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Chronic kidney disease:risk factors, assessment and nursing care

NS368 Redmond A, McClelland H (2006) Chronic kidney disease: risk factors, assessment and nursing care. Nursing Standard. 20, 10, 48-55. Date of acceptance: October 13 2006.

Summary
This article provides an overview of chronic kidney disease in adults and outlines nursing management in primary and secondary care. Patient assessment, including the stages of chronic kidney disease, common causes and risk factors, are also discussed.

Introduction
Chronic kidney disease, also called chronic renal failure, leads to permanent loss of kidney function (Weller 2000) and can result from damage to the kidney tissue. Chronic kidney disease can progress to established renal failure either rapidly, over a period of months, or slowly over many years (Stein et al 2004). It cannot be cured, but there are interventions that can slow its progress and improve symptoms. Chronic kidney disease is common and associated with increased risk of cardiovascular events. Established renal failure, however, is rare compared with ischaemic heart disease, diabetes and cancer (Stein et al 2004), and renal replacement therapies, such as dialysis or transplantation, are expensive. The UK Renal Registry (2005) reported that in 2004 an estimated 37,800 adult patients received renal replacement therapy, equating to a prevalence of 638 patients per million population. In the UK it is predicted that there will be an increase in demand for renal replacement therapies of 4.5 per cent to 6 per cent until 2010 (Roderick et al 2004), with demand not levelling off for at least 25 years. However, not all patients will progress to established renal failure requiring renal replacement therapy and it is expected that early treatment interventions for chronic kidney disease will delay, if not prevent, progression to established renal failure (Lameire et al 2005). Chronic kidney disease is therefore a major public health issue. Part two of The National Service Framework (NSF) for Renal Services (Department of Health (DH) 2005) recommends that chronic kidney disease is identified and managed in primary and secondary care to help delay the disease progress NURSING STANDARD

Authors
Avril Redmond is clinical education facilitator; Heather McClelland is team leader, haemodialysis unit, Belfast City Hospital, Belfast. Email: avril.redmond@bch.n-i.nhs.uk

Keywords
Chronic illness; Chronic renal failure; Kidney disease; Nursing care These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords.

Aims and intended learning outcomes

The aim of this article is to provide an overview of chronic kidney disease. After reading this article you should be able to: Describe the excretory and secretory functions of the kidneys. Identify the tests and investigations that can help to diagnose renal impairment and assess renal function. Discuss the measures required to reduce cardiovascular risks in patients with chronic kidney disease. Understand the management of patients with chronic kidney disease and the nurses role in patient management. 48 november 15 :: vol 21 no 10 :: 2006

and avoid secondary complications. Chronic kidney disease was awarded 27 points in the clinical domain against a set of evidence-based indicators totalling a maximum of 655 points in the Quality and Outcomes Framework (DH 2003) from April 2006. The framework is a component of the General Medical Services contract for general practices, introduced on April 1 2004. The Quality and Outcomes Framework rewards practices for the provision of quality care, and helps to fund further improvements in the delivery of clinical care (DH 2003). Nurses and medical staff in primary and secondary care are important to the education, identification and monitoring of high-risk patients.

identifiable cause of established renal failure in Europe and the US, with the percentage of patients on renal replacement therapy who have diabetes doubling over the past 20 years (Levy et al 2001).

Stages of chronic kidney disease

Identification of the stages allows for early intervention to reduce cardiovascular risk, slow progression and avoid the need for dialysis. Serum creatinine measurement is a traditional marker of renal function and is calculated at the rate of production of creatinine, which is dependent on muscle mass and the rate at which the kidney excretes creatinine (Thomas et al 2006). Glomerular filtration rate (GFR) is the best measure of overall kidney function and FIGURE 1 Longitudinal section of the kidney

Time out 1
Before reading on, revise the anatomy and physiology of the kidneys using a general anatomy and physiology textbook.

Anatomy and physiology

The kidneys are two bean-shaped organs positioned retroperitoneally in the posterior abdominal wall at the level of the upper lumbar vertebrae (Figure 1). The nephron is the functional unit of the kidney each kidney contains about one million nephrons (Marieb 2004). The kidneys have a number of functions, including regulation of the volume and composition of body fluids within narrow limits (Field et al 2001). The functions of the kidney are summarised in Box 1.

Medulla

Cortex

Renal pyramids Renal artery Renal vein

Renal pelvis Ureter

Epidemiology
Data are limited on the extent of chronic kidney disease in the general population, but surveys have indicated that up to 11 per cent of the United States adult population could have some degree of chronic kidney disease (Coresh et al 2003). Although not all patients with chronic kidney disease will require renal replacement therapy, their renal function will require lifelong monitoring. Optimal management of cardiovascular risk factors reduces the risk of progression from early chronic kidney disease to established renal failure. Patients with established renal failure require treatment with dialysis or a kidney transplant to survive (Sehgal et al 1992). The mortality of patients with established renal failure is high relative to the general population, with 79 per cent of patients in the UK still alive at the end of their first year of renal replacement therapy 90 per cent of those are under the age of 45 years. This declines to only 48 per cent after four years of treatment (Kimmel 2001). Diabetes mellitus is now the most common NURSING STANDARD

Papilla

BOX 1 Functions of the kidney

Excretion Removal of the waste products of metabolism: urea and creatinine. Removal of excess fluid: concentration and dilution of urine. Regulation of acid-base balance: excretion of hydrogen ions and conservation of bicarbonate ions. Regulation of electrolyte levels, for example, potassium. Secretion Regulation of blood pressure: renin-angiotensin mechanism. Regulation of red blood cell production: erythropoietin. Regulation of calcium metabolism: activated vitamin D.
(Adapted from Thomas 2002)

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progression of renal failure. GFR is the volume of water filtered out of the plasma through the glomerular capillary walls into the Bowmans capsules per unit of time. The GFR in healthy young adults is approximately 100ml/min/1.73m2. GFR only becomes significant if it falls to approximately 15ml/min/1.73m2, when patients develop uraemic symptoms (Marshall 2002). Modifications in laboratory testing can now estimate the GFR (eGFR), based on a persons serum creatinine and taking into account differences in gender, muscle mass, age and ethnicity. The eGFR is becoming a more important measure of renal function than serum creatinine. It makes it easier for physicians to appropriately refer patients for specialist investigations and treatments. The reporting of eGFR will enable GPs to create a register of patients with differing stages of chronic kidney disease. Part two of the NSF for Renal Services (DH 2005) recommends that local health organisations and pathology services develop protocols to report kidney function using eGFR. Information on eGFR calculations is available at: www.renal.org/eGFR/eguide.html Table 1 shows the relationship between eGFR, the stages of kidney disease and the suggested frequency of eGFR testing to be adopted. The chronic kidney disease staging system recognises that patients with progressive renal failure follow a number of stages before reaching established renal failure and the need for renal replacement therapy. TABLE 1 Stages of chronic kidney disease: a clinical action plan
Stage Stage 1 Chronic kidney disease with normal GFR Stage 2 Mild chronic kidney disease with decrease in GFR Stage 3 Moderate chronic kidney disease Stage 4 Severe chronic kidney disease Stage 5 Established renal failure eGFR (ml/min/1.73m2) >90 Management/action

Most patients with stages 1 to 3 chronic kidney disease will be asymptomatic and few will require dialysis. Those at most risk of progression of kidney disease will have higher blood pressure, more proteinuria and are at increased risk of cardiovascular events and premature death.

Assessment of renal function

Screening for renal disease when patients attend the GP, practice nurse or on admission to hospital can help identify high risk asymptomatic patients with chronic kidney disease at stages 1 to 3 and allow for the timely introduction of treatment to prevent progression and reduce cardiovascular risk (Levy et al 2006). The following tests and investigations can assist healthcare professionals to diagnose renal impairment and assess renal function.

Time out 2
Urinalysis is an important indicator of urine abnormalities. List the specific indicators for urine abnormalities on urinalysis that might suggest the patient has renal impairment. Urinalysis Urinalysis assesses the appearance, quantity and chemical characteristics of urine, as well as microscopy to identify formed elements (cells, casts, crystals and bacteria). The urine dipstick has a long-established role as a tool for diagnosing renal disease specifically when proteinuria and/or haematuria is present (Box 2). Urinary protein excretion This has traditionally been measured using 24-hour urine collection.

Frequency of eGFR testing Annual

Diagnose and treat underlying cause, treat co-morbid conditions, slow progression by controlling blood pressure and reducing cardiovascular risk. Control blood glucose and reduce proteinuria. As for stage 1 and estimate progression

60-89

Annual

30-59

Prevent and treat complications

Six monthly

15-29

Prepare for renal replacement therapy (dialysis or transplantation)

Three monthly Three monthly

<15 or on dialysis Start renal replacement therapy

eGFR = estimated glomerular filtration rate

(Adapted from National Kidney Foundation 2002, Joint Specialty Committee 2006, Levy et al 2006)

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This is often inconvenient for patients, frequently incomplete and therefore an underestimation of total urinary protein excretion. It is being replaced by the albumin-creatinine ratio (ACR) or protein-creatinine ratio (PCR) performed on a spot urine sample. A protein-creatinine ratio greater than 45mg/mmol or albumin-creatine ratio greater than 30mg/mmol should be considered as positive tests for proteinuria (Joint Specialty Committee 2006). Both conditions are associated with increased cardiovascular risk. Progression of renal failure is more common in patients with increased proteinuria. Renal imaging Ultrasound scanning is a non-invasive technique used to determine the presence, size and shape of the kidney, its position and the presence of cysts or neoplasm. It is also used to exclude any renal obstruction and guide the operator in renal biopsy procedures. All patients with chronic kidney disease stages 4 and 5 should undergo ultrasound scanning. Patients with chronic kidney disease stages 1 to 3 should have an ultrasound if they have lower urinary tract symptoms or a falling eGFR. Renal biopsy Renal biopsy is an invasive procedure where a small core of kidney tissue is removed with a special biopsy needle and sent to the laboratory for histological analysis. This may provide a definitive diagnosis to assist in patient management or indicate a prognosis for the disease process (Bradley and Smith 1999). In chronic kidney disease with significant proteinuria, biopsy may be justified to assist with decisions on immunosuppressive regimens (Tomson 2003). BOX 2 Urinalysis
Characteristic pH Protein Analysis of result

Baseline investigations and assessment for the different stages of chronic kidney disease are outlined in Table 2.

Time out 3
Wilma is a diabetic patient who has attended the GP because of lethargy and oedema. The GP has requested blood tests as he suspects that Wilma may have some degree of renal impairment. In the light of what you have read, discuss with Wilma the rationale for these tests.

Common causes of chronic kidney disease

Most renal diseases fall into six categories (UK Renal Registry 2005): Systemic disease this may include generalised diseases such as systemic lupus erythematosus and vasculitis. Diabetes mellitus is the most common cause of about 20 per cent of renal disease in most countries. Progressive kidney damage may begin after many years of poorly controlled high blood pressure and blood glucose. High blood pressure hypertension damages the kidneys, but this damage can be halted or reversed in some cases by early detection and appropriate treatment regimens. Hypertension is the most common cause of renal failure in patients of African origin. Autoimmune disease glomerulonephritis

Healthy urine usually has a pH of between 5 and 6. A pH of 8 may indicate renal tubular acidosis, or urinary tract infection (UTI) with ammonia-forming organisms. Protein in urine is a manifestation of renal disease and is identified as a risk factor for cardiovascular disease. Normal urine protein excretion is less than 150mg/day or less than 140mg/m2 in children. Routine urinalysis only detects albumin (macroalbuminuria). Microalbuminaria, which is not detected by usual dipstick testing, is also an indicator of renal disease.

Haematuria

The presence of blood in the urine is commonly caused by infection, glomerulonephritis or malignancy in the urinary tract (Levy et al 2006). Urinalysis enables estimation of the degree of haematuria.

Glucose Microscopy

The presence of glucose may indicate diabetes mellitus. This should be performed to confirm the presence of red blood cells. Misshapen or dysmorphic red blood cells may indicate glomerular haematuria. Red cell casts may indicate glomerulonephritis. High levels of leucocytes may indicate a UTI.

(Adapted from Johnson and Feehally 1999, Thomas 2002, Levy et al 2006)

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describes a group of diseases in which the glomeruli (capillaries within the nephron) are damaged by the bodys immunological response to tissue changes or infections. All forms of nephritis account for about 30 per cent of renal failure in Britain. Obstruction anything that causes an obstruction to the free flow of urine within the kidneys and renal tract can cause back pressure in the kidneys. Enlarged prostrate is the most common cause of obstruction in older men. Urine infections infections of urine caused by renal calculi, obstruction or abnormalities of the urinary tract can result in scarring of the kidney and eventual kidney failure Genetic disease polycystic kidney disease and other rare genetic diseases account for 8 per cent of kidney failure in Britain. Although present from birth, polycystic kidney disease often does not cause symptoms until middle age or later.

Risk factors for chronic kidney disease

Patients who are at most risk of developing chronic kidney disease are older patients and those with diabetes mellitus, hypertension, TABLE 2

vascular disease, a family medical history of chronic kidney disease and recovery from acute renal failure (DH 2005). Primary care providers, GPs and practice nurses are important in the monitoring and evaluation of at-risk patients. Diabetes Diabetes mellitus is the most common cause of chronic kidney disease worldwide (Burrows-Hudson 2005, Levy et al 2006). Chronic kidney disease is increasing in patients with diabetes because they are living longer, the complications of diabetes are better controlled and patients are now routinely accepted onto dialysis programmes from which they were previously excluded. There is great variation in the incidence of diabetes among racial and ethnic groups, with people of South Asian, African, African-Caribbean and Middle Eastern descent having a higher than average risk of type 2 diabetes (DH 2001). Research studies indicate that intensive glycaemic control reduces the rate of micro and macroalbuminuria and the manifestations of diabetic nephropathy (Gross et al 2005). Persistent hyperglycaemia results in thickening of the basement membranes and accumulation of proteins in the glomeruli (Levy et al 2006). Improvement in blood glucose control may reduce the risk of patients with diabetes developing cardiovascular disease and microvascular complications (DH 2001). Progression of renal failure in diabetic patients can be delayed, and in some cases

Baseline investigations and assessment for chronic kidney disease

Chronic kidney disease stage Stages 1-2 eGFR greater than 90ml/min/1.73m2 but not less than 60ml/min/1.73m2 plus albuminuria or haematuria Stages 3-5 eGFR less than 60ml/min/1.73m2 Baseline investigations Annual urea and electrolytes including eGFR. Annual urine ACR or PCR. Annual blood pressure. Assessment Regular clinical and laboratory assessment. Advice on lifestyle modifications.

Random urine ACR or PCR. Blood pressure. Dipstick urinalysis for haematuria and proteinuria as baseline. Blood glucose. Cholesterol. Full blood count. Urea and electrolytes including eGFR. Parathyroid hormone level.

Exclude acute renal failure. Review previous creatinine and eGFR results. Review medication, particularly non-steroidal anti-inflammatory drugs. Assess clinically for: urinary symptoms, heart failure, hypovolaemia, sepsis, palpable bladder, oedema. Immunise against influenza, pneumococcus and hepatitis B.

ACR = albumin-creatinine ratio; eGFR = estimated glomerular filtration rate; PCR = protein-creatinine ratio
(Adapted from Clinical Resource Efficiency Support Team 2006, Royal College of General Practitioners 2006)

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prevented, by effective blood pressure control and the reduction of proteinuria. Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) can delay the onset of diabetic nephropathy in patients with diabetes who have microalbuminuria (DH 2001). ACE inhibitors and ARBs also provide some protection to the kidney tissue of at-risk patients. However, patients taking these medications should be monitored closely because in the first few weeks of beginning an ACE inhibitor, serum creatinine levels may rise by as much as 30 per cent (Holcomb 2005). It is widely recommended that patients with diabetes mellitus undergo a minimum of annual testing for microalbuminuria (Kissmeyer et al 1999, National Institute for Clinical Excellence (NICE) 2002). Hypertension Hypertension is the most common chronic disease in the Western world. By the age of 60 years, more than 50 per cent of the population will have developed high blood pressure (Levy et al 2006). In adults aged 18 years and over, optimal blood pressure is defined as 120/80mmHg, while blood pressure greater than 140/90mmHg is defined as hypertensive (Hricik et al 1999). The Renal Association recommends blood pressure targets of 125/75mmHg for patients with progressive kidney disease and 130/80mmHg for those with stable renal function (Renal Association 2002). Cardiovascular risk Cardiovascular disease is the most common cause of death in patients with chronic kidney disease and established renal failure (Kundhal and Lok 2005). Prompt recognition and treatment are essential because cardiovascular disease including coronary artery disease, atherosclerosis, stroke and left ventricular hypertrophy generally begins in the early stages of chronic kidney disease. Risk reduction measures to prevent cardiovascular disease may also delay the onset and progression of kidney disease (McCarley and Salai 2005). Lifestyle modifications as well as appropriate medical interventions are important for the management of patients with chronic kidney disease and cardiovascular disease (Box 3). Nurses have a pivotal role in the monitoring, education and management of this group of patients.

Symptoms of chronic kidney disease

The clinical symptoms of chronic kidney disease often do not become apparent until renal failure is well advanced (Levy et al 2006). Patients can be asymptomatic even at stage 5 of chronic kidney disease. Early recognition and ongoing assessment of known risk factors are therefore essential (Burrows-Hudson 2005). Patients attending the GP practice or hospital may present with one or more symptoms (Box 4). Healthcare professionals BOX 3 Management of chronic kidney disease
Health issue/condition Smoking Hypertension Target and/or treatment Cessation Reduce blood pressure to less than 140/90mmHg (NICE 2006) or below 130/80mmHg (Renal Association 2002). Introduction of inhibitors to slow progression of renal failure Reduce glycosylated haemoglobin (HbA1c) to 6.5-7.5 per cent Appropriate dietary advice and aim for a body mass index of 18.5-24.9 Encourage regular aerobic activity Use of statins to reduce cholesterol to less than 5mmol/l No more than three units a day for men No more than two units a day for women Less than 100mmol/day Increase haemoglobin to more than 10g/dl with iron and erythropoiesis stimulating agent Control blood pressure, treat anaemia Serum phosphate should be less than 1.9mmol/l Reduce parathyroid hormone to less than 200pg/ml with phosphate binder and vitamin D analogue Improve nutritional/calorie intake

Diabetes Obesity Physical inactivity Cholesterol Alcohol Dietary salt Anaemia Left ventricular hypertrophy Hyperphosphataemia Hyperparathyroidism

Malnutrition

(Adapted from Renal Association 2002, UK Renal Registry 2005, Levy et al 2006)

BOX 4 Symptoms of chronic kidney disease

Time out 4
Bill, who is 46, is obese and has hypertension. He is at risk of developing chronic kidney disease and cardiovascular disease. What advice would you give Bill with regard to modification of his lifestyle, medications and diet? NURSING STANDARD

Fatigue Weight loss Loss of appetite Nausea and/or vomiting Peripheral ankle oedema Change in sleep pattern

Change in urination reduced volume/increased frequency/nocturia Headaches Pruritus Difficulties with memory or concentration

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should be mindful of these symptoms when initiating investigations for chronic kidney disease.

Nursing care
Part two of the NSF for Renal Services (DH 2005) recommends that the identification and management of early chronic kidney disease are the BOX 5 Nursing care for patients with chronic kidney disease
Disease stage Stage 1 Nursing plan of patient care

responsibility of primary and secondary healthcare professionals (Thomas et al 2006). Nurses in both care settings have an important role, not only in the identification and management of these patients, but also in the education of patients about chronic kidney disease and lifestyle modifications. Evidence suggests that nurses can improve chronic care by communicating effectively with patients and helping them to understand their illness and concordance with medication and treatment regimens (Bodenheimer et al 2005). Information leaflets produced by, for example, the National

Identify and treat specific causes of chronic kidney disease Assess for cardiovascular risk factors, which might cause rapid decline in eGFR Vigilant monitoring of blood pressure Good glucose control Monitor weight and instigate weight management plans Monitor cholesterol levels Annual eGFR Annual urine PCR or ACR (if dipstick protein present) Good glucose control Monitor and treat blood pressure Encourage patients with self-management strategies Encourage patients with lifestyle modifications Monitor cholesterol levels Annual eGFR Concordance with medications Good blood pressure control Six monthly eGFR Six monthly blood tests to include haemoglobin, potassium, calcium and phosphate Routine referral to nephrology services if progressive fall in eGFR, microscopic haematuria present, uncontrolled blood pressure, urinary PCR 45mg/mmol or ACR >30mg/mmol Immunise against influenza and pneumococcus Review all medications ensure correct dose Avoid nephrotoxic drugs, for example, non-steroidal anti-inflammatory drugs Provide information to enable patients to make informed choice about renal replacement therapy and conservative management Dietary advice to prevent malnutrition Psychological support Three monthly eGFR Three monthly blood tests as stage 3, also bicarbonate and parathyroid hormone level Immunisation against hepatitis B Assist patients to prepare for renal replacement therapy or conservative management Liaise effectively between primary and secondary care Provide timely access for dialysis treatments More intensive management of cardiovascular complications and bone disease Treat symptoms associated with established renal failure, that is, altered sleep pattern, itching, fatigue and loss of appetite Refer to dietician, social worker and pharmacist Manage and treat renal anaemia and renal bone disease As in stage 4 Commence renal replacement therapy or conservative management approach Prevent malnutrition Maintain adequacy of dialysis Promote general health and wellbeing

Stage 2

Stage 3

Stage 4

Stage 5

ACR = albumin-creatinine ratio; eGFR = estimated glomerular filtration rate; PCR = protein-creatinine ratio
(Joint Specialty Committee 2006)

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Kidney Federation (2006), can help patients to better understand chronic kidney disease. Box 5 summarises the nursing strategies to be used at each stage of chronic kidney disease whether patients are being treated in primary or secondary care.

Conclusion
Chronic kidney disease is a significant public health issue and challenge to healthcare professionals (Holcomb 2005). Many patients with stages 1 to 3 of chronic kidney disease are managed effectively in the community with minimal medical and nursing intervention and will rarely reach the latter stages of chronic kidney disease. By identifying those patients at

risk of developing chronic kidney disease and having effective management strategies in place, such as good glycaemic control, blood pressure and cholesterol control, it is likely that the progress of chronic kidney disease will be delayed. Nurses in primary and secondary care can help patients to understand chronic kidney disease, lifestyle modifications and concordance with medications NS

Time out 5
Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 60.

References
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Baillire Tindall, London. Thomas N, Coldstream F, Cox S et al (2006) Managing chronic kidney disease in the community. British Journal of Renal Medicine. 11, 1, 26-28. Tomson CR (2003) Indications for renal biopsy in chronic kidney disease. Clinical Medicine. 3, 6, 513-517. United Kingdom Renal Registry (2005) Eighth Annual Report. UK Renal Registry, Bristol. Weller BF (Ed) (2000) Baillires Nurses Dictionary. Twenty third edition. Baillire Tindall/Royal College of Nursing, London.

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