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423 -Nephrology Social Work

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– Identify the causes of kidney failure
– Explore the consequences of kidney failure

Facts about CKD
– 1 in 7 or 30 million American adults have CKD and 1 in 3 are at increased risk.
– Early detection can help prevent the progression of kidney disease to kidney failure.
– Heart disease is the major cause of death for all people with CKD.
– Hypertension causes CKD and CKD causes hypertension.
– High risk groups include
– those with diabetes, hypertension and family history of kidney failure.
– African Americans (diabetes, HBP), Hispanics, Pacific Islanders, American Indians and Seniors
– The progression of CKD can be stopped if caught before stage 4

Causes of Kidney Disease
– Diabetes
– 30-40% of people with diabetes also have kidney disease (>2% of the adult population)
– People with diabetes and CKD are more prone infections and anemia increasing their vulnerability to acute complications
– High blood pressure
– Glomerulonephritis, a group of diseases that cause inflammation and damage to the kidney's filtering units.
– Inherited diseases, such as polycystic kidney disease
– Malformations that occur as a baby develops
– Lupus and other diseases that affect the body's immune system.
– Obstructions caused by problems like kidney stones, tumors or an enlarged prostate gland in men.
– Repeated urinary infections.

– Feel more tired and have less energy
– Have trouble concentrating
– Have a poor appetite
– Have trouble sleeping
– Low back pain
– Have muscle cramping at night
– Have swollen feet and ankles
– Have puffiness around your eyes in the morning
– Have dry, itchy skin
– Need to urinate more often, especially at night
– Blood in the urine
– Nausea
– High blood pressure (headache, blurred vision, pounding in ears)

End Stage Renal Disease
– End stage renal disease (ESRD) is the point when the kidneys cannot filter waste and excess fluid from the body.
– Dialysis mechanically removes waste when the body is no longer able to do so and takes 3-4 hours per session.
– In hemodialysis, blood travels through a tube and is filtered by an artificial kidney
– In-center hemodialysis is done three times per week in a clinic setting
– In peritoneal dialysis, a solution is administered through a catheter in the abdomen and is later removed
– Peritoneal dialysis and home hemodialysis can be done at a time and a location chosen by the patient
Functions of a Nephrology Social Worker
– Psychosocial evaluation and treatment planning
– Counseling and conferences with patients, families, and support networks
– Discharge planning
– Groupwork (education, emotional support, self-help)
– Information and referral
– Facilitation of community agency referrals
– Team care planning and collaboration
– Advocacy on patients’ behalf within the setting and with appropriate local, state, and federal agencies and programs
– Patient and family education

Problems Addressed
– Adjustment to chronic illness and treatment as they relate to quality of life
– Changes in activities and friendships/ Inability to engage in previous activities
– Transportation assistance
– Childcare needs
– Fatigue
– Age, employment and finances were significant predictors of adjustment issues and treatment compliance
– The perception of an illness rather than the actual symptoms themselves that best account for adaption to CKD
– Prevention of concurrent issues
– CKD have been regarded as a nontraditional risk factor for stroke, sleep apnea, chronic inflammation, and malnutrition

Problems Addressed
– Neuropsychiatric conditions including depression, anxiety disorders, and cognitive impairment are prevalent in patients with chronic kidney disease (CKD)
– The most common hypothesis is based on the occurrence of cerebrovascular disease and accumulated uremic toxins in adult patients with CKD.
– Inflammation is a common feature in brain and kidney lesions. This increase in inflammatory cytokines contributes to the development of depression
– Adults with chronic kidney disease (CKD) exhibit alterations in tryptophan metabolism, which have been associated with various neurological and psychological disorders including depression and/or anxiety and decline in cognitive functioning.

Problems Addressed
– Suicide rates are 10-400 times higher in people with chronic kidney disease
– Mood is a superior predictor of the physical and mental components of HRQOL in patients compared with the number and severity of physical symptoms. Highlighting the importance of assessing negative emotional states to reduce the impact of CKD on HRQOL.

Problems Addressed–Depression
– Depression and poor quality of life affect adherence to rigid dietary restrictions, and medication regimens.
– The most commonly used tool to assess depression and HRQOL is the Kidney Disease Quality of Life (KDQOL) survey
– Improvements on the KDQOL increase the chance of being listed for a kidney transplant which is associated with better outcomes
– Those undergoing hemodialysis showed more depression and worse physical well-being, occupational functioning, spiritual fulfillment and more health interference with work than transplant patients
– Transplant patients receiving the immunosuppressor sirolimus exhibited more cardiac/renal, cognitive and physical limitations than the rest.
– Dialysis type correlated positively with sleep disturbances and depression scores and negatively with total Quality of Life.
– HD patients experienced more distress than peritoneal dialysis patients (PD)

Problems Addressed-Emotional Issues
– Emotional repercussions (grief, resentment, overwhelmed):
– Receiving of diagnosis
– Treatment-related fatigue
– The need to rearrange their lives to accommodate treatment
– Potential concerns about body image i.e. the arteriovenous fistula which is noticeable and an ever-present reminder
– Receiving a transplant from a deceased donor
– Having to learn about the equipment and treatment protocols creates a great deal of anxiety
– Problems related to treatment options or setting transfers
– Resource needs, including finances, living arrangements, transportation, and legal issues
– Decision making regarding advance directives

Chronic Pain Management
– >60-70% of patients with advanced and end-stage kidney disease have chronic pain
– Increased drug levels and associated adverse effects may occur due to reduced renal clearance and development of toxicity due to reduced protein binding associated with hypoproteinemia/hypoalbuminemia and/or acidemia.
– Drug removal by various modes of dialysis must also be considered.
– Opioids are contraindicated until the pain is severe
– Codeine and hydrocodone are specifically not recommended.
– Methadone may be recommended in cases of severe pain which doesn’t respond to other interventions.

Nutritional Issues
– Nutritional deficiency complications include high mortality, increased risk of atherosclerosis, inflammation, oxidative stress, anemia, polyneuropathy, encephalopathy, weakness and fragility, muscle cramps, bone disease, depression, or insomnia.
– In CKD nutritional deficiencies develop for several reasons including dietary restrictions, loss of appetite, medication side effects, impaired intestinal absorption, age, and the use of diuretics and dialysis.
– Specific deficiencies common in patients with CKD include vitamin C, thiamine, vitamin B6, folic acid, zinc and selenium
– Iron deficiency anemia is common in patients with chronic kidney disease

Sleep Issues
– Sleep disturbance were found in 36.2% of the patients

– Among caregivers, 33% have anxiety and/or depression
– Caregivers report insufficient practical social support and moderate emotional social support.
– 14.3% reported being ‘extremely tired’
– About 70% reported that they were unable to engage in all activities that they usually performed before the patient's illness.
– Results confirm the interrelation between caregiver burden and depression.

– Patient activation
– Activated patients use knowledge, skills, and confidence to manage their health
– Activated patients tend to participate in more health promotion activities, like engaging in routine exercise or receiving annual eye exams, experience fewer hospitalizations
– Activation varies depending on their health, confidence, willingness to engage, and life situations.
– Declining activation from CKD stage 3 to stage 5 may suggest that patients in stage 4 may need re-boosting of their knowledge, skills and confidence as the difficulty of CKD self management increases
– Patients as early as CKD stage 2 begin to experience a decline in their physical function, vitality and energy, social function, mental health and emotional well-being

– Knowledge includes understanding how the kidneys function and recognizing symptoms associated with disease progression which increases treatment participation.
– Educating patients early in their disease process regarding how BP SM may delay complications such as heart disease associated with CKD
– CKD literacy, coping with anxiety, prerequisites for self-management, and reciprocity in information provision. The participants filled deficiencies in their CKD knowledge with misconceptions and half-truth about causes, symptoms, and treatment.
– The anxiety about CKD at the time of diagnosis versus the feeling of irrelevance later on was due to the absence of CKD symptoms and their physicians' minimization of the seriousness of CKD.
– Patients often fail to connect lifestyle and cardiovascular disease with CKD.
– CKD literacy and willingness to change were both necessary to accept lifestyle changes

– Self Management core SM skills, such as problem-solving, decision making, action planning, goal-setting, patient/healthcare provider partnership and resource utilization is central to improving adherence to daily SM behaviors.
– Reading food labels, healthy eating
– Sleep hygiene
– Stress management
– Enhancing communication between patients and their healthcare providers
– Improving medication compliance and disease monitoring

– Confidence or self-efficacy increases over time and is associated with positive health outcomes
– Risk factor modifications
– Increased physiological and psychosocial functioning,
– Improved self management behaviors and medication adherence

Assessment Measures
– The PROMIS, Patient Reported Outcomes Measurement Information System (PROMIS), measures depression, anxiety, social-peer relationships, pain interference, and mobility and is sensitive to the clinical status of people with chronic kidney disease
– HealthMeasures consists of four precise, flexible, and comprehensive measurement systems that assess physical, mental, and social health, symptoms, well-being and life satisfaction; along with sensory, motor, and cognitive function.

– Mood and HRQOL are significant predictors of outcomes in people with CKD
– Finances, employment, social support are significant predictors of mood and HQORL
– Clinicians working with people with CKD should
– Identify and address perceived obstacles to HRQOL
– Enhance client and SO knowledge about CKD
– Empower them to take active steps toward disease prevention and self-management by increasing health literacy and reducing treatment related anxiety
– Highlight successes to increase efficacy