Conservative management for patients with chronic kidney disease refusing dialysis

Novel Approaches in Chronic Renal Failure without Renal Replacement Therapy: A Review

Chronic kidney disease (CKD) is characterized by renal parenchymal damage leading to a reduction in the glomerular filtration rate. The inflammatory response plays a pivotal role in the tissue damage contributing to renal failure. Current therapeutic options encompass dietary control, mineral salt regulation, and management of blood pressure, blood glucose, and fatty acid levels. However, they do not effectively halt the progression of renal damage. This review critically examines novel therapeutic avenues aimed at ameliorating inflammation, mitigating extracellular matrix accumulation, and fostering renal tissue regeneration in the context of CKD. Understanding the mechanisms sustaining a proinflammatory and profibrotic state may offer the potential for targeted pharmacological interventions. This, in turn, could pave the way for combination therapies capable of reversing renal damage in CKD. The non-replacement phase of CKD currently faces a dearth of efficacious therapeutic options. Future directions encompass exploring vaptans as diuretics to inhibit water absorption, investigating antifibrotic agents, antioxidants, and exploring regenerative treatment modalities, such as stem cell therapy and novel probiotics. Moreover, this review identifies pharmaceutical agents capable of mitigating renal parenchymal damage attributed to CKD, targeting molecular-level signaling pathways (TGF-β, Smad, and Nrf2) that predominate in the inflammatory processes of renal fibrogenic cells.

POTENTIAL THERAPEUTIC OPTIONS TARGETING THE GUT DYSBIOSIS IN CHRONIC KIDNEY DISEASE

The gut microbiota plays an important physiological role in controlling not only the function of the gastrointestinal tract, but also in maintaining systemic homeostasis. Quantitative and /or qualitative disturbances of the gut microbiota (dysbiosis) are an important element in the complex pathogenesis of many diseases, including chronic kidney disease (CKD). In the disease, the mutual interactions between disturbed gut microbiota and the progression of CKD (pathophysiological "kidney-gut axis") have been demonstrated. The kidney failure causes water and nitrogen waste retention which leads to disturbances of motility, secretion and absorption in the gastrointestinal tract. These abnormalities contribute to the development of gut dysbiosis, accompanied by overproduction of toxic bacterial metabolites, with their translocation to the peripheral blood and development of endotoxemia. As a consequence, chronic kidney "low-grade" inflammation and oxidative stress develop, with further deterioration of kidney function in the mechanism of the "vicious cycle" of the kidney-gut axis. Considering the key role of gut dysbiosis and the kidney-gut axis, the attempts to restore the gut eubiosis seem to have an important role in the treatment of CKD and may be even regarded as a form of causal therapeutic intervention. The paper briefly discusses the basics of the pathophysiological kidney-gut axis in CKD and potential methods of modulating the abnormal gut microbiota in this disease, including the use of probiotic or prebiotic preparations, agents that absorb bacterial-derived toxins in the intestinal lumen, fecal microbiota transplantation and drugs used so far for other indications (acarbose, meclofenamate, lubiprostone).

Urinary tract infection in patients with chronic kidney disease under conservative treatment

OBJECTIVES

to assess the prevalence and associated risk factors for urinary tract infection in patients with chronic kidney disease under conservative treatment and identify the microorganisms isolated in the urine of these patients and the staging of chronic kidney disease.

METHODS

a cross-sectional, analytical study carried out at the Conservative Treatment Outpatient Clinic of a university hospital in the city of São Paulo.

RESULTS

the prevalence of urinary tract infection is 22%. The risk factors Diabetes Mellitus, hypertension, heart disease, neoplasms and thyroid and autoimmune diseases stand out in the infected group (p < 0.001). Most of the microorganisms found in urine cultures (87.9%) were Gram-negative, being Escherichia coli (50.70%), followed by Klebsiella pneumoniae (23.1%) and Enterococcus spp. (9.7%).

CONCLUSIONS

the findings of this investigation reveal the intrinsic association between risk factors and microorganisms for the development of urinary tract infection.

Validation of Nursing Diagnoses for people with chronic kidney conditions on conservative treatment

OBJECTIVE

To develop and validate Nursing Diagnoses statements of the International Classification for Nursing Practice (ICNP®) aimed at the care of people with chronic kidney conditions undergoing conservative treatment.

METHOD

This is a methodological research structured in sequenced construction stages, cross-mapping, content validation by the Delphi Technique by specialist nurses, and categorization of Nursing Diagnoses.

RESULTS

Forty-two specialist nurses participated in the first round and 34 in the second. A total of 179 Nursing Diagnoses statements were prepared, categorized according to Roy's adaptation model, of which 160 were validated for content, with Content Validity Index ≥ 0.80.

CONCLUSION

The Diagnoses developed and validated show the modes of adaptation to health of people with chronic kidney conditions undergoing conservative treatment, influenced by biological, psychological, social, and cultural needs, with the Physiological Mode being the most prevalent.

Management of Kidney Failure in Patients with Diabetes Mellitus: What Are the Best Options?

Diabetic kidney disease (DKD) is the most frequent cause of kidney failure (KF). There are large variations in the incidence rates of kidney replacement therapy (KRT). Late referral to nephrology services has been associated with an increased risk of adverse outcomes. In many countries, when patients reach severely reduced glomerular filtration rate (GFR), they are managed by multidisciplinary teams led by nephrologists. In these clinics, efforts will continue to halt chronic kidney disease (CKD) progression and to prevent cardiovascular mortality and morbidity. In patients with diabetes and severely reduced GFR and KF, treating hyperglycemia is a challenge, since some drugs are contraindicated and most of them require dose adjustments. Even more, a decision-making process will help in deciding whether the patient would prefer comprehensive conservative care or KRT. On many occasions, this decision will be conditioned by diabetes mellitus itself. Effective education should cover the necessary information for the patient and family to answer these questions: 1. Should I go for KRT or not? 2. If the answer is KRT, dialysis and/or transplantation? 3. Dialysis at home or in center? 4. If dialysis at home, peritoneal dialysis or home hemodialysis? 5. If transplantation is desired, discuss the options of whether the donation would be from a living or deceased donor. This review addresses the determinant factors with an impact on DKD, aiming to shed light on the specific needs that arise in the management and recommendations on how to achieve a comprehensive approach to the diabetic patient with chronic kidney disease.

Terms of specialized nursing language for chronic renal patients undergoing conservative treatment

OBJECTIVES

to validate the terms of the specialized nursing language used in the care of people with chronic kidney disease undergoing conservative treatment identified in the literature by mapping them with terms of the International Classification for Nursing Practice, version 2019, and representing them by means of a mandala.

METHODS

descriptive, documentary and methodological study. The terms were collected in 53 scientific articles, standardized and mapped with the terminology. The validation was performed by six nurses through a focus group. The Content Validity Index was used and terms with a value ≥ 0.80 were validated.

RESULTS

the normalization resulted in 957 relevant terms, of which 499 were constant and 458 not included in the terminology. Terms were validated when Content Validity Index was between 0.86 and 1.0.

CONCLUSIONS

the study allowed the validation of terms that will contribute to unify the professional language of nursing in the care of people with chronic kidney disease.

Senses and Meanings of Conservative Treatment in People with Chronic Kidney Disease

Objective: To unveil the senses and meanings of conservative treatment in people with chronic kidney disease (CKD). Materials and Methods: A descriptive and exploratory study with a qualitative approach. It was developed in 2017, with a sample of individuals with CKD undergoing conservative treatment. A semi-structured interview was used and the data were analyzed using simple descriptive statistics and content analysis. Results: 25 individuals participated in the study, of which 56 % were female; 52 % belonged to the 60-79-year-old age group; 48 % were white-skinned; 48 % did not complete elementary school; and only 12 % worked. Content analysis revealed two categories: food restriction: anguishes and impacts that affect the daily lives of patients with CKD and the social imaginary and fear related to renal replacement therapy. Conclusions: The results revealed that diet and fear about dialysis therapy produce uncertainty, anxiety, and insecurity, in addition to a wide and impacting change in people’s lives.

Contextos de experiência de estar (des)confortável de pacientes com doença renal crônica

Resumo Objetivo estabelecer os contextos da experiência de estar (des)confortável, conforme percepções de pacientes com doença renal crônica, durante tratamento hemodialítico. Método estudo qualitativo, realizado em clínica de hemodiálise, entre maio e junho de 2018, com 30 pacientes com doença renal crônica, em tratamento hemodialítico, capazes de comunicar-se verbalmente. Utilizou-se da entrevista semiestruturada, com perguntas norteadoras que buscaram elucidar os contextos de experiência de sentir-se e estar confortável, baseadas no referencial teórico de Kolcaba. Dados submetidos à análise de conteúdo temática. Resultados emergiram quatro categorias analíticas, no tocante aos contextos de (des)conforto: físicos (imobilidade, hipotensão, dor, fome, cãibra, cansaço, poliúria, prurido, edema, sede); ambientais (luz, barulho, cadeira, frio); psicoespirituais (desespero, sensibilidade, isolamento social); e sociais (mudança de rotina). Considerações finais o significado do conforto para pacientes em tratamento hemodialítico se configurou como necessidade humana básica, pois os pacientes apresentaram desconfortos diários relacionados aos contextos físicos, ambientais, psicoespirituais e sociais. Implicações para a prática os resultados do estudo possibilitam que profissionais de saúde realizem assistência ao paciente renal crônico de forma holística, pautada na promoção do conforto.