July 20, 2008
Management of Mineral and Bone Disorders In Patients on Dialysis: A Team Approach To Improving Outcomes
By Carver, Michelle Carder, Jacqueline; Hartwell, Lori; Arjomand, Mahiyar
Most patients with mineral and bone disorders do not simultaneously achieve KDOQI(TM) target goals for parathyroid hormone, calcium, phosphorus, and the calcium-phosphorus product. A multidisciplinary team composed of the patient, nephrologists, nephrology nurses, renal dietitians, social workers, patient care technicians, clinical pharmacists, and physical therapists can help improve the coordination of care for mineral and bone disorders. The roles of team members are reviewed, with emphasis on nephrology nurses. The care of patients on dialysis is complex, and the federal government, recognizing this complexity, has mandated that care be coordinated by a team of core providers to achieve patient-specific treatment goals (Joy et al., 2005). One aspect of care, management of chronic kidney disease mineral and bone disorders (CKD-MBD), guided by the Kidney Disease Outcomes Quality Initiative (KDOQI(TM)), requires a coordinated effort by a multidisciplinary team (National Kidney Foundation [NKF], 2003).The multidisciplinary approach to treating CKD-MBD should focus on patients and includes them as active participants. Medical professional team members who may contribute to the care of these patients - nephrologists, nephrology nurses, renal dietitians, social workers, patient care technicians, clinical pharmacists, and physical therapists (see Figure 1) - each contribute a unique perspective. The training for this core of professionals resulted in the NKF's creating specialties and councils for many of these disciplines to recognize each one's contribution and to provide a forum for interacting with interdisciplinary colleagues (NKF, 2008). This article reviews the goals of CKD-MBD therapy and the roles of the multidisciplinary team members, with a focus on nephrology nurses.
Treating CKD-MBD: Goals of Therapy
A large body of evidence suggests that abnormalities in bone and mineral metabolism in patients receiving dialysis are associated with increased mortality and morbidity (for example, bone pain, fractures, bone deformity, myopathy, muscle pain, tendon ruptures, pruritus) (Alem et al., 2000; NKF, 2003; Stehman-Breen et al., 2000). The effect of prolonged CKDMBD on soft tissue calcification is also a growing concern in the care of these patients. Calcification of the myocardium, cardiac valves, and coronary arteries has been increasingly recognized as a major factor in the development of congestive heart failure, cardiac arrhythmias, ischemic heart disease, and death (Raggi et al., 2002; Uwatoko et al., 2007). Similarly, calcification of the lungs can lead to pulmonary hypertension, right ventricular hypertrophy, rightside congestive heart failure, pulmonary fibrosis, and impaired pulmonary function ( Joy, Karagiannis, & Peyerl, 2007; Kerr & Guerin, 2007; Toussaint & Kerr, 2007), while vascular calcification can result in soft-tissue necrosis and ischemic lesions. Vascular calcification can involve arteries throughout the body, and the calcification may be so extensive that arteries become rigid, the pulse is not palpable, and Korotkoff sounds are difficult to hear during measurement of blood pressure. The rigidity of the vasculature may also present difficulties during surgery for the creation of arteriovenous shunts or fistulas, or during kidney transplantation (NKF, 2003; Toussaint & Kerr, 2007).
Recognizing the wide range of negative systemic effects associated with CKD-MBD, the KDOQI has developed recommended target levels for parathyroid hormone (PTH), serum calcium and phosphorus, and the calcium-phosphorus product (see Table 1) (NKF, 2003). Despite these recommendations and a renewed focus on managing CKD- MBD, data indicate that most patients on dialysis do not achieve all four of these targets simultaneously. For example, the Dialysis Outcomes Practice Patterns Study (DOPPS) evaluated data from 2,246 patients receiving hemodialysis in the United States and found that the percentage with laboratory values within the KDOQI targets was 26.2% for PTH, 44.4% for serum phosphorus, 46.1% for serum calcium, and 60.8% for calcium-phosphorus product (Young et al., 2004). Further, an analysis of these laboratory values for 6,864 patients from 7 countries found that only 5.5% were within the range recommended by KDOQI for all four parameters (Young et al., 2004). Similar results have been found in other studies, which have consistently shown that most patients do not achieve these four KDOQI targets (Aly, Gonzalez, Martin, & Gellens, 2004; Arenas et al., 2006). These results highlight the need for a concentrated, coordinated, and aggressive effort to ensure that all members of the nephrology team are working in concert to help patients achieve the recommended therapeutic goals.
Multidisciplinary Team Roles In Achieving the Goals Of CKD-MBD Therapy
Role of Patients in Managing CKD-MBD
Patients are the center of care for CKD-MBD therapy and should be established as integrated partners who work with team members to ensure that goals are achieved. Patients should be empowered to take responsibility for their own health and work in partnership with health professionals rather than be viewed as passive recipients (Hartwell, 2002; Jenkins, Jones, Thomas, & Prichard, 2007). Data indicate that well-informed patients on dialysis are better able to manage their health treatment, experience less anxiety, and have fewer exacerbations and lower hospital admission rates. Increased self-responsibility and self-management may also improve overall health while reducing health care costs ( Jenkins et al., 2007).
The importance of establishing patients as integrated partners on the health care team is especially important when managing conditions such as CKD-MBD, in which an understanding of the benefits of achieving and maintaining treatment goals can help ensure adherence to the individualized therapeutic regimen. Patients who understand the importance of achieving KDOQI targets for all four laboratory measures are more likely to keep track of trends in their numbers, adhere to scheduled dialysis appointments, follow the prescribed diet, take prescribed medications, and inform the medical team about any new medications (both prescription and over the counter) or changes in their diet (Hartwell, 2002).
Information is the most powerful ally patients have - if they do not understand what effect their actions can have, they cannot make educated decisions that can position them as self-advocates for improving their own outcomes (Hartwell, 2002). Patients need to be active participants in the educational process and be encouraged to ask questions about conditions such as CKD-MBD and the lifestyle decisions that will help improve their quality of care. Patients' understanding of how lifestyle choices, such as dietary habits and smoking, can affect comorbid conditions such as CKD-MBD may also help improve their ability to make choices that will improve their own outcomes (Hartwell, 2002; Kammerer, Garry, Hartigan, Carter, & Erlich, 2007). Similarly, when patients understand how prescribed medications help control CKD-MBD-related laboratory values, it can offer them hope for better long-term outcomes, resulting in improved adherence (Hartwell, 2002).
Role of Nephrologists in Managing CKD-MBD
As the medical team leaders, nephrologists are ultimately responsible for establishing treatment goals and determining prescriptions. Physicians oversee the provision of care for CKD-MBD by establishing patientspecific treatment goals, assessing patient status regularly, approving management protocols, and prescribing therapeutic regimens (NKF, 2003).
Role of Dietitians in Managing CKD-MBD
Dietitians are key members of the CKD-MBD team. Initially, many patients look to renal dietitians for recipes to help them cope with the complex diet required to manage their disease - balancing optimal nutritional health with the nutrient limitations imposed by CKD. However, the specialized knowledge of renal dietitians also allows them to help patients address a broad range of issues, ranging from CKD-MBD target laboratory values to how the patient's appearance may change as a result of fluid or dietary choices (Gonyea, 2003).
The dietitian's role in CKD-MBD management can vary broadly among dialysis facilities and range from minimal input to a leading role in working with nephrologists and nephrology nurses to implement physician-approved CKD-MBD management protocols (McCann, 2005). Renal dietitians are often responsible for working with other team members to evaluate a patient's nutritional status, coordinate and recommend appropriate therapies for conditions such as CKD-MBD, educate patients and medical care team colleagues on dietrelated issues, and recommend goals that will improve patient outcomes (Reams, 2002).
Dietitians recognize the limitations and costs of various therapies, as well as the inconvenience of a daily schedule that requires patients to take many pills. They often work closely with social workers to overcome financial challenges and ensure that patients have continual access to CKD-MBD management therapies. In addition, dietitians collaborate with other team members to address lack of adherence to recommended dietary and medication regimens and they have regular access to patients to provide education, encouragement, and progress reports (McCann, 2005). Role of Social Workers in Managing CKD-MBD
Social workers assess a variety of needs for patients and their families and can help coordinate services, such as housing, transportation, and child care to ensure that patients can keep scheduled appointments. Social workers can play a key role in achieving CKD-MBD treatment goals by addressing adherence issues and assisting patients to find appropriate financial coverage to ensure access to therapies (Reams, 2002).
Role of Nephrology Patient Care Technicians in Managing CKD-MBD
Nephrology technicians and technologists work under the supervision of nephrology nurses to provide direct care for patients receiving dialysis, maintain and repair medical equipment, coordinate the reuse of hemodialyzers, and provide quality assurance as well as research and development (National Association of Nephrology Technicians/Technologists, 2008). Interdisciplinary communication and cooperation are inherent parts of the nephrology technician's position. Technicians are often the team members with the most one-on-one time with patients. These close working relationships may result in discussions that reveal pertinent information about status, adherence to medication regimens, or financial challenges that could have an impact on CKD-MBD outcomes and necessitate indepth assessment by nurses or other team members.
Role of Pharmacists in Managing CKD-MBD
Patients receiving dialysis typically have 5 to 6 comorbid conditions and are taking an average of 12 medications (Manley, Cannella, Bailie, & St. Peter, 2005). Studies have consistently shown that medication-related problems occur at a relatively high rate in patients on dialysis. In a metaanalysis of 7 clinical studies of 395 patients receiving hemodialysis, 1,593 medication- related problems were identified, including improper drug selection, subtherapeutic dose, overdose, drug-drug interaction, and inappropriate laboratory monitoring (Manley et al., 2005). Accordingly, there is an emerging role for consultant nephrology pharmacists in helping to manage CKD-MBD dosing and medication- related problems and the risk for drug-related complications (Nguyen, 2007).
Role of Physical Therapists In Managing CKD-MBD
Although physical therapists are not traditionally thought of as part of the core dialysis team, they can play an important role in improving the quality of life for patients with CKDMBD. Physical therapists are trained to assess and treat a wide array of functional problems, many of which are common in CKD-MBD. These include back pain, muscle weakness, limited range of motion, balance disorders, alterations in gait, joint pain, loss of functional mobility, and alterations in posture. Physical therapy can help prevent or modify some of the functional deterioration that may be associated with the disease in patients on dialysis (Pianta, 1999). Physical therapists can also help coordinate aids to mobility, develop and implement appropriate exercise programs, and enhance recovery from fractures and other bone-related effects of CKD-MBD (Burrows- Hudson & Prowant, 2005).
Role of Nurses in Managing CKD-MBD
The role of nurses has been defined by the American Nephrology Nurses' Association's Standards of Practice and Guidelines for Care, which outline specific patient-oriented outcome goals that focus on nursing practice in the management of CKD-MBD (see Table 2) (Burrows- Hudson & Prowant, 2005). These roles are categorized by the nursing care process and include a broad range of responsibilities for assessments, interventions, and patient education.
Nursing assessment of CKDMBD. Assessments provide a standardized methodology for nephrology nurses to collect comprehensive patient data. These data should be collected in a systematic and ongoing process that involves the patient, the family, and other health care providers. The assessments should include information on not only the patient's clinical status, but also his or her psychosocial status and environment (both home and work), as appropriate (Burrows- Hudson & Prowant, 2005).
Nursing assessment of patients with CKD-MBD should include a periodic review of risk factors for osteoporosis and bone disease that may influence the bone complications attributed to CKD-MBD. These risk factors include older age, postmenopausal status, malignancy, a history of injuries or falls, and adherence to diet and treatment regimens. The unique knowledge base that nurses have allows them to conduct regular, systematic assessments of a patient's physical status to determine whether signs point to a change in CKDMBD. This physical assessment should include a review of muscle strength, gait, range of motion, joint changes, blood pressure, and heart rate. The patient should be examined carefully for signs of local tissue injury, macules, papules, other skin changes, pruritus, the quality of pulses in the extremities, and vascular insufficiency (Burrows-Hudson & Prowant, 2005).
In many cases, nurses are the first members of the medical team to review laboratory results pertinent to CKD-MBD. Consequently, they are those who first note changes in PTH, serum calcium, phosphorous, and the calcium-phosphorus product. The nurse's assessment of laboratory results can provide valuable information on changes in status that necessitate modifying the therapeutic regimen and that need to be shared with other members of the team (Burrows- Hudson & Prowant, 2005).
Although nurses are not directly responsible for diagnostic tests such as bone X-rays, dual energy X-ray absorptiometry, electrocardiograms, and echocardiograms, the results of these tests can affect the treatment plan. Nurses should therefore be familiar with both the results (for example, data on fractures, risk of fracture, and vascular calcification) and the implications for patient care (Burrows-Hudson & Prowant, 2005).
Ongoing nursing assessments, in conjunction with proper documentation, can help the team refine diagnoses, identify patient- specific goals and outcomes, and develop a plan that uses prescribed strategies and alternatives to attain expected outcomes (Burrows- Hudson & Prowant, 2005). Nephrology nurses typically use these data to collaborate with nephrologists and dietitians in planning an appropriate treatment regimen for CKD-MBD and in implementing the care plan to achieve expected outcomes.
Nursing interventions for CKDMBD. Once the patient-specific care plan has been developed, nephrology nurses are responsible for implementing it in collaboration with other members of the team. Nurses typically administer prescribed intravenous medications while collaborating with other team members to ensure patient adherence to oral medications. Nurses should also provide ongoing encouragement to help patients adhere to prescribed dietary and medication regimens, work with other members of the team to ensure that all outcome goals are met, and initiate physician-requested consultations and referrals, as appropriate (Burrows-Hudson & Prowant, 2005).
Patient teaching pertinent to CKD-MBD. Nephrology nurses are responsible for helping to ensure that patients with CKD-MBD understand the importance of working with the team to simultaneously achieve all of KDOQI targets for PTH, calcium, phosphorus, and calcium-phosphorus product. Patients need to understand the relationship between kidney function and mineral and bone metabolism, the consequences of uncontrolled CKD-MBD, and the ways the disease is affected by dialysis, medication, and dietary prescriptions, as well as lifestyle choices, dietary indiscretions, and over-the-counter preparations. Patients should also be able to demonstrate the ability to recognize the signs and symptoms of CKDMBD, participate in an appropriate exercise regimen, and reduce mobility hazards at home and at work. In addition, it is vital that patients understand the type of information that needs to be reported to the health care team (for example, changes in medications prescribed by other physicians or changes in the diet or over-the-counter preparations, falls, injuries, pain) (Burrows- Hudson & Prowant, 2005).
The educational plan should be customized to ensure that it is appropriate to the individual patient's developmental level, learning needs, readiness and ability to learn, language preference, and culture. All educational efforts should also include a systematic method for soliciting feedback and evaluating the effectiveness of the strategies (Burrows-Hudson & Prowant, 2005).
Additional Roles for Advanced Practice Nephrology Nurses
Advanced practice nephrology nurses synthesize clinical data with evidence- based guidelines and theoretical frameworks to effect positive improvements in the CKD-MBD treatment regimen and individual patient care plans. The expanded role of advanced practice nephrology nurses in the management of CKD-MBD includes both consultative and prescriptive responsibilities. Consultative responsibilities typically involve recommending enhancements to the care plan and mentoring other members of the team to improve the overall quality of care. Prescriptive authority is applied to medication regimens, procedures, and other therapies in accordance with state and federal laws and regulations. For CKD-MBD, these activities may include assessing a patient's response to the treatment plan and the achievement of the KDOQI target values, prescribing medication and dietary modifications, ordering and interpreting diagnostic studies, and monitoring for the development of bone disease and signs of extraskeletal calcification (Burrows- Hudson & Prowant, 2005).
Working in Collaboration with Team Members
The standards of practice described by Burrows-Hudson & Prowant (2005) cite nephrology nurses as the coordinators of care delivery. This does not mean that nurses are responsible for implementing all aspects of care for conditions such as CKD-MBD. With time constraints, changes in staffing patterns, and the wide variety of factors that influence success in managing bone and mineral disease, it is impossible for one team member to be responsible for all aspects of care, especially with the additional responsibility of managing the other comorbidities in patients receiving dialysis. However, nurses should be responsible for coordinating the care delivery plan to provide direction to other nonphysician members of the health care team. Each member brings a unique set of skills, specialized training, and a different point of view that can help reinforce goals and educational information to improve outcomes. Communication among disciplines is therefore vital to patients' overall health, and the team needs to work together to maintain or improve CKD-MBD-related outcomes for each patient. Nurses, patients, and other team members should devise a coordinated, systematic method for communicating vital information that affects CKD-MBD status (Showers, 2004). Conclusion
Most patients do not simultaneously achieve KDOQI target laboratory values for PTH, calcium, phosphorus, and calcium- phosphorus product. A concentrated and aggressive effort on the part of all team members - including the patient - is required to ensure that everyone is working in synergy. Nephrology nurses play an integral role in this team effort and can have a significant impact on improving the management of CKD-MBD.
Note: This article is supported by a financial grant from Amgen. The manuscript has undergone peer review. The information does not necessarily reflect the opinions of ANNA or the sponsor.
Nephrology Nursing Practice Goals for Managing CKD-MBD
* Patient will achieve and maintain metabolic bone parameters and acid-base balance within the targeted ranges.
* Patient will be free of disability related to bone disease and signs and symptoms of extraskeletal calcification.
* Patient will demonstrate knowledge of CKD-MBD.
* Patient will demonstrate a reduction in modifiable risk factors for the development of cardiovascular disease.
* Patient will demonstrate knowledge of extraskeletal calcification, including the development of cardiovascular disease.
Source: Burrows-Hudson & Prowant, 2005. Used with permission.
Alem, A.M., Sherrard, D.J., Gillen, D.L., Weiss, N.S., Benesford, S.A., Heckbert, S.R., et al. (2000). Increased risk of hip fracture among patients with end-stage renal disease. Kidney International, 58(1), 396-399.
Aly, A.A., Gonzalez, E.A., Martin, K.J., & Gellens, M.E. (2004). Achieving K/DOQI laboratory target values for bone and mineral metabolism: An uphill battle. American Journal of Nephrology, 24, 422-426.
Arenas, M.D., Alvarez-Ude, F., Gil, M.T., Soriano, A., Egea, J.J., Millan, I., et al. (2006). Application of NKF-K/DOQI clinical practice guidelines for bone metabolism and disease: Changes of clinical practice and their effects on outcomes and quality standards in three haemodialysis units. Nephrology Dialysis & Transplantation, 21(6), 1663-1668.
Burrows-Hudson, S., & Prowant, B.F. (Eds.). (2005). ANNA Nephrology nursing standards of practice and guidelines for care. Pitman, NJ: American Nephrology Nurses' Association.
Gonyea, J. (2003). Laboratory data evaluation: How does the renal dietitian interpret results? Nephrology Nursing Journal, 30(6), 666- 667.
Hartwell, L. (2002). Chronically happy: Joyful living in spite of chronic illness. San Francisco: Poetic Media Press.
Jenkins, J., Jones, A., Thomas, N., & Prichard, A. (2007). The "expert" renal patients: A CKD support programme. British Journal of Renal Medicine, 12(4), 33-34.
Joy, M.S., DeHart, R.M., Gilmartin, C., Hachey, D.M., Hudson, J.Q., Pruchnicki, M., et al. (2005). Clinical pharmacists as multidisciplinary health care providers in the management of CKD: A joint opinion by the nephrology and ambulatory care practice and research networks of the American College of Clinical Pharmacy. American Journal of Kidney Diseases, 45(6), 1105-1118.
Joy, M.S., Karagiannis, P.C., & Peyerl, F.W. (2007). Outcomes of secondary hyperparathyroidism in chronic kidney disease and the direct costs of treatment. Journal of Managed Care Pharmacy, 13(5), 397-411.
Kammerer, J., Garry, G., Hartigan, M., Carter, B., & Erlich, L. (2007). Adherence in patients on dialysis: strategies for success. Nephrology Nursing Journal, 34(5), 479-487.
Kerr, P.G., & Guerin, A.P. (2007). Arterial calcification and stiffness in chronic kidney disease. Clinical Experimental Pharmacology and Physiology, 34(7), 683-687.
Manley, H.J., Cannella, C.A., Bailie, G.R., & St. Peter, W.L. (2005). Medication-related problems in ambulatory hemodialysis patients: A pooled analysis. American Journal of Kidney Diseases, 46(4), 669-680.
McCann, L. (2005). K/DOQI practice guidelines for bone metabolism and disease in chronic kidney disease: Another opportunity for renal dietitians to take a leadership role in improving outcomes for patients with chronic kidney disease. Journal of Renal Nutrition, 15(2), 265-274.
National Association of Nephrology Technicians/Technologists. (2008). NANT bylaws. Retrieved January 10, 2008 from www.nant.biz/ store/article_info.php/articles_id/6
National Kidney Foundation. (NKF). (2003). Clinical practice guidelines for bone metabolism and disease in chronic kidney disease. American Journal of Kidney Diseases, 35(Suppl 2), S1-S202.
National Kidney Foundation. (NKF). (2008). Information for professionals. Retrieved January 10, 2008 from www.kidney.org/ professionals
Nguyen, T.V. (2007). The consultant pharmacist's role in dialysis: An introduction. Consultant Pharmacist, 22(12), 1035- 1044.
Pianta, T.F. (1999). The role of physical therapy in improving physical functioning of renal patients. Advances in Renal Replacement Therapy, 6(2), 149-158.
Raggi, P., Boulay, A., Chasan-Taber, S., Amin N., Dillon, M., Burke, S.K., et al. (2002). Cardiac calcification in adult hemodialysis patients. A link between end-stage renal disease and cardiovascular disease? Journal of the American College of Cardiology, 39, 695-701.
Reams, S.M. (2002). The T.E.A.M. approach. Nephrology Nursing Journal, 29(6), 604, 610.
Showers, D. (2004). Strategies to improve albumin in patients on peritoneal dialysis. Nephrology Nursing Journal, 31(5), 592-593.
Stehman-Breen, C.O., Sherrard, D.J., Alem, A.M., Gillen, D.L., Heckbert, S.R., Wong, C.S., et al. (2000). Risk factor for hip fracture among patients with end-stage renal disease. Kidney International, 58, 2200-2205.
Toussaint, N.D., & Kerr, P.G. (2007). Vascular calcification and arterial stiffness in chronic kidney disease: Implications and management. Nephrology, 12(5), 500-509.
Uwatoko, T., Toyoda, K., Inoue, T., Yasumori, K., Hirai, Y., Makihara, N., et al. (2007). Carotid artery calcification on multislice detector-row computed tomography. Cerebrovascular Diseases, 24(2), 20-26.
Young, E.W., Akiba, T., Albert, J., McCarthy, J.T., Kerry, T.G., Medelsshohn, D.C., et al. (2004). Magnitude and impact of abnormal mineral metabolism in hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). American Journal of Kidney Diseases, 44(Suppl 2), S34-S38.
Michelle Carver, BSN, RN, CNN, is the Home Dialysis Manager, The Dialysis Center of Lincoln, Inc., Lincoln, NE, and a Member of the Platte River Chapter of ANNA.
Jacqueline Carder, MS, RD, CDE, LMNT, is a Renal Dietitian and Exercise Coordinator, The Dialysis Center of Lincoln, Inc., Lincoln, NE.
Lori Hartwell is President and Founder, the Renal Support Network, Glendale, CA.
Mahiyar Arjomand, Pharm D , is a Senior Manager, Medical Communications, Amgen, Inc., Thousand Oaks, CA.
Author's Note: The authors would like to thank Michael Josbena, MS, RN, for providing medical writing assistance with funding provided by Amgen, Inc.
Copyright Anthony J. Jannetti, Inc. May/Jun 2008
(c) 2008 Nephrology Nursing Journal. Provided by ProQuest Information and Learning. All rights Reserved.