HealthPathway: Chronic Kidney Disease
Chronic kidney disease (CKD) is an important public health concern, one in three Australians are at risk of developing CKD. (1) The health pathway about CKD identifies red flags to recognize acute kidney injury over CKD. In CKD assessment the HealthPathway lists investigations to assess kidney function and diagnose CKD. Furthermore, under management it provides a guideline to categorize chronic kidney disease in stages using GFR and recommends management accordingly. Finally, under the referral section it warns about immediate nephrology assessment if red flags are identified or the patients are at high risk according to the list of criteria’s mentioned in the HealthPathway.
The existing prevention action in the HealthPathway includes lifestyle modifications such as smoking cessation, weight reduction, low salt diet and regular physical activity. These are conservative recommendations which are ideal first line strategies however the HealthPathway fails to provide details or step based approaches required to implement these strategies in CKD patients. Moreover, the HealthPathway includes actions suchas managing chronic conditions; hypertension, hyperlipidemia and diabetes and also toreplace and avoid nephrotoxic drugs. Both these actions are good suggestions to prevent the progression of CKD but are less likely to be classified as primary prevention to prevent the onset of CKD within the population.
b. Describe two additional actions to prevent further progression of the disease and/or to strengthen existing prevention actions in the pathway (i.e. what other actions are required?)
The first additional action to prevent further progression of chronic kidney disease among that population that can be included in the HealthPathway is preventing psychological distress and depression in patients. One in four patients diagnosed with CKD struggle with depression at anytime. Patients with CKD suffer from severe psychological distress especially during the early period of their diagnosis. There are biological, psychological and social factors identified in the context of CKD causing depression that impacts the patient's quality of life. Using multidisciplinary intervention, depression and psychological distress should be managed in CKD patients to improve clinical outcomes and their overall quality of life.
The second prevention action to add in the HealthPathway guideline for CKD is nutrition in the context of CKD. There is evidence that a detailed nutritional plan with a control of protein intake, is effective in correcting metabolic disorders including proteinuria. Inflammation is a common disorder in CKD and it can cause anorexia and catabolism and with reduced or inadequate nutritional intake it can result in increased mortality risk among CKD patients.
c. Comment on likely impact of the two additional actions on population health indicators: progression of the disease; disability rate; mortality; morbidity etc.
In literature there is an association between depression and morbidity and mortality in patients with chronic kidney disease. Studies show that CKD patients with moderate to severe depression requiring kidney transplant have poor clinical outcomes, requiring dialysis or having an increased risk of death during kidney transplants. CKD patients with depression have poor prognosis of their disease due to behavioral and medical factors.Identifying and treating psychological distress and depression in CKD patients on an individual level can improve behavioral factors such as adhering to strict fluid and dietary restrictions, compliance with medications, cooperating with the medical team to manage their condition, etc. All of which lead to better clinical outcome. On a population level, treating for depression can result in overall improvement of the elderly patients since CKD patients may have other comorbid conditions such as cardiovascular disease.
Nutrition plays a vital role in the disease progression of CKD patients. Studies show low protein diets can significantly decrease the decline of mild and moderate disease. Moreover, there are recommendations that therapeutic diets such as using protein from plant sources over animal sources can have additional benefits for CKD patients. This indicates that prescribing appropriate nutritional guidelines can have a significant impact on progression of CKD. The demographic at high risk of chronic kidney disease are of older age who are otherwise at high risk of malnutrition and frailty hence improved nutrition will have beneficial impact on the health of the population in this demographic.
The two actions I recommended to be included in the HealthPathway for chronic kidney disease patients is screening and managing depression and including nutritional recommendations that slow down the progression of decline in kidney function. Being diagnosed with chronic kidney disease has a significant impact on quality of life, having to be compliant with a long list of medications and be required to frequently visit hospitals. Evidence shows this has an affect on the mental health of patients and treating patients with a CKD diagnosis can help with better clinical outcomes. Chronic kidney disease causes a wide range of dysregulation in the body including fluid and electrolyte imbalance, hence the management for CKD requires strict monitoring of input and output to ensure good outcomes. Especially CKD patients on dialysis required diet control to limit buildup of waste in the body which cannot be eliminated due to declining kidney function. Evidence discusses the adverse outcomes in CKD patients with inadequate nutrition and also the positive clinical outcome of controlled diet. Hence adding nutritional guidelines in the HealthPathway for CKD is recommended.
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