Healthcare Consideration: Symptoms of vitamin D deficiency may include bone pain and muscle weakness, but the symptoms are often subtle and can be confused for other conditions. Pharmacists can encourage assessment of vitamin D levels as part of preventive health screening. Low blood levels of vitamin D have been associated with the following (Kheiri et al., 2018): ● Increased risk of cardiovascular disease. ● Cognitive impairment in older adults. ● Increased risk of bone disorders and fractures. ● Insulin resistance. disturbances, which often progress to amenorrhea by the time end-stage renal disease develops. Women with a creatinine level greater than 3 mg/dL are rarely able to carry a pregnancy to term (Rosenberg, 2021). ● Neurological effects, including restless leg syndrome, periph- eral neuropathy, and encephalopathy. ● Dermatological effects such as pruritus, dry skin, and ecchy- mosis. ● Pericarditis. ● Platelet dysfunction, leading to an increased risk of bleeding. ● Treating the underlying condition causing chronic kidney dis- ease. ● Treating high lipid levels to bring levels to targets established by current guidelines. ● Aggressive treatment of high blood pressure to bring levels to targets established by current guidelines. ● Aggressive treatment of high blood sugar in diabetic patients to bring levels to targets established by the American Diabe- tes Association, such as hemoglobin A1C levels of less than 7%. ● Avoiding nephrotoxic medications such as IV contrast dyes, aminoglycosides, and nonsteroidal anti-inflammatory drugs. ● Using medications that block the renin–angiotensin system, such as angiotensin-converting enzyme inhibitors (ACE inhib- itors) or angiotensin receptor blockers (ARBs) in patients with proteinuria. ● Using sodium-glucose cotransporter 2 (SGLT2) inhibitors to slow disease progression onary disease, prior ischemic stroke, diabetes, or an estimated 10-year risk of coronary death or nonfatal myocardial infarc- tion greater than 10%. ● Statins should not be started in patients on dialysis, though those already on a statin when dialysis begins should contin- ue. ● Kidney transplant patients should receive a statin, as these pa- tients are at a higher risk of coronary events. ● LDL alone is an insufficient test to identify cardiovascular risk in CKD patients; a complete lipid profile should be assessed. The majority of adults with CKD do not require follow-up mea- surement of lipid levels. of 140 mmHg and was found to be highest among patients with SBP of at least 150 mmHg (Peralta et al., 2012). Patients with high blood pressure and CKD should be advised to spend at least 150 minutes per week undertaking moderate-in- tensity physical activity, or a level compatible with their physical and cardiovascular tolerance. This should be implemented on a patient-specific basis, while considering the patient’s physical limitations, risk of falls, and cognitive function. Even if physical
with phosphate, contributing to lower blood calcium levels and additional release of parathyroid hormone (Rosenberg, 2021). Overall, these mineral abnormalities contribute to specific types of bone structure abnormalities commonly seen in CKD patients, such as osteitis fibrosa, osteomalacia, and adynamic bone dis - ease. Preventative measures such as dietary phosphate restriction and phosphate binders can help prevent the progression of bone and mineral disease. Parathyroid hormone levels can be assessed to help determine the most appropriate preventative measures for chronic kidney disease patients (Rosenberg, 2021). Sexual dysfunction Patients with advanced kidney disease frequently experience abnormalities in reproductive and sexual function. More than 50% of men with uremia experience symptoms that include de- creased libido, erectile dysfunction, and reduced frequency of in- tercourse. Women with CKD commonly experience menstruation Other effects of chronic kidney disease Other clinical syndromes associated with end-stage renal disease, particularly in patients who are not receiving adequate dialysis, include (Arora, 2021): ● Gastrointestinal effects such as nausea, vomiting, diarrhea, or anorexia. ● Malnutrition and failure to thrive.
MANAGEMENT OF CHRONIC KIDNEY DISEASE
The focus of chronic kidney disease management should be on determining the underlying cause of kidney disease and imple- menting secondary prevention measures to slow or potentially stop disease progression. Treatment of the underlying condition, as well as treatment and prevention of adverse effects of chron- ic kidney disease, should be implemented soon after diagnosis. Referral to a nephrologist should occur in patients with a GFR of less than 30 mL/min/1.73m 2 in order to discuss and plan for kid- ney replacement therapy. Patients with a rapid decline in kidney function should also see a nephrologist in order to ensure the best possible outcomes (Rosenberg, 2021). Clinical practice guidelines have been published by the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) to guide management of all CKD stages, as well as associated complications. Recommendations to delay or cease CKD progression include (Arora, 2021; KDIGO Work Group, 2013): Cardiovascular risk management The KDIGO workgroup guidelines recommend wide use of statins to reduce cardiovascular risk in patients with chronic kidney disease. Their recommendations include (KDIGO Work Group, 2013b): ● Treatment with a statin or statin plus ezetimibe for adults aged 50 and older with an estimated GFR of less than 60 mL/ min/1.73m 2 who are not on long-term dialysis or treated with kidney transplantation. ● Adults aged 50 and older with CKD and an estimated GFR of greater than 60 mL/min/1.73m 2 should also receive a statin. ● Adults 18-49 with an estimated GFR of less than 60 mL/ min/1.73m 2 who are not on long-term dialysis or treated with kidney transplantation should receive a statin if they have cor- Blood pressure control Aggressive control of blood pressure can help slow the decline in kidney function in CKD patients. The KDIGO Work Group suggests a target systolic blood pressure less than 120 mmHg in CKD patients. Kidney transplant patients should have blood pressure treated to a target of less than 130/80 mmHg (KDIGO Work Group, 2021). A 2012 study by Peralta et al. noted that high systolic blood pressure (SBP) accounted for the majority of the risk of progression to end-stage kidney disease. Risk began at a SBP
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