Advanced chronic kidney disease (CKD)

This section provides useful information to patients who have advanced chronic kidney disease (CKD).

CKD is a condition in which the kidneys are less able than normal to perform their usual functions. 

These functions include:

• Removing toxins

• Removing excess water

• Helping to control blood pressure

• Helping to regulate red blood cell production

• Helping to keep the bones strong and healthy.

This usually happens gradually, often over a period of many years.  Eventually, the kidneys can stop working almost completely – a condition called end stage renal failure.

What are the symptoms?

In the early stages of renal failure, there are often no symptoms.  Later as end-stage kidney failure approaches, the condition may cause any of the following:

• Itching

• Weakness or tiredness

• Loss of appetite

• Poor concentration

• Restless legs

• Leg cramps

• Swollen ankles

• Shortness of breath

• Poor sleeping

• Low sex drive

• Feeling cold

• Alteration in taste.

Anaemia Management in people with CKD

Many patients with renal failure have a condition called anaemia.  This means that there is a reduction in the number of circulating red blood cells or a deficiency in their haemoglobin content. Red blood cells are needed to transport oxygen around the body.
Haemoglobin levels are measured through blood tests and in people with CKD the target maintenance range is 10.0 – 12 g/dl (NICE Clinical guideline CG114 Feb 2011 Anaemia management in people with chronic kidney disease www.nice.org.uk/guidance/CG114).

Symptoms of anaemia: 

• Tiredness 

• Shortness of breath – difficulty in climbing stairs 

• Lethargy 

• Poor appetite 

• Irritability 

• Low sex drive

Causes of anaemia:

There are many causes of anaemia.  In CKD anaemia is usually caused by:

• Lack of the hormone Erythropoietin (EPO) 

• Lack of iron, 

• Vitamin B12 and Folate deficiency 

• Blood loss during dialysis 

• Blood loss from the gut or other organs.  

Treatment of Anaemia:

EPO is often used as an abbreviation for erythropoietin.  This is a hormone naturally produced by the kidney, which stimulates the bone marrow to constantly produce red blood cells, thus ensuring that the haemoglobin is kept at a normal level. When the kidneys become diseased, they do not produce enough Erythropoietin, so anaemia can develop.

Drugs called Erythropoiesis Stimulating Agents (ESAs) can be used to treat renal anaemia.  ESAs are given as an injection just under the skin, in the arm, leg or abdomen. Within this Health Trust most patients requiring ESA therapy are encouraged to self-administer Mircera® either  fortnightly or monthly. This is a long term treatment and the dose is individualised to each patient.

Iron Supplementation: A lot of iron is utilised when making new red blood cells. It is important therefore that there is sufficient iron stored in the body before starting ESA therapy.  A blood test can determine the amount of iron stored in the body and it’s availability for use. If iron levels are low then iron supplementation can correct this. This may be in the form of tablets or in cases of very low iron markers, intravenous iron is used.  Intravenous iron therapy is carried out in nurse-led clinics at Renal Satellite Units in Margate, Ashford, Medway and Maidstone. At the Kent and Canterbury Hospital, this treatment is administered on the Nephrology Ward, Marlowe General. 

Hepatitis B Vaccinations

The Department of Health recommends that all people with chronic kidney disease who may require future dialysis or transplantation should be vaccinated against the hepatitis B virus for their own protection. Due to the nature of renal replacement therapy, exposure to blood and other body fluids during treatment means there is an increased risk of exposure to the hepatitis B virus.  The vaccination encourages the production of antibodies, so that the body is prepared to fight the virus if it enters the blood stream.

The full vaccination course consists of four injections over a six month period. For the vaccine to be fully effective it is important that the full course is completed and that all injections are received at the correct time intervals. Hepatitis B Vaccinations are administered by the Advanced Kidney Care nurses in clinics at Canterbury, Margate, Ashford, Medway and Maidstone.

Immunity levels are checked eight weeks after the course has been completed. If immunity is not achieved after the initial course, further vaccination will not be required.  If immunity has been achieved, antibody levels will be checked six monthly and booster vaccinations given as required.