the amount of time per week that the patient must set aside for the treatments. One important factor to mention to the patient is the possibility of performing the hemodialysis at home. In all cases it is not necessary to go to an outpatient setting to have dialysis performed. This option is often more acceptable to patients and allows them more independence than having to attend scheduled appointments. Another important fact that I did not mention in the presentation is the choice to do either hemodialysis or peritoneal dialysis. If the choice of peritoneal dialysis is made the patient will need to be aware a surgical procedure to place a abdominal catheter will be needed in order for treatments to take place. “During PD, sterile dialysate fluid is introduced in the patient’s peritoneal cavity and remains there for 6–8 hours while excess body fluid and toxins are filtered across the peritoneal membrane; at the completion of treatment, the dialysate fluid is drained from the peritoneal cavity” (Schub, Mennella, 2018, p. 1). This type of dialysis differs from hemodialysis because typically a catheter is placed in the chest until a graft can be established in the arm and then the blood is filtered rather than the peritoneal fluid. Again, it is important to educate the patient that both can be performed at home independently as long as compliance is achieved. After explaining all options of dialysis to the patient, inform the patient of the complications of not having dialysis such as electrolyte imbalances, fluid overload, toxin build up, and ultimately death. Healthcare is patient driven and ultimately it will be the patient’s decision whether or not he or she wants to have dialysis or not. The job of the healthcare provider is to educate and supply patients with the appropriate options and tools the live the best life possible living with this chronic disease.

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For patients with renal disease a kidney transplant is life changing and unless complications occur, will allow for a life without the disease. Patients who received a kidney transplant will be required to take medications for immunosuppression. The reasoning behind this is to prevent the body from rejecting the transplanted kidney. In the event of rejection, the patient will begin so show symptoms similar to that of infection and ultimately if not treated the patient can lose the transplanted kidney, enter into a state of shock, or even death. Drugs that are often times used in the immunosuppressive therapy are as follows: Rituxan, Rapamune, Prograf, Astagraf XL, Prednisone, CellCept, Nulojix, Cytoxan, Cyclosporine, Campath, Thymoglobulin, Imuran, and Simulect (Colaneri, 2014). These drugs are often times used in combination and it is imperative the patient does not miss a dose. Patients will also need to see the primary care provider to have blood drawn regularly in order to monitor levels such as with the medication Prograf. “immunosuppression should modify the immune system enough to prevent rejection, but not allow infection, malignancies, and other side effects” (Colaneri, 2014, p. 550). It is imperative to monitor transplant patients to ensure proper kidney health and the optimal life post-surgery.

NR 507 Assignment Recorded Disease Process Presentation Peer Review

References

Colaneri, J. (2014). An Overview of Transplant Immunosuppression – History, Principles, and Current Practices in Kidney Transplantation. Nephrology Nursing Journal, 41(6), 549-561.

Schub, T. B., & Mennella, H. A. (2018). Hemodialysis vs Peritoneal Dialysis. CINAHL Nursing Guide.

Regarding this question, if a patient is told they will need dialysis, but they refuse, they have an approximate survival time of six months. What would you do to change the patient’s mind about dialysis?

References

Colaneri, J. (2014). An Overview of Transplant Immunosuppression – History, Principles, and Current Practices in Kidney Transplantation. Nephrology Nursing Journal, 41(6), 549-561.

Schub, T. B., & Mennella, H. A. (2018). Hemodialysis vs Peritoneal Dialysis. CINAHL Nursing Guide.

Please allow me to humbly disagree with one of your comments in response to Paige’s presentation. In the post; Nephrectomy was mentioned as a treatment for chronic renal disease and further stated that “Retroperitoneal robotic partial nephrectomy is, however, more effective in the treatment of chronic kidney disease” (Spence, 2018).

In a recent article published in ‘The World Journal of Clinical Urology’; Nephrectomy was identified as the treatment of choice for renal cancers. The authors further explained the association of nephrectomy with new-onset of chronic renal disease (Yong, & Kareeann, 2017). This seems very logical to me because the removal of one or more kidneys either put an extra burden on the leftover kidney hence increasing the risk of its functions getting decreased or if radical nephrectomy was performed, then there are no kidneys at all for the job; which means patient had to be on dialysis.

Moreover, it was deduced that the aim of the cited study in the comment was to examine the effects of kidney tumor’s location (anterior versus posterior), the chosen surgical approach in performing the needed nephrectomy, and their subsequent outcomes on the patients’ prognosis (Paulucci et al., 2018).

The following was a direct quote of the conclusion statement from the cited article.

“The transperitoneal approach to partial nephrectomy for posterior tumors resulted in no difference in operative time, WIT, EBL, LOS, positive surgical margins, reduction in eGFR, or postoperative complications. The TPRPN approach to treat a posterior tumor is reasonable and is the preferred technique at our institution” (Paulucci et al., 2018).

Thank you

References

Spence, I. (2018). Re: Chronic Renal Disease: Treatment and prevention [web log comment]. Retrieved from https://chamberlain.instructure.com/coursesdiscussion_topics/633364?module_item_id=3471579

Paulucci, D. J., Beksac, A. T., Porter, J., Abaza, R., Eun, D. D., Bhandari, A., . . . Badani, K. K. (2018). A Multi-institutional propensity score-Matched comparison of transperitoneal and retroperitoneal partial nephrectomy for cT1 posterior tumors. Journal of Laparoendoscopic & Advanced SurgicalTechniques. doi:10.1089/lap.2018.0313

Yong, T. Y., & Khow, K. S. (2017). Chronic kidney disease after radical nephrectomy for suspected renal cancers. World Journal of Clinical Urology,6(1), 10. doi:10.5410/wjcu.v6.i1.10

Thank you for your reply and feedback in regard to my presentation. I am glad that you agreed with my risk factors presented and was also able to provide me with additional risk factors that should be taken into consideration. I also appreciate your suggestion of including a nephrectomy as a treatment of chronic renal disease but according to current research this might not be a highly favorable option for most patients. Since a nephrectomy is used in one of two ways including radical nephrectomy and partial nephrectomy, this might actually cause the patient further complication rather than improving the disease process. In a radical nephrectomy the whole kidney is removed. For patients with chronic renal disease often times both kidneys are impacted since this is a chronic disease rather than acute kidney injury. The other option which is a partial nephrectomy allows for the surgeon to remove a diseased portion of the kidney. Again, this route might not be beneficial to the patient with chronic renal disease since typically the whole kidney is impacted due to decreased function rather than a single portion. In order for this procedure to be beneficial the patient would need to have one normal functioning kidney and as mentioned in most cases with chronic renal disease this is not a common finding. Reasons that a nephrectomy or partial nephrectomy might be considered include: cancer, infection, kidney injury, and birth defects. While this is not a common procedure for the patient living with chronic renal disease, it is more common among kidney donors who choose to undergo a nephrectomy to provide another individual with a needed kidney (Kohnle, 2016). Thank you again for all your great feedback.

As you rightly mentioned, stage four CKD is characterized by a glomerular filtration rate (GFR) of 15-29 milliliters/minute (ml/min). At this point, though the kidney functions had deteriorated significantly but the patient is not yet in kidney failure hence dialysis is usually not initiated at that stage. A recent multicenter prospective cohort study by Park et al. and other multiple studies showed that early initiation of dialysis with GFR of over 15ml/min was associated with higher mortality rate and it did not enhance patient survival rate (Park et al., 2017). It was shown that premature initiation of dialysis increases the loss of kidney residual function, which is harmful to the patient (Park et al., 2017). Dialysis is indicated in stage five when GFR is less than 15 ml/min and this is considered as end-stage renal disease or kidney failure (Kaplan, Fedorowicz, & Aird, 2018). The indication and timing of starting dialysis was recommended when there are life-threatening changes in fluid, electrolytes, and acid-base balance or when one or more of the following conditions exists in a CK D patient: Signs of serositis, life-threatening fluid and electrolyte balance, pruritus, uncontrollable blood pressure, cognitive impairment, malnutrition that is not responding to dietary intervention. These usually manifest when the GFR is between 5 to 10 ml/ per minute (Kaplan, Fedorowicz, Aird, & Trebbin, 2016).

In conclusion, the primary aim of treatment in CK D is to slow down the progression of kidney damage and avoid the loss of residual kidney functions and these could be undermined by premature initiation of dialysis (Kaplan, Fedorowicz, Aird, & Trebbin, 2016).

The implications for nurse practitioner practice #8

Question: what other healthcare professionals should be involved in the care of patients with a chronic renal disease?

Feedback: According to the Kidney Disease Outcomes Quality Initiatives (KDOQI) recommendations, stage 4 CK D patients (GFR 15-29 ml/min) should be provided with treatment options education for available renal replacement therapy modalities and be made aware that dialysis will be needed when the GFR drops below 10 to 15 ml/ minute with the manifestation of life-threatening symptoms (Kaplan, Fedorowicz, Aird, & Trebbin, 2016).

A team approach was highly recommended before and even after the initiation of dialysis both the American Society of Nephrology and Canadian Society of nephrology recommended against and the initiation in the absence of clinical indications and without an established shared decision-making process that involves the patients, their families, and nephrology healthcare team. A study shows that early referral to nephrologist was associated with a reduced mortality rate in CK D (Kaplan, Fedorowicz, Aird, & Trebbin, 2016).

Thank you for your response and feedback. I am so happy that the information I provided allowed you to further investigate in relation to initiation of dialysis and treatment team. I take care of so many patients and have also had a close member who had to undergo dialysis due to chronic renal disease and it was not until doing this presentation that I realized when the process should be initiated. I agree with your finding that dialysis is typically implemented when the patient is diagnosed with end stage renal failure. Unfortunately without a transplant the patient will have to undergo dialysis for the rest of his or her life. I did find your last statement in regard to dialysis being implemented to soon interesting and feel that in the future it might be studied to better care or chronic renal disease patients.

For your second category of feedback you chose implications for the nurse practitioner. I agree with you that a team approach is the best choice and often times is implemented before the diagnosis occurs. Many times, the patient is being assessed by his or her primary care provider and this is when the discovery that labs or symptoms might indication renal disease. The patient is often times then referred to a nephrologist to further investigate. With these physicians working together it is also important to remember the impact lifestyle can have on these patients. According to Jones (2014, p.1) “The waste products and fluid that your kidneys remove come from the foods you eat.”. Consulting a dietitian might be a wise choice in order to make certain the patient understands what foods they should be consuming. A trainer might also be a good option since exercise can optimize the life for a chronic renal disease patient. For patients with other conditions such as diabetes, they might require care from a endocrinologist. As you can see, team work in healthcare is essential and as one of the providers you must ensure consultation with the other providers when care changes so ensure it does not negatively impact the patients care in another portion of the body system. As I mentioned in my presentation chronic renal disease impacts all body systems, so team care will essential.

Reference

Jones, P. (2014). What Can I Do About Kidney Disease?. Health Library: Evidence-Based Information.

NR 507 Assignment Recorded Disease Process Presentation Peer Review