Medication Management for People with Kidney Disease

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By Tricia Patterson, BSN, RN

Hello AAKP members. My name is Tricia Patterson, BSN, RN. I had the pleasure of attending  the AAKP National Patient Meeting in Washington, DC in September and met many of you and heard some great lectures. I am a nephrology nurse and a member of the American Nephrology Nurses Association (ANNA). In recognition of “Talk about Your Medication Month”, I’m partnering with AAKP to blog about the importance of medication management. Since I donated a kidney three years ago, I am also a person with CKD who needs to carefully manage my labs and medications.

Please skip down to read the section for each type of kidney patient - CKD, dialysis or transplant:

Medication Management for People with CKD (Chronic Kidney Disease)

 

We all know that the kidneys are responsible for clearing toxins and fluids in the urine. But many people do not understand that the kidneys are also responsible for keeping the body in chemical balance. This is called homeostasis. For example, acid and base, potassium, calcium, and sodium are balanced by the kidneys. The kidneys have a hormone that helps with the blood levels for anemia.  In addition, the kidneys have a hormonal system for blood pressure control. When the kidneys are working well, they keep all of these things in balance every day, every hour, every minute. When the kidneys are not working well, the nephrologist (kidney doctor) works to manage homeostasis (your body’s chemical balance) by doing frequent lab checks to determine the right dose of all the medicines you need to get the values to the proper level and feel your best.

 

As people with CKD, we have a crucial role in keeping our bodies in balance. We should make sure that we schedule regular visits with our doctor(s) and make sure that the labs are drawn a few days before the visit to get the most accurate and timely results. It is important to fill new prescriptions right away and update your medication list, which should always be tucked inside your wallet. Many patients even find it convenient to store this information on their smart device or an app.  We all see multiple doctors, and each one should have an accurate updated list of your current medication, dosage and frequency. Over the counter medications (OTC) should be included on this list and should also be approved by your nephrologist before use.

 

For blood pressure management, it is helpful to your doctor if you keep a record of blood pressures every day so that the doctor can see trends and how you are responding to your BP meds. Record the morning BP 30 to 60 minutes after taking the BP medications, and take another reading before bed. Blood pressure that is too low is dangerous too, so call the doctor if you see pressures below 110/70.

 

For high phosphorus there are several medications called “binders” that are to be taken with the first bite of food at each meal to bind the excess phosphorus from the foods we eat that your body will not be able to get rid of, due to your kidney disease. The phosphorus is then excreted in the stool. Some of these pills should be kept in a small pill bottle that travels with you everywhere so you don’t forget to take it with your meals.

 

For high potassium (also known as hyperkalemia) there are medications that are mixed with water and should be taken every day as a maintenance medication. Lab results that show potassium at normal level means that the medicine is working, it does not mean it is time to stop taking the potassium binder. The level would creep back up. Your doctor will stop the medication only if your levels drop below normal.

 

For anemia some people with CKD will need to take a synthetic version of a kidney hormone that signals the bone marrow to make new red blood cells. This medicine is given as a small injection under the skin once every two weeks. Frequent lab draws are required to keep the dose at the correct level. 

 

 

Medication Management for People with ESRD (End Stage Renal Disease) on Dialysis

We all know that the kidneys are responsible for clearing toxins and fluids in the urine. But many people do not understand that the kidneys are responsible for keeping the body in chemical balance. This is called homeostasis. For example, acid and base, potassium, calcium, and sodium are balanced by the kidneys. The kidneys have a hormone that helps with the blood levels for anemia.  In addition, the kidneys have a hormonal system for blood pressure control. When the kidneys are working well, they keep all of these things in balance every day, every hour, every minute. When the kidneys are not working well, the nephrologist (your kidney doctor) works to manage homeostasis (your body’s chemical balance) by doing frequent lab checks to determine the right dose of all the medicines needed to get the values to the proper level and feel your best.

As people with ESRD, you have a crucial role in keeping your bodies in balance. Dialysis will remove some fluids, but it is less stressful to your body when less fluid is removed during dialysis. That is why the staff at dialysis is frequently reminding you to limit fluid intake and sodium in foods. In the same way, managing your blood pressure with medications is better than the high and low peaks of pre and post dialysis blood pressures.  The nephrologist reviews the labs that are drawn at dialysis monthly and  will tweak your medications based on these results. It is important to fill new prescriptions right away and update your medication list, which should always be tucked inside your wallet. We all see multiple doctors, and each one should have an accurate updated list. Over the counter medications (OTC) should be included on the list and should also be approved by your nephrologist before use.

For blood pressure management, it is helpful to your doctor if you keep a record of blood pressures every day so that he can see trends and how you are responding to the BP meds. Record the morning BP 30 to 60 minutes after taking the BP medications, and take another reading before bed. Blood pressure that is too low is dangerous too, so call the doctor if you see pressures below 110/70.

For high phosphorus there are several medications called “binders” that are to be taken with the first bite of food at each meal to bind the phosphorus from the foods we eat. The phosphorus is then excreted in the stool. Some of these pills should be kept in a small pill bottle that travels with you everywhere.  When phosphorus levels get too high in the blood, the phosphorus binds with calcium in the blood to form little “pebbles” of a material that is hard like your teeth. These phosphorus-calcium pebbles lodge in every little fork in the blood stream. The pebbles can build up and cause a blockage in crucial places like the heart muscle. Phosphorus binders work to prevent that buildup, but the medicine is not able to remove the old plaque buildup. I tell my patients that taking your binders every day is serious. Serious as a heart attack.

For high potassium there are medications that are mixed with water and should be taken every day as a maintenance medication. Lab results that show potassium in normal level means that the medicine is working, it does not mean it is time to stop taking the potassium binder. The level would creep back up. The doctor will stop the medication only if your levels drop below normal.

 

Medication Management for People with Kidney Transplants

We all know that the kidneys are responsible for clearing toxins and fluids in the urine. But many people do not understand that the kidneys are responsible for keeping the body in chemical balance. This is called homeostasis. For example, acid and base, potassium, calcium, and sodium are balanced by the kidneys. The kidneys have a hormone that helps with the blood levels for anemia.  In addition, the kidneys have a hormonal system for blood pressure control. When the kidneys are working well, they keep all of these things in balance every day, every hour, every minute. When the kidneys are not working well, the nephrologist (kidney doctor)works to manage homeostasis(your body’s chemical balance) by doing frequent lab checks to determine the right dose of all the medicines needed to get the values to the proper level and feel your best.

As people with CKD, we have a crucial role in keeping our bodies in homeostasis. We should make sure that we schedule regular visits with the nephrologist and make sure that the labs are drawn a few days before the visit. It is important to fill new prescriptions right away and update your medication list, which should always be tucked inside your wallet.

For post-transplant medications, it is required to have frequent lab tests to monitor the medication levels in your blood. Levels that are too low cause a risk of organ rejection, and levels that are too high are a risk of poisoning. Be sure to have your labs drawn on the dates ordered. You should have access to your lab results online and be educated on what levels are normal for you.  

For blood pressure management, it is helpful to your doctor if you keep a record of blood pressures every day so that the doctor can see trends and how you are responding to the BP meds. Record the morning BP 30 to 60 minutes after taking the BP medications, and take another reading before bed. Blood pressure that is too low is dangerous too, so call the doctor if you see pressures below 110/70.

For high phosphorus there are several medications called “binders” that are to be taken with the first bite of food at each meal to bind the phosphorus from the foods we eat. The phosphorus is then excreted in the stool. Some of these pills should be kept in a small pill bottle that travels with you everywhere. When phosphorus levels get too high in the blood, the phosphorus binds with calcium in the blood to form little “pebbles” of a material that is hard like your teeth. These phosphorus-calcium pebbles lodge in every little fork in the blood stream. The pebbles can build up and cause a blockage in crucial places like the heart muscle. Phosphorus binders work to prevent that buildup, but the medicine is not able to remove the old plaque buildup. I tell my patients that taking your binders every day is serious. Serious as a heart attack.

For anemia some people with CKD will need to take a synthetic version of a kidney hormone that signals the bone marrow to make new red blood cells. This medicine is given as a small injection under the skin once every two weeks. Frequent lab draws are required to keep the dose at the correct level. 

I hope these few tips were helpful. Stay healthy! 

 

 

 

 

 

Tricia Patterson, BSN, RN is a CKD Nephrology Nurse, Annapolis Nephrology Associates, Annapolis Maryland.  She spent seven years as Peritoneal Dialysis Nurse.  She is a Home Therapies Specialty Practice Network Lead for American Nephrology Nurses Association (ANNA).  She has published two articles in Nephrology Nursing Journal and was a presenter at national ANNA conference in 2018, 2019.

 

 

 

 

 

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Ask the Doc: The Flu Shot


Admin

By Stephen Z. Fadem, MD, FASN, AAKP Medical Advisory Board Chairman

While in most circumstances, the flu (influenza) is a mild seasonal infection that is characterized by fever, achiness, discomfort with a headache, cough and runny nose, it can be more serious, particularly in people who are at greater risk.

This risk population includes dialysis and kidney patients, patients with other health problems like chronic lung, heart, liver or hematologic diseases, as well as those over 50 years of age. At-risk populations also include those who are immunocompromised, children under 5 years of age, and women who are pregnant. Healthcare workers who commonly manage high-risk patients should also receive the vaccine to help further protect those they care for.  The disease is of concern because it can spread rapidly through a dialysis unit, hospital, clinic, nursing home or school and is spread by coughing and sneezing. It can also be spread by the hands. During flu season, we should all be extra vigilant in covering our mouths when coughing, and religiously sanitizing our hands. While most persons who have a seasonal flu illness may not require antiviral therapy, the disease should be treated with antiviral drugs in those with a severe clinical picture.

There are four types of seasonal flu, A, B, C and D but only the A and B viral strains are of public health importance. The flu vaccine is offered annually, around the time that flu season begins – usually around October. The National Influenza Centers and the World Health Organization monitor the many types of flu strains and then update their recommendations on which strains to target each flu season. They generally target the three most prevalent viral strains (trivalent vaccine – two A strains and one B virus) but may also target four strains (quadrivalent vaccine – two A viral strains and two B viral stains). This year’s Centers for Disease Control and Prevention (CDC) recommendations were published August 23, 2019 1. The flu vaccine is not recommended for those with a prior or known allergy to any component of the vaccine, including those with allergies to eggs, or to those who have had the Guillain-Barre syndrome in the past 6 weeks.

There are three vaccine types – the inactivated vaccine, the recombinant vaccine and the live attenuated (or live weakened) vaccine. The live attenuated vaccine is recommended for the high-risk or older population, including those undergoing dialysis. It is also recommended in healthcare workers who might come in contact with high-risk patients.

In 2009, a high dose vaccine was released, and there is also an adjuvanted vaccine (which means there is an ingredient added to a vaccine that helps create a stronger immune response to vaccination). The adjuvanted vaccine is designed to enhance immunity, while the high dose vaccine is stronger, and has been clinically studied. The high dose trivalent inactive vaccine was been shown to provide 22% better protection against developing the flu or in requiring a hospitalization in the age group over 652. It has also been studied in dialysis patients. During the 2016 season, those dialysis patients who received the high-dose trivalent inactivated flu vaccine had a significantly lower hospitalization rate3.

In summary, the flu shot is generally recommended for all persons over 6 months of age. In the dialysis population, the high dose trivalent vaccine has been shown so far to have the best results. While getting the flu shot may not guarantee that you will not receive one of the other strains of the virus, it does offer proven protection against significant illness and hospitalization.

References and Further Reading

  1. Grohskopf LA, Alyanak E, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2019-20 Influenza Season. MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports. 2019;68(3):1-21.
  2. Izurieta HS, Thadani N, Shay DK, Lu Y, Maurer A, Foppa IM, et al. Comparative effectiveness of high-dose versus standard-dose influenza vaccines in US residents aged 65 years and older from 2012 to 2013 using Medicare data: a retrospective cohort analysis. The Lancet Infectious diseases. 2015;15(3):293-300.
  3. Miskulin DC, Weiner DE, Tighiouart H, Lacson EK, Meyer KB, Dad T, et al. High-Dose Seasonal Influenza Vaccine in Patients Undergoing Dialysis. Clinical Journal of the American Society of Nephrology. 2018;13(11):1703.

 

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Dialysis Technicians – an important part of your health care team!

Admin

AAKP is celebrating National Dialysis Technician Recognition Week October 14 – 19, 2019.  Let’s learn more about the types of dialysis technicians, how they are educated to better help you throughout your care and how you can celebrate this week with YOUR special dialysis technician.

Kidney Disease by the Numbers

  • Kidney disease is the 9th leading cause of death in adults
  • More than 40 million Americans are living with kidney disease
  • More than 700,000 Americans have kidney failure and need dialysis or a kidney transplant to live
  • Approximately 850 million people worldwide have kidney disease

 

Hemodialysis is the far more common type of dialysis—about 90% of all dialysis patients.  During this process, as a patient, you likely got to know your dialysis technician as the individual who spends a great deal of time with you before, during and after each treatment.

There are two types of technicians in your dialysis clinic: the Biomedical Nephrology Technologist (BNT) is the individual responsible for maintaining the equipment used during your dialysis treatment.  A well-functioning dialysis machine is a key component of a successful dialysis treatment.  BNTs have specific training on the hemodialysis machines and water treatment and often have national certification that validates their grasp of a specific body of knowledge and best practices.

The Clinical Nephrology Technician (CNT) is the individual who stands watch over your treatment to ensure it stays on track.   Your CNT knows how to set the dialysis machine to meet the prescription your nephrologist has provided, mix the dialysate and ensure the water has been properly treated. The CNT is constantly monitoring treatments, recording your health information every 30 minutes and double and triple checking the safety measures during your treatment.  If there is a concern, the CNT will notify a nurse to further assess the treatment.  Even if you fall asleep during dialysis, your CNT remains on full alert.

Most in-center hemodialysis patients receive treatments at least three times a week for at least four hours a day.  Working with the same CNT means that s/he learns what best works for your care.  That means anomalies in your treatment can be spotted easily. Your CNT can see changes that indicate you need further assistance from other members of your health care team – and can make sure you get that care.

Your CNT knows that compassion is often the best medicine. Kidney disease is a chronic battle that touches many aspects of your life.  Your CNT has seen the worst aspects of kidney disease and how it can impact a patient physically, emotionally and psychologically.  Your CNT knows how to listen, understand and validate your concerns – all designed to help you have a better treatment.

Since 2012, CNTs are federally mandated to earn a nationally recognized dialysis technician certification.  Your CNT may have one of the following set of initials after their name: CHT, CCHT, CNCT, CCHT-A are some of the more common certification designations.  To earn the certification, a CNT must have a certain number of hours in training and successfully complete a comprehensive multiple-choice question exam.  Every three years, your CNT must be re-certified every 3 or 4 years by completing at least 30 hours of continuing education directly related to dialysis technology.  Technicians who do not re-certify are no longer allowed to work in a dialysis unit.

National Dialysis Technician Recognition Week is a great time to give thanks for those special technicians in your dialysis unit.  Here are some ideas of how you can show your gratitude:

  • Find out about which certification they hold – they worked hard for it and would enjoy sharing with you what they learned!
  • Ask if they are a member of the National Association of Nephrology Technicians/Technologists (NANT) – some technicians don’t yet know about how NANT can help them.  It’s easy to join – just go to www.DialysisTech.NET to learn more about it. NANT promotes education and advances the professional role of the multidisciplinary team in delivering the highest quality of care to the CKD patient. It provides educational opportunities, represents the nephrology technology professionals in the regulatory and legislative arena, encourages the development of nephrology professionals in leadership roles, and achieves recognition for the contribution of the nephrology technology practitioners to the total care of the CKD patient.
  • Give them a shout-out on Twitter.  Use one of these hashtags: #LoveMyNCTWeek / #LoveMyNBTWeek / #LoveMyDialysisTechWeek – let everyone know how happy you are that they help you keep healthy.

Want to know more?  Check out www.DialysisTech.NET to see all that NANT offers dialysis technicians.  NANT supports all dialysis technicians as a vital part of YOUR healthcare team.

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THE AMERICAN ASSOCIATION OF KIDNEY PATIENTS CALLS FOR NOMINATIONS FOR ITS 2020 MEDAL OF EXCELLENCE AWARDS

The AAKP Medal of Excellence Program recognizes renal healthcare professionals in seven categories: Physician, Transplant Surgeon, Transplant Professional, Nurse, Social Worker, Dietitian and Dialysis Technician. Recipients demonstrate the skills and compassion that reflect AAKP’s mission of providing patients with quality care in order for them to understand their condition, make informed decisions regarding their treatment plan, and align their course of care to achieve their aspirations. Candidates for the award may be nominated by colleagues, patients in their home institutions or through professional affiliations. Candidates may also self-nominate.

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The AAKP Medal of Excellence Program recognizes renal healthcare professionals in seven categories: Physician, Transplant Surgeon, Transplant Professional, Nurse, Social Worker, Dietitian and Dialysis Technician. Recipients demonstrate the skills and compassion that reflect AAKP’s mission of providing patients with quality care in order for them to understand their condition, make informed decisions regarding their treatment plan, and align their course of care to achieve their aspirations.
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Rejection Fears Dominate Transplant Patient Concerns; CareDx and American Association of Kidney Patients collaboration reveal key patient insights

AAKP President Richard Knight, a former dialysis patient and current, thirteen-year transplant recipient stated, “AAKP patient members welcome research efforts that inform national care discussions and educate policy-makers on the concerns that dominate patient-thinking. This survey revealed insights that are widely understood among patients, but will be eye-opening to non-patients and officials in posts that impact patient outcomes.”

Admin
AAKP President Richard Knight, a former dialysis patient and current, thirteen-year transplant recipient stated, “AAKP patient members welcome research efforts that inform national care discussions and educate policy-makers on the concerns that dominate patient-thinking. This survey revealed insights that are widely understood among patients, but will be eye-opening to non-patients and officials in posts that impact patient outcomes.
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