DISSERTATIONS | THEODORA KAFKIA | ASSESSMENT AND MANAGEMENT OF PAIN IN PATIENTS ON... | No 379
uef.fi
PUBLICATIONS OF
THE UNIVERSITY OF EASTERN FINLAND Dissertations in Health Sciences
ISBN 978-952-61-2272-4 ISSN 1798-5706
Dissertations in Health Sciences
THEODORA KAFKIA
ASSESSMENT AND MANAGEMENT OF PAIN IN PATIENTS ON RENAL REPLACEMENT THERAPY
Chronic Kidney Disease patients experience not only their renal disease, with its manifestations
and complications, but also, quite often, pain that affects their everyday life. A study of pain
self-perception and self-management among patients on haemodialysis and peritoneal dialysis was conducted. An increasing trend of
pain perception was found as age progressed, along with the fact that both groups of patients
experienced equally high levels of pain, and used similar ways of self-management. Early identification of the patient in pain is the key to
the provision of higher quality of care.
THEODORA KAFKIA
ASSESSMENT AND MANAGEMENT OF PAIN IN PATIENTS ON RENAL
REPLACEMENT THERAPY
THEODORA KAFKIA
Assessment and management of pain in patients on Renal Replacement Therapy
To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in Medistudia MS301, Kuopio, on Friday, December 8th 2016, at 12 noon
Publications of the University of Eastern Finland Dissertations in Health Sciences
Number 379
Department of Nursign Science, Faculty of Health Sciences, University of Eastern Finland
Kuopio 2016
THEODORA KAFKIA
Assessment and management of pain in patients on Renal Replacement Therapy
To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in Medistudia MS301, Kuopio, on Friday, December 8th 2016, at 12 noon
Publications of the University of Eastern Finland Dissertations in Health Sciences
Number 379
Department of Nursign Science, Faculty of Health Sciences, University of Eastern Finland
Kuopio 2016
Grano Oy Jyväskylä, 2016
Series Editors:
Professor Tomi Laitinen, M.D., Ph.D.
Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences
Professor Hannele Turunen, Ph.D.
Department of Nursing Science Faculty of Health Sciences Professor Kai Kaarniranta, M.D., Ph.D.
Institute of Clinical Medicine, Opthalmology Faculty of Health Sciences
Associate Professor (Tenure Track) Tarja Malm, Ph.D.
A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences
Lecturer Veli-Pekka Ranta, Ph.D. (pharmacy) School of Pharmacy
Faculty of Health Sciences Distributor:
University of Eastern Finland Kuopio Campus Library
P.O.Box 1627 FI-70211 Kuopio, Finland http://www.uef.fi/kirjasto ISBN (print): 978-952-61-2272-4
ISBN (PDF): 978-952-61-2273-1 ISSN (print): 1798-5706
ISSN (PDF): 1798-5714 ISSN-L: 1798-5706
Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO
FINLAND
Supervisors: Professor Katri Vehviläinen-Julkunen, Ph.D.
Department of Nursing Science University of Eastern Finland KUOPIO
FINLAND
Professor Despina Sapountzi Krepia, Ph.D.
Nursing Department Frederick University NICOSIA
CYPRUS
Reviewers: Associate Professor Sophia Zyga, Ph.D.
Department of Nursing
Faculty of Human Movement & Quality of Life Sciences University of Peloponese
SRARTA GREECE
Docent Anna Liisa Aho, Ph.D. School of Health Sciences University of Tampere TAMPERE
FINLAND
Opponent: Professor Päivi Åstedt-Kurki, Ph.D.
School of Health Sciences University of Tampere TAMPERE
FINLAND
Grano Oy Jyväskylä, 2016
Series Editors:
Professor Tomi Laitinen, M.D., Ph.D.
Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences
Professor Hannele Turunen, Ph.D.
Department of Nursing Science Faculty of Health Sciences Professor Kai Kaarniranta, M.D., Ph.D.
Institute of Clinical Medicine, Opthalmology Faculty of Health Sciences
Associate Professor (Tenure Track) Tarja Malm, Ph.D.
A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences
Lecturer Veli-Pekka Ranta, Ph.D. (pharmacy) School of Pharmacy
Faculty of Health Sciences Distributor:
University of Eastern Finland Kuopio Campus Library
P.O.Box 1627 FI-70211 Kuopio, Finland http://www.uef.fi/kirjasto ISBN (print): 978-952-61-2272-4
ISBN (PDF): 978-952-61-2273-1 ISSN (print): 1798-5706 ISSN (PDF): 1798-5714
ISSN-L: 1798-5706
Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO
FINLAND
Supervisors: Professor Katri Vehviläinen-Julkunen, Ph.D.
Department of Nursing Science University of Eastern Finland KUOPIO
FINLAND
Professor Despina Sapountzi Krepia, Ph.D.
Nursing Department Frederick University NICOSIA
CYPRUS
Reviewers: Associate Professor Sophia Zyga, Ph.D.
Department of Nursing
Faculty of Human Movement & Quality of Life Sciences University of Peloponese
SRARTA GREECE
Docent Anna Liisa Aho, Ph.D.
School of Health Sciences University of Tampere TAMPERE
FINLAND
Opponent: Professor Päivi Åstedt-Kurki, Ph.D.
School of Health Sciences University of Tampere TAMPERE
FINLAND
Kafkia, Theodora
Assessment and management of pain in renal patients. A study of patiients on Renal Replacement Therapy University of Eastern Finland, Faculty of Health Sciences
Publications of the University of Eastern Finland. Dissertations in Health Sciences Number. 2016. 379,129 pp.
ISBN (print): 978-952-61-2272-4 ISBN (PDF): 978-952-61-2273-1 ISSN (print): 1798-5706 ISSN (PDF): 1798-5714 ISSN-L: 1798-5706
ABSTRACT
Introduction: Chronic Kidney Disease (CKD) is a global health problem, with increasing incidence, prevalence and poor outcomes. CKD patients are frequent users of healthcare services due to pain which can result from the primary kidney disease (Polycystic Kidney Disease or Systemic Lupus Erythematous), comorbidities (Diabetes Mellitus, Peripheral Vascular Disease and Cardiovascular Disease), or situations associated with renal disease (calcific uremic arteriolopathy, secondary hyperparathyroidism, nephrogenic fibrosing dermopathy). In addition, Renal Replacement Therapy (steal syndrome from an arteriovenous fistula for Haemodialysis (HD), abdominal distension from Peritoneal Dialysis (PD), needle insertion, and muscle cramps). A person’s coping mechanisms depend mainly on physical, emotional, spiritual and financial factors and not on the effectiveness of pharmacological and non-pharmacological methods.
Aims: The purpose of the study was to explore: a) the self-perception of pain in patients undergoing Renal Replacement Therapy (RRT) and b) their pain self-management patterns/techniques.
Methods: The study was conducted from November 2010 to December 2011 in the five state HD and PD units in a big city of Greece. All (n=930) patients on RRT were approached to participate in the study, and 700 (response rate 75.3%) agreed to do so. Data were collected by personal interviews during RRT session using the Visual Analog Scales (VAS), the Wong- Baker Pain Scales (WBPS) and the McGill Pain Questionnaire enriched with an open-ended question on pain self-management practices. Background variables were considered as pain (dependent variable) and gender, age, type of RRT and time on dialysis (independent variables). Patients had to be on RRT at least six months in order to be included in the study.
Exclusion criteria were major hearing or visual problems, inability to communicate in the spoken language of the country and coma or confusion/disorientation. Data were analyzed using frequencies for nominal variables and measures of central tendency and variability for continuous ones. As the variables were not normally distributed, non parametric tests were used (Man-Whitney, Kruskal-Wallis) along with Spearman’s ρ and x2. Finally, for the open- ended question data were analysed with inductive content analysis.
Results: The mean age of the patients was 68.81 (±13.22) years old, with 56.7% male and 82.9%
on HD. WBPS and VAS showed that 30.4% and 32% of the participants rated pain as moderate, six in a ten point scale. Almost forty eight percent pinpointed internal pain in the legs and sixty two at the fistula site. There was no statistical significance regarding gender or modality. Alas, six out of ten patients, both HD and PD, were using painkillers to self- manage pain, over 80% were using massage, only 5.34% of HD and 4.16% of PD were exercising whereas more than 90% of both modalities were walking in order to manage pain.
Conclusions: Renal patients under study experience similar high levels of pain, which increased as age progressed. Eventhough pain levels were reported similar by both genders;
in males more bodily parts were affected. Pain self-managing techniques choosen were
Kafkia, Theodora
Assessment and management of pain in renal patients. A study of patiients on Renal Replacement Therapy University of Eastern Finland, Faculty of Health Sciences
Publications of the University of Eastern Finland. Dissertations in Health Sciences Number. 2016. 379,129 pp.
ISBN (print): 978-952-61-2272-4 ISBN (PDF): 978-952-61-2273-1 ISSN (print): 1798-5706 ISSN (PDF): 1798-5714 ISSN-L: 1798-5706
ABSTRACT
Introduction: Chronic Kidney Disease (CKD) is a global health problem, with increasing incidence, prevalence and poor outcomes. CKD patients are frequent users of healthcare services due to pain which can result from the primary kidney disease (Polycystic Kidney Disease or Systemic Lupus Erythematous), comorbidities (Diabetes Mellitus, Peripheral Vascular Disease and Cardiovascular Disease), or situations associated with renal disease (calcific uremic arteriolopathy, secondary hyperparathyroidism, nephrogenic fibrosing dermopathy). In addition, Renal Replacement Therapy (steal syndrome from an arteriovenous fistula for Haemodialysis (HD), abdominal distension from Peritoneal Dialysis (PD), needle insertion, and muscle cramps). A person’s coping mechanisms depend mainly on physical, emotional, spiritual and financial factors and not on the effectiveness of pharmacological and non-pharmacological methods.
Aims: The purpose of the study was to explore: a) the self-perception of pain in patients undergoing Renal Replacement Therapy (RRT) and b) their pain self-management patterns/techniques.
Methods: The study was conducted from November 2010 to December 2011 in the five state HD and PD units in a big city of Greece. All (n=930) patients on RRT were approached to participate in the study, and 700 (response rate 75.3%) agreed to do so. Data were collected by personal interviews during RRT session using the Visual Analog Scales (VAS), the Wong- Baker Pain Scales (WBPS) and the McGill Pain Questionnaire enriched with an open-ended question on pain self-management practices. Background variables were considered as pain (dependent variable) and gender, age, type of RRT and time on dialysis (independent variables). Patients had to be on RRT at least six months in order to be included in the study.
Exclusion criteria were major hearing or visual problems, inability to communicate in the spoken language of the country and coma or confusion/disorientation. Data were analyzed using frequencies for nominal variables and measures of central tendency and variability for continuous ones. As the variables were not normally distributed, non parametric tests were used (Man-Whitney, Kruskal-Wallis) along with Spearman’s ρ and x2. Finally, for the open- ended question data were analysed with inductive content analysis.
Results: The mean age of the patients was 68.81 (±13.22) years old, with 56.7% male and 82.9%
on HD. WBPS and VAS showed that 30.4% and 32% of the participants rated pain as moderate, six in a ten point scale. Almost forty eight percent pinpointed internal pain in the legs and sixty two at the fistula site. There was no statistical significance regarding gender or modality. Alas, six out of ten patients, both HD and PD, were using painkillers to self- manage pain, over 80% were using massage, only 5.34% of HD and 4.16% of PD were exercising whereas more than 90% of both modalities were walking in order to manage pain.
Conclusions: Renal patients under study experience similar high levels of pain, which increased as age progressed. Eventhough pain levels were reported similar by both genders;
in males more bodily parts were affected. Pain self-managing techniques choosen were
group of healthcare service users and pain is affecting their everyday life, it is essential to individualize pain evaluation. It is mandatory to provide further education to clinical nurses in order to effectively assess and manage pain. (524)
National Library of Medicine Classification: WB 176, WJ 378, WL 704, WL 704.6, WY 100.4, WY 152.2, WY 164 Medical Subject Headings: Pain; Pain Measurement; Pain Management; Self Care; Renal Replacement Therapy;
Renal Dialysis; Nephrology Nursing; Surveys and Questionnaires; Interviews as Topic; Greece
Foreword
It can be argued that a nursing research study is valuable, if its findings can be implemented to improve the delivered nursing care. Within this context, the present dissertation was conducted. The experience of pain is an intrinsic part of human life, its relief a basic human right, as it is described by Maslow’s’ pyramid of needs, and a main priority of nursing practice. For a nurse, reaching an understanding of the patient’s caring needs can be regarded as one of the ‘most important things’ as Florence Nightingale stressed. Despite the improvements in pain assessment and management, pain is often undermanaged in the modern healthcare system.
Chronic Kidney Disease, a progressive loss of renal function over a period of time, is a global health problem, with increasing incidence, prevalence and poor outcomes. Patients with Chronic Kidney Disease often experience pain that affects their Health Related Quality of Life. Despite the availability of effective pain management interventions and guidelines for pain management in other patient groups (oncology or surgical patients), renal patients continue to receive inadequate pain management due to a number of reasons such as delayed seek for care, fear of addiction, altered pharmacokinetics and pharmacodynamics and increased risk of toxicity.
Clinical and research focus in the area of renal patients’ pain experiences in Greece and in Europe is limited. Having worked for fifteen years with renal patients, gave me the trigger to choose this topic for my PhD dissertation, wanting to increase awareness about pain assessment and management among renal healthcare professionals.
group of healthcare service users and pain is affecting their everyday life, it is essential to individualize pain evaluation. It is mandatory to provide further education to clinical nurses in order to effectively assess and manage pain. (524)
National Library of Medicine Classification: WB 176, WJ 378, WL 704, WL 704.6, WY 100.4, WY 152.2, WY 164 Medical Subject Headings: Pain; Pain Measurement; Pain Management; Self Care; Renal Replacement Therapy;
Renal Dialysis; Nephrology Nursing; Surveys and Questionnaires; Interviews as Topic; Greece
Foreword
It can be argued that a nursing research study is valuable, if its findings can be implemented to improve the delivered nursing care. Within this context, the present dissertation was conducted. The experience of pain is an intrinsic part of human life, its relief a basic human right, as it is described by Maslow’s’ pyramid of needs, and a main priority of nursing practice. For a nurse, reaching an understanding of the patient’s caring needs can be regarded as one of the ‘most important things’ as Florence Nightingale stressed. Despite the improvements in pain assessment and management, pain is often undermanaged in the modern healthcare system.
Chronic Kidney Disease, a progressive loss of renal function over a period of time, is a global health problem, with increasing incidence, prevalence and poor outcomes. Patients with Chronic Kidney Disease often experience pain that affects their Health Related Quality of Life. Despite the availability of effective pain management interventions and guidelines for pain management in other patient groups (oncology or surgical patients), renal patients continue to receive inadequate pain management due to a number of reasons such as delayed seek for care, fear of addiction, altered pharmacokinetics and pharmacodynamics and increased risk of toxicity.
Clinical and research focus in the area of renal patients’ pain experiences in Greece and in Europe is limited. Having worked for fifteen years with renal patients, gave me the trigger to choose this topic for my PhD dissertation, wanting to increase awareness about pain assessment and management among renal healthcare professionals.
Acknowledgements
I would like to thank my two wonderful supervisors, Prof. Katri Vehviläinen-Julkunen and Prof. Despina Sapountzi-Krepia, for their patience and encouragement during my studies. It was Prof. Sapountzi-Krepia that suggested applying to the University of Eastern Finland and the journey towards the PhD started. And it was Prof. Katri Vehviläinen-Julkunen that accepted and guided me.
I wouldn’t have arrived at the present day of finalising the PhD monograph if it wasn’t for my family. I am grateful to you guys for your support throughout the process of the present PhD dissertation. Dimos without your patience, support and love this booklet would not have been published. Billy, Mary and Anthi your help and support is countless. Thekla and George, Dimitra and Panos, you see it is never too late! Apostolos forgive me if I have neglected you sometimes, but it was for you that I wanted to conclude and graduate, to show you that if we set our mind on something there is nothing that can stop us. Byron, if you continue to be as efficient as you are now, I am sure that another, the fourth, PhD is going to be added to the family. Isabel and Apostolos thanks for being available when I needed you.
My dear friends and colleagues Thalia and Eugenia, you know how much you helped, each one of you in your own way. I am very pleased and grateful that you are my friends.
Michael, friend and brother, I remember the first day we met, back in 2002. You may say that you achieved a lot due to me but it is the same for me also. Finally, Alice thank you for passing on the virus of research, back in the early 1990s. It was you that showed the way, even with hand-moved overhead projectors. Tania, my oldest and dearest colleague and friend, it is your time now! I would like, also, to thank Maria Grizioti for her friendly advice during the statistical analysis of my dissertation.
In conclusion, and at the end of such a long trip towards the PhD, this dissertation is attributed to those that with their misfortune made me love and respect nephrology and nephrology nursing. Thank you very much for your patience and good will to help me learn by you, on you and from you.
Thessaloniki, Greece, October 2016 Theodora Kafkia
Acknowledgements
I would like to thank my two wonderful supervisors, Prof. Katri Vehviläinen-Julkunen and Prof. Despina Sapountzi-Krepia, for their patience and encouragement during my studies. It was Prof. Sapountzi-Krepia that suggested applying to the University of Eastern Finland and the journey towards the PhD started. And it was Prof. Katri Vehviläinen-Julkunen that accepted and guided me.
I wouldn’t have arrived at the present day of finalising the PhD monograph if it wasn’t for my family. I am grateful to you guys for your support throughout the process of the present PhD dissertation. Dimos without your patience, support and love this booklet would not have been published. Billy, Mary and Anthi your help and support is countless. Thekla and George, Dimitra and Panos, you see it is never too late! Apostolos forgive me if I have neglected you sometimes, but it was for you that I wanted to conclude and graduate, to show you that if we set our mind on something there is nothing that can stop us. Byron, if you continue to be as efficient as you are now, I am sure that another, the fourth, PhD is going to be added to the family. Isabel and Apostolos thanks for being available when I needed you.
My dear friends and colleagues Thalia and Eugenia, you know how much you helped, each one of you in your own way. I am very pleased and grateful that you are my friends.
Michael, friend and brother, I remember the first day we met, back in 2002. You may say that you achieved a lot due to me but it is the same for me also. Finally, Alice thank you for passing on the virus of research, back in the early 1990s. It was you that showed the way, even with hand-moved overhead projectors. Tania, my oldest and dearest colleague and friend, it is your time now! I would like, also, to thank Maria Grizioti for her friendly advice during the statistical analysis of my dissertation.
In conclusion, and at the end of such a long trip towards the PhD, this dissertation is attributed to those that with their misfortune made me love and respect nephrology and nephrology nursing. Thank you very much for your patience and good will to help me learn by you, on you and from you.
Thessaloniki, Greece, October 2016 Theodora Kafkia
Contents
1 INTRODUCTION……… ... 1
2 CHRONIC KIDNEY DISEASE AND ITS TREATMENT ... 4
2.1 Chronic Kidney Disease ... 4
2.2 Stages of Chronic Kidney Disease ... 5
2.3 Management of Chronic Kidney Disease ... 6
2.3.1 Haemodialysis (HD) ... 6
2.3.2 Peritoneal Dialysis (PD) ... 8
2.3.3 Transplantation (Tx) ... 8
2.4 Medication use in Chronic Kidney Disease ... 9
3 DEFINITIONS, THEORIES AND CLASSIFICATION OF PAIN 12 3.1 Definitions of pain ... 12
3.2 Theories on pain perception and management ... 12
3.3 Classification of pain ... 15
4 CHRONIC KIDNEY DISEASE AND PAIN PERCEPTION ... 17
4.1 Aetiology of pain in Chronic Kidney Disease patients ... 18
4.1.1 Primary or secondary disease initiated pain ... 18
4.1.1.1 Polycystic Kidney Disease ... 18
4.1.1.2 Hyperparathyroidism ... 19
4.1.1.3 Dialysis-related amyloidosis ... 20
4.1.1.4 Diabetes Mellitus ... 20
4.1.2 Clinically inflicted pain ... 20
5 ASSESSMENT OF PAIN IN RENAL PATIENTS ... 21
5.1 Pain assessment tools ... 22
5.1.1 Uni-dimensional pain assessment tools ... 23
5.1.2 Multi-dimensional pain assessment tools ... 24
5.1.3 Pain assessment tools for renal patients ... 25
6 MANAGEMENT OF PAIN IN RENAL PATIENTS ... 27
6.1 Physical methods ... 28
6.2 Psycho-behavioral modification methods ... 29
6.3 Medication therapy ... 30
6.3.1 Analgesics ... 30
6.3.2 Non-steroidal Anti-inflammatories (NSAIDs) ... 31
6.3.3 Opioid agents ... 31
6.3.3.1 Opiates... 31
6.3.3.2 Semi-synthetic opiates ... 32
6.3.3.3 Synthetic opiates ... 32
6.3.4 Adjuvant therapies ... 33
Contents
1 INTRODUCTION……… ... 1
2 CHRONIC KIDNEY DISEASE AND ITS TREATMENT ... 4
2.1 Chronic Kidney Disease ... 4
2.2 Stages of Chronic Kidney Disease ... 5
2.3 Management of Chronic Kidney Disease ... 6
2.3.1 Haemodialysis (HD) ... 6
2.3.2 Peritoneal Dialysis (PD) ... 8
2.3.3 Transplantation (Tx) ... 8
2.4 Medication use in Chronic Kidney Disease ... 9
3 DEFINITIONS, THEORIES AND CLASSIFICATION OF PAIN 12 3.1 Definitions of pain ... 12
3.2 Theories on pain perception and management ... 12
3.3 Classification of pain ... 15
4 CHRONIC KIDNEY DISEASE AND PAIN PERCEPTION ... 17
4.1 Aetiology of pain in Chronic Kidney Disease patients ... 18
4.1.1 Primary or secondary disease initiated pain ... 18
4.1.1.1 Polycystic Kidney Disease ... 18
4.1.1.2 Hyperparathyroidism ... 19
4.1.1.3 Dialysis-related amyloidosis ... 20
4.1.1.4 Diabetes Mellitus ... 20
4.1.2 Clinically inflicted pain ... 20
5 ASSESSMENT OF PAIN IN RENAL PATIENTS ... 21
5.1 Pain assessment tools ... 22
5.1.1 Uni-dimensional pain assessment tools ... 23
5.1.2 Multi-dimensional pain assessment tools ... 24
5.1.3 Pain assessment tools for renal patients ... 25
6 MANAGEMENT OF PAIN IN RENAL PATIENTS ... 27
6.1 Physical methods ... 28
6.2 Psycho-behavioral modification methods ... 29
6.3 Medication therapy ... 30
6.3.1 Analgesics ... 30
6.3.2 Non-steroidal Anti-inflammatories (NSAIDs) ... 31
6.3.3 Opioid agents ... 31
6.3.3.1 Opiates... 31
6.3.3.2 Semi-synthetic opiates ... 32
6.3.3.3 Synthetic opiates ... 32
6.3.4 Adjuvant therapies ... 33
6.3.4.1 Anticonvulsnat agents ... 33
6.3.4.2 Antidepressant agents ... 34
6.3.5 Medical cannabis ... 34
6.4 Physical interventions ... 36
6.5 Invasive procedures ... 37
6.6 Palliative care ... 37
7 BARRIERS TO EFFECTIVE ASSESSMENT AND MANAGEMENT OF PAIN IN RENAL PATIENTS ... 39
7.1 Barriers to pain assessment and management ... 39
7.2 Resent research data on renal patients’ pain levels ... 40
8 PAIN AND QUALITY OF LIFE ... 51
9 PURPOSE OF THE STUDY ... 55
9.1 Hypothesis ... 55
9.2 Variables ... 55
10 METHODS ... 56
10.1 Study design and settings ... 56
10.2 Study population and samples ... 57
10.3 Research tools ... 58
10.4 Data collection ... 59
10.5 Data analyses ... 60
10.6 Ethical considerations ... 62
11 RESULTS ... 63
11.1 Patients' demographic characteristics ... 63
11.2 Renal patients' assessment of pain ... 65
11.3 Localisation of pain in renal patients ... 66
11.3.1 Patients’ personal actions regarding pain management ... 67
11.4 Factors associated with pain perception ... 69
11.4.1 Patients' pain perception according to gender ... 69
11.4.2 Patients' pain perception according to age ... 73
11.4.3 Patients' pain perception according to Renal Replacement Therapy…………. ... 74
11.4.4 Patients' pain perception according to time on dialysis…… ... 78
11.5 Summary of results ... 80
12 DISCUSSION ... 82
12.1 Main findings ... 82
12.1.1 Demographic and treatment data ... 82
12.1.2 Localisation of pain ... 84
12.1.3 Pain self-management interventions ... 84
12.2 Validity and reliability of the study ... 86
12.2.1 Validity ... 86
12.2.2 Reliabilityof the research tools used ... 87
12.2.3 Reliability of the research ... 87
12.2.4 Internal and external validity of the results ... 88
12.3 Study limitations ... 88
13 CONCLUSSION AND IMPLICATIONS... 90
13.1 Clinical implications ... 90
13.2 Implications for further research ... 91
REFERENCES ... 92
APPENDICES ... 117
APPENDIX 1 (Research tools) ... 117
APPENDIX 2 (Tables) ... 120
6.3.4.1 Anticonvulsnat agents ... 33
6.3.4.2 Antidepressant agents ... 34
6.3.5 Medical cannabis ... 34
6.4 Physical interventions ... 36
6.5 Invasive procedures ... 37
6.6 Palliative care ... 37
7 BARRIERS TO EFFECTIVE ASSESSMENT AND MANAGEMENT OF PAIN IN RENAL PATIENTS ... 39
7.1 Barriers to pain assessment and management ... 39
7.2 Resent research data on renal patients’ pain levels ... 40
8 PAIN AND QUALITY OF LIFE ... 51
9 PURPOSE OF THE STUDY ... 55
9.1 Hypothesis ... 55
9.2 Variables ... 55
10 METHODS ... 56
10.1 Study design and settings ... 56
10.2 Study population and samples ... 57
10.3 Research tools ... 58
10.4 Data collection ... 59
10.5 Data analyses ... 60
10.6 Ethical considerations ... 62
11 RESULTS ... 63
11.1 Patients' demographic characteristics ... 63
11.2 Renal patients' assessment of pain ... 65
11.3 Localisation of pain in renal patients ... 66
11.3.1 Patients’ personal actions regarding pain management ... 67
11.4 Factors associated with pain perception ... 69
11.4.1 Patients' pain perception according to gender ... 69
11.4.2 Patients' pain perception according to age ... 73
11.4.3 Patients' pain perception according to Renal Replacement Therapy…………. ... 74
11.4.4 Patients' pain perception according to time on dialysis…… ... 78
11.5 Summary of results ... 80
12 DISCUSSION ... 82
12.1 Main findings ... 82
12.1.1 Demographic and treatment data ... 82
12.1.2 Localisation of pain ... 84
12.1.3 Pain self-management interventions ... 84
12.2 Validity and reliability of the study ... 86
12.2.1 Validity ... 86
12.2.2 Reliabilityof the research tools used ... 87
12.2.3 Reliability of the research ... 87
12.2.4 Internal and external validity of the results ... 88
12.3 Study limitations ... 88
13 CONCLUSSION AND IMPLICATIONS... 90
13.1 Clinical implications ... 90
13.2 Implications for further research ... 91
REFERENCES ... 92
APPENDICES ... 117
APPENDIX 1 (Research tools) ... 117
APPENDIX 2 (Tables) ... 120
Abbreviations
CKD Chronic Kidney Disease HD Haemodialysis
PD Peritoneal Dialysis Tx Transplantation
NSIAIDs Non-steroid Antiinflamatory Drugs
Abbreviations
CKD Chronic Kidney Disease HD Haemodialysis
PD Peritoneal Dialysis Tx Transplantation
NSIAIDs Non-steroid Antiinflamatory Drugs
1 Introduction
Health is consistent with endurable suffering (Eriksson 1997, Ferrell & Coyle 2008), two different, but integrating, sides to the process of life. Pain, as a main component of suffering, can be present in a person’s everyday life (Ferrell & Coyle 2008) and is an important contributor to the psychosocial impact of illness. It can disturb an individual’s daily routine, either by the necessity of hospitalisation, changes in social relationships and activities or by insecurities and doubts that arise from pain itself, resulting in high socio-economic burden for both the sufferer and his/her family (Leadley et al. 2012, Vaajoki 2012). Despite the advances in the medical and health-related sciences over the last century, pain continues to be seen as an “intriguing puzzle” and a challenge to those entrusted with the responsibility for its relief (Madjar 1998, Greek Nurses Code of Ethics 2001, Ferrell & Coyle 2008, IOM 2011).
The phenomenon of pain is considered to be multidimensional with physical, psychological as well as social components often determined by cultural values and beliefs (Turk & Okifuji 2002, IOM 2011, Vaajoki et al. 2013). It is the subjective bodily response to physical and psychological stressors associated with the individual, healthcare professionals and clinical environment (Wilkström et al. 2014). It is associated with depression, difficulties in interpersonal relationships, excessive use of health care facilities, psychological distress and activity limitations in work, social life and family (Dysvik et al. 2004, Davison 2007a, Heiwe & Bjuke 2009, Hogan & Norby 2010). It is a vital defense mechanism, as it warns the human body for any health-threatening situations and is recognised as an important contributor to the psychosocial impact of illness and the adoption of chronic sick role (Madjar 1998, Curtin & Mapes 2001, Davison 2007).
The first study on pain measurement and its pharmacological management is reported in the 1940s by Wolff et al. During the the ‘60s and ‘70s more researchers focused on the issue of pain, its aetiology, assessment and management (Kast 1962, Poser 1962, Gould 1962, Melzack & Wall 1965, McCaffery 1968, Jacox & Stewart 1973, Merskey 1974, IASP 1979).
Nevertheless, it is in recent years that significant breakthrough has been achieved in the understanding of pain aetiology and mechanisms, as well as assessment and management.
It is regarded as the “fifth” vital sign and is recommended to be assessed frequently and systematically, during physical examination and everyday nursing rounds (Rehm et al. 2003, Alhani et al. 2010, Vaajoki 2012). Pain assessment is focusing on the recording of the nature and intensity of pain and is aiming at the recording of the broader experience that the person is having (Vaajoki 2012).
Pain is also an ethical issue from the patient’s perspective as, like death, it is a disvalue and demeaning. The more intense the pain, the more it dominates the patient’s self-defining human characteristics of intelligence, autonomy, and self-esteem (Lisson 1989, Borneman &
Ferrell 1996). Sometimes, individuals cannot think of anything else but pain. It can destroy the individual’s autonomy and sense of self-esteem; it can make him/her feeling helpless and a burden to family and close friends. Severe and unbearable pain may affect the willingness to live and lead to suicides (Kurella et al. 2005, Kaba et al. 2007, Karasouli et al. 2014, Weisbord et al. 2014, Andrade et al. 2015).
The experience of pain is as old as the recorded history. The manners in which people perceive and the ways they manage pain have varied across countries and time. From the ancient times, pain was regarded to have both natural and supernatural origin. Pain associated with injury or trauma was seen as a natural phenomenon. Pain associated with disease was more mysterious, and regarded as a result of supernatural and divine forces and a punishment for inappropriate or sinful behavior. The later, pain as a punishment for sin, was first seen in the Assyro-Babylonian civilisation (Procacci & Maresca 1984). Even in the Christian ethic, pain is regarded as a result of sinful actions (Tu 1980). The concept of pain
1 Introduction
Health is consistent with endurable suffering (Eriksson 1997, Ferrell & Coyle 2008), two different, but integrating, sides to the process of life. Pain, as a main component of suffering, can be present in a person’s everyday life (Ferrell & Coyle 2008) and is an important contributor to the psychosocial impact of illness. It can disturb an individual’s daily routine, either by the necessity of hospitalisation, changes in social relationships and activities or by insecurities and doubts that arise from pain itself, resulting in high socio-economic burden for both the sufferer and his/her family (Leadley et al. 2012, Vaajoki 2012). Despite the advances in the medical and health-related sciences over the last century, pain continues to be seen as an “intriguing puzzle” and a challenge to those entrusted with the responsibility for its relief (Madjar 1998, Greek Nurses Code of Ethics 2001, Ferrell & Coyle 2008, IOM 2011).
The phenomenon of pain is considered to be multidimensional with physical, psychological as well as social components often determined by cultural values and beliefs (Turk & Okifuji 2002, IOM 2011, Vaajoki et al. 2013). It is the subjective bodily response to physical and psychological stressors associated with the individual, healthcare professionals and clinical environment (Wilkström et al. 2014). It is associated with depression, difficulties in interpersonal relationships, excessive use of health care facilities, psychological distress and activity limitations in work, social life and family (Dysvik et al. 2004, Davison 2007a, Heiwe & Bjuke 2009, Hogan & Norby 2010). It is a vital defense mechanism, as it warns the human body for any health-threatening situations and is recognised as an important contributor to the psychosocial impact of illness and the adoption of chronic sick role (Madjar 1998, Curtin & Mapes 2001, Davison 2007).
The first study on pain measurement and its pharmacological management is reported in the 1940s by Wolff et al. During the the ‘60s and ‘70s more researchers focused on the issue of pain, its aetiology, assessment and management (Kast 1962, Poser 1962, Gould 1962, Melzack & Wall 1965, McCaffery 1968, Jacox & Stewart 1973, Merskey 1974, IASP 1979).
Nevertheless, it is in recent years that significant breakthrough has been achieved in the understanding of pain aetiology and mechanisms, as well as assessment and management.
It is regarded as the “fifth” vital sign and is recommended to be assessed frequently and systematically, during physical examination and everyday nursing rounds (Rehm et al. 2003, Alhani et al. 2010, Vaajoki 2012). Pain assessment is focusing on the recording of the nature and intensity of pain and is aiming at the recording of the broader experience that the person is having (Vaajoki 2012).
Pain is also an ethical issue from the patient’s perspective as, like death, it is a disvalue and demeaning. The more intense the pain, the more it dominates the patient’s self-defining human characteristics of intelligence, autonomy, and self-esteem (Lisson 1989, Borneman &
Ferrell 1996). Sometimes, individuals cannot think of anything else but pain. It can destroy the individual’s autonomy and sense of self-esteem; it can make him/her feeling helpless and a burden to family and close friends. Severe and unbearable pain may affect the willingness to live and lead to suicides (Kurella et al. 2005, Kaba et al. 2007, Karasouli et al. 2014, Weisbord et al. 2014, Andrade et al. 2015).
The experience of pain is as old as the recorded history. The manners in which people perceive and the ways they manage pain have varied across countries and time. From the ancient times, pain was regarded to have both natural and supernatural origin. Pain associated with injury or trauma was seen as a natural phenomenon. Pain associated with disease was more mysterious, and regarded as a result of supernatural and divine forces and a punishment for inappropriate or sinful behavior. The later, pain as a punishment for sin, was first seen in the Assyro-Babylonian civilisation (Procacci & Maresca 1984). Even in the Christian ethic, pain is regarded as a result of sinful actions (Tu 1980). The concept of pain
as a natural phenomenon can be traced back to Greek philosophers. Plato described pain as a sensation opposite to pleasure and Aristotle described it as a ‘passion of the soul’. Galen, in accordance with the previous two philosophers, stated the importance of the central nervous system and brain in pain process. Later on, Descartes described pain as a channel form the skin to the brain, a “spark” from a fire stimulating threads in the surface of the skin to operate “bells” in the brain. During the Renaissance (14th to 17th century) and the Enlightenment (end of 17th to 18th century), it was believed that the heart was the centre of all sensations, including pain (Procacci & Maresca 1984). For centuries, people, due to attitudes and beliefs about pain, were forced to accept the particular feeling as beneficial, spiritually enhancing, character building, unavoidable during disease or injury or even a result of witchcraft or evil eye. In a study by Lovering et al. (2006) it was reported that Saudi Arabian, Muslim, as well as Filipinos (Catholic in religion) healthcare professionals and patients attributed pain to the will of God, as it was the right set of circumstances to compensate for sins and earn greater reward in the afterlife. In addition, Muslims attributed pain to supernatural spirits such as evil eye.
It was during the 19th century that the scientific study of pain begun, with two major groups of scientists conflicting (Procacci & Maresca 1992, Procacci & Maresca 1994, Madjar 1998). The first group of physiologists and few psychologists argued that pain is a sensory phenomenon, and the second group of philosophers and psychologists supported the traditional Aristotelian concept of pain (Procacci & Maresca 1984). It is argued that the evolution of science, with the promise to diminish human suffering, and the acceptance of the spiritually of pain made the ‘modern Western man’ more sensitive to pain and less willing to tolerate it (Madjar 1998).
The sociopolitical context of pain has changed, worldwide, since the 1980s (Madjar 1998).
New analgesic medicines have been produced; new means of drug administration, new technologies in the areas of nerve stimulation and new types of healthcare facilities have been created to alleviate particular kinds of pain, such as cancer pain. A new approach to the problem of chronic pain has led to establishment of pain clinics. One-dimensional, iatrogenic models of health, which view pain only in the frame of cause and effect (stimulus-response), have been rejected because they lead to the assumption that intensity of pain is the most important of all its aspects. Still pain is a multidimensional phenomenon with five components, at least. The emotions related to pain, such as fear, anxiety, depression (affective dimension), the behavioral responses to pain, such as express pain to others, reduce pain intensity, tolerate pain (behavioral) and the beliefs, attitudes and goals about pain and pain management (cognitive). All the above affect the way pain is perceived by the individual (sensory dimension) modifying the transmission of stimuli to the brain, pain mechanism and physiologic aspects of pain (physiological). Nowadays, administrations, the World Health Organisation, the International Association for the Study of Pain, various foundations and advocacy groups are asking for a holistic approach to pain control, stressing that it is a bio-psychosocial phenomenon which requires interdisciplinary care (Lasch 2002, Khan et al. 2015).
By the end of 1990s researchers have started to focus on pain management in general population, children and adult acute care. In Scotland, first in 1999 and then in the follow- up study in 2002, it was found that slightly over half of the general population experienced some form of chronic pain (Elliott et al. 1999, Elliott et al. 2002, Hasselström et al. 2002, Torrance et al. 2011). In Denmark, Eriksen et al. (2003) reported an overall chronic pain of one fifth of the population. Research data suggest that the management of pain in healthcare facilities has not been the optimum. In hospitalised patients major studies reveal a quite wide pain variety, from 61% (Bruster et al. 1994) to 22% (Taverner 2003). In more details, in medical wards pain is ranging from one (Dix et al. 2004) to three fifths (Whelan et al. 2004) of the patients. In day surgery clinics, where pain has to be effectively managed, it is reported from 45% (Wu et al. 2002) to 21% even in two days postoperatively (McHugh & Thoms 2002).
In endoscopic procedures, such as colonoscopy or cystoscopy, patients report moderate to
severe pain levels reduced after 4 to 7 days (Ylinen et al. 2009, Seklehner et al. 2015).
Furthermore, in children care research, in various countries, there has been found that the majority of these young patients experience moderate to severe pain postoperatively (Hamers & Abu-Saad 2002, Pölkki et al. 2003, Pölkki et al. 2008, He et al. 2015, Zhu et al. 2015).
Salonen et al. (2002) and Tuomilehto et al. (2002), studing postoperative pain in Finnish children having undergone adenoidectomy, reported significant postoperative pain lasting from 3 to 9 days. Five years later, He et al. (2007), reported that more than 90% of the children undergone elective surgery in Fujian Province, China, experienced pain on the second day after discharge and one fourth of them were still on pain four weeks postoperatively.
Furthermore, in a comparative study of Finnish and American parents’ perception of their childrens’ pain, it was found that eight out of ten children in both countries required analgesics at discharge, and a lot were experiencing pain up to two weeks postoperatively (Kankkunen et al. 2012). Since the late ‘00s, research has turned on pain assessement in elderly people with cognitive impairment managed in acute and long-term care settings.
Numerous studies reveal significant levels of pain that are undertreated (Yu & Petrini 2007, Zanolin et al. 2007, Zwakhalen et al. 2007, Ng et al. 2014).
Kidney Disease can be manifested either as a result of acute obstruction (Acute Renal Failure, ARF) or as a result of a long procedure of deterioration of renal function (Chronic Kidney Disease, CKD). Literature regards Chronic Kidney Disease as a major medical problem of the modern societies as it is found to affect almost 10% of the global population.
Acute or Chronic Kindey Disease can cause a number of painful sings and symptoms and/or a number of painful interventions and outcomes. To the best of the researchers’ knowledge, in the literature there is enough information on renal patient’s pain perception and management (Bajwa et al. 2001, Davison 2003, Davison et al. 2005, Harris et al. 2012, Hsu et al. 2014, Kaza et al. 2014), but very little research has been conducted in patients of Greek origin (Kontodimopoulos et al. 2009, Spaia et al. 2009, Theofilou 2012, Zyga et al. 2015) correlating Chronic Kidney Disease with pain and quality of life.
Thus, the aim of this study was to explore whether Greek renal patients believe that they experience any type of pain (chronic or acute) and the methods of self-managing painful situations. In the particular study when using the term “renal patietns” it is meant patients with gradual and progressive deterioration of kidney function, and that are on Renal Replacement Therapy (RRT), either with Haemodialysis (HD) or with Peritoneal Dialysis (PD).
as a natural phenomenon can be traced back to Greek philosophers. Plato described pain as a sensation opposite to pleasure and Aristotle described it as a ‘passion of the soul’. Galen, in accordance with the previous two philosophers, stated the importance of the central nervous system and brain in pain process. Later on, Descartes described pain as a channel form the skin to the brain, a “spark” from a fire stimulating threads in the surface of the skin to operate “bells” in the brain. During the Renaissance (14th to 17th century) and the Enlightenment (end of 17th to 18th century), it was believed that the heart was the centre of all sensations, including pain (Procacci & Maresca 1984). For centuries, people, due to attitudes and beliefs about pain, were forced to accept the particular feeling as beneficial, spiritually enhancing, character building, unavoidable during disease or injury or even a result of witchcraft or evil eye. In a study by Lovering et al. (2006) it was reported that Saudi Arabian, Muslim, as well as Filipinos (Catholic in religion) healthcare professionals and patients attributed pain to the will of God, as it was the right set of circumstances to compensate for sins and earn greater reward in the afterlife. In addition, Muslims attributed pain to supernatural spirits such as evil eye.
It was during the 19th century that the scientific study of pain begun, with two major groups of scientists conflicting (Procacci & Maresca 1992, Procacci & Maresca 1994, Madjar 1998). The first group of physiologists and few psychologists argued that pain is a sensory phenomenon, and the second group of philosophers and psychologists supported the traditional Aristotelian concept of pain (Procacci & Maresca 1984). It is argued that the evolution of science, with the promise to diminish human suffering, and the acceptance of the spiritually of pain made the ‘modern Western man’ more sensitive to pain and less willing to tolerate it (Madjar 1998).
The sociopolitical context of pain has changed, worldwide, since the 1980s (Madjar 1998).
New analgesic medicines have been produced; new means of drug administration, new technologies in the areas of nerve stimulation and new types of healthcare facilities have been created to alleviate particular kinds of pain, such as cancer pain. A new approach to the problem of chronic pain has led to establishment of pain clinics. One-dimensional, iatrogenic models of health, which view pain only in the frame of cause and effect (stimulus-response), have been rejected because they lead to the assumption that intensity of pain is the most important of all its aspects. Still pain is a multidimensional phenomenon with five components, at least. The emotions related to pain, such as fear, anxiety, depression (affective dimension), the behavioral responses to pain, such as express pain to others, reduce pain intensity, tolerate pain (behavioral) and the beliefs, attitudes and goals about pain and pain management (cognitive). All the above affect the way pain is perceived by the individual (sensory dimension) modifying the transmission of stimuli to the brain, pain mechanism and physiologic aspects of pain (physiological). Nowadays, administrations, the World Health Organisation, the International Association for the Study of Pain, various foundations and advocacy groups are asking for a holistic approach to pain control, stressing that it is a bio-psychosocial phenomenon which requires interdisciplinary care (Lasch 2002, Khan et al. 2015).
By the end of 1990s researchers have started to focus on pain management in general population, children and adult acute care. In Scotland, first in 1999 and then in the follow- up study in 2002, it was found that slightly over half of the general population experienced some form of chronic pain (Elliott et al. 1999, Elliott et al. 2002, Hasselström et al. 2002, Torrance et al. 2011). In Denmark, Eriksen et al. (2003) reported an overall chronic pain of one fifth of the population. Research data suggest that the management of pain in healthcare facilities has not been the optimum. In hospitalised patients major studies reveal a quite wide pain variety, from 61% (Bruster et al. 1994) to 22% (Taverner 2003). In more details, in medical wards pain is ranging from one (Dix et al. 2004) to three fifths (Whelan et al. 2004) of the patients. In day surgery clinics, where pain has to be effectively managed, it is reported from 45% (Wu et al. 2002) to 21% even in two days postoperatively (McHugh & Thoms 2002).
In endoscopic procedures, such as colonoscopy or cystoscopy, patients report moderate to
severe pain levels reduced after 4 to 7 days (Ylinen et al. 2009, Seklehner et al. 2015).
Furthermore, in children care research, in various countries, there has been found that the majority of these young patients experience moderate to severe pain postoperatively (Hamers & Abu-Saad 2002, Pölkki et al. 2003, Pölkki et al. 2008, He et al. 2015, Zhu et al. 2015).
Salonen et al. (2002) and Tuomilehto et al. (2002), studing postoperative pain in Finnish children having undergone adenoidectomy, reported significant postoperative pain lasting from 3 to 9 days. Five years later, He et al. (2007), reported that more than 90% of the children undergone elective surgery in Fujian Province, China, experienced pain on the second day after discharge and one fourth of them were still on pain four weeks postoperatively.
Furthermore, in a comparative study of Finnish and American parents’ perception of their childrens’ pain, it was found that eight out of ten children in both countries required analgesics at discharge, and a lot were experiencing pain up to two weeks postoperatively (Kankkunen et al. 2012). Since the late ‘00s, research has turned on pain assessement in elderly people with cognitive impairment managed in acute and long-term care settings.
Numerous studies reveal significant levels of pain that are undertreated (Yu & Petrini 2007, Zanolin et al. 2007, Zwakhalen et al. 2007, Ng et al. 2014).
Kidney Disease can be manifested either as a result of acute obstruction (Acute Renal Failure, ARF) or as a result of a long procedure of deterioration of renal function (Chronic Kidney Disease, CKD). Literature regards Chronic Kidney Disease as a major medical problem of the modern societies as it is found to affect almost 10% of the global population.
Acute or Chronic Kindey Disease can cause a number of painful sings and symptoms and/or a number of painful interventions and outcomes. To the best of the researchers’ knowledge, in the literature there is enough information on renal patient’s pain perception and management (Bajwa et al. 2001, Davison 2003, Davison et al. 2005, Harris et al. 2012, Hsu et al. 2014, Kaza et al. 2014), but very little research has been conducted in patients of Greek origin (Kontodimopoulos et al. 2009, Spaia et al. 2009, Theofilou 2012, Zyga et al. 2015) correlating Chronic Kidney Disease with pain and quality of life.
Thus, the aim of this study was to explore whether Greek renal patients believe that they experience any type of pain (chronic or acute) and the methods of self-managing painful situations. In the particular study when using the term “renal patietns” it is meant patients with gradual and progressive deterioration of kidney function, and that are on Renal Replacement Therapy (RRT), either with Haemodialysis (HD) or with Peritoneal Dialysis (PD).
2 Chronic Kidney Disease and its treatment
2.1 CHRONIC KIDNEY DISEASE (CKD)
Chronic Kidney Disease (CKD) is a growing health problem worldwide as it causes high rates of morbidity, mortality, decreased quality of life and increased healthcare expenditures (Williams & Manias 2007, Kara 2009).
Chronic Kidney Disease can be regarded as an epidemic in the modern societies. It affects approximately 10% of the global population, as it is found in 8% of the European population, 1.7 million (10%) Australians over 18 years old, and 8% of Americans. It is estimated that 250.000 Europeans and 1.4 million Americans with Chronic Kidney Disease stages 4-5 require RRT (USRDS 2013, European Kidney Health Alliance 2012 & 2013, CDC 2014). In the developing world the number of patients requiring RRT cannot be calculated due to inadequate reporting mechanisms and less available access to dialysis services. In Europe the incidence of Chronic Kidney Disease has reached 135 patients per million population (pmp), with UK reaching 101 patients pmp, in USA 336 and in Greece particular 100 pmp (European Kidney Health Alliance 2012 & 2013, CDC 2014).
It is estimated that more than 10% of adults in the United States — more than 20 million people — have Chronic Kidney Disease, of varying levels of seriousness (Centers for Disease Control and Prevention, CDC, 2014), whereas in Europe the individuals with some kind of renal problems are counted at 992 per million population (pmp) (ERA-EDTA Registry 2014).
The prevalence of End Stage Renal Disease is estimated to be approximately 1.8 million patients (Eggers 2011). Furthermore, it is rapidly increasing in the US, from 10000 individuals in 1973, to 86354 in 1983 and 615899 by the end of 2011. The rate of new ESRD cases pmp was stable since 2000, and it fell 3.8% in 2011, reaching 362 patients pmp (United States Renal Data System Annual Report 2013). Furthermore in Japan, the prevalence of ESRD reached 2309 patients pmp in 2011, in China 300 cases pmp and 1661 in Singapore (Collins et al. 2015), as well as 1104 pmp in Greece (Ioannidis & Papadaki 2013).
Kidney function can be assessed by measurement of serum creatinine which depends on creatine production and its kidney excretion rate. Despite the fact that serum creatinine is an easy and cheap test to measure kidney function, its levels can be affected by body size, weight and muscle mass. In the last few years estimation of Glomerular Filtration Rate (eGFR) is recommended for assessing kidney function. Clinicians are encouraged to combine serum creatinine results with gender and age of the patient for estimation of eGFR. An adjustment in the eGFR values (multiply by 1.21) should be made if the patient is African-Caribbean in origin (not mixed race). Furthermore, attention should be paid in malnourished patients, pregnant women and children (Hurst & Thomas 2014).
Chronic Kidney Disease can be defined as a gradual and progressive loss of the ability of the kidneys to excrete waste products, concentrate urine, secrete hormones and conserve electrolyte balance as evidenced by:
• Glomerular Filtration Rate (GFR) <60mL/min/1.73m2 for more than 3 months, irrespective of the presence or absence of kidney damage,
• abnormal findings on renal imaging (structural abnormalities or kidney stones) or renal biopsy (chronic glomerulonephritis),
• persistent urinary findings, such as microalbuminuria, proteinuria or haematuria and/or PCR >45mg/mmol, indicating impairment of the primary filtering function of the kidney, and
• persistent blood findings, such as unexplained anaemia (Hb≤11g/dL), increased calcium, phosphate or potassium, indicating impairment of the primary filtering function of the kidney (NKF K/DOQIs 2003, Chalmers 2014).
The onset and progression of Chronic Kidney Disease depends on the presence of a variety of modifiable and non-modifiable risk factors. The first group of risk factors includes obesity, smoking, hypertension or diabetes (poorly controlled) and dietary habits; whereas the latter contains age, gender, race and genetics. Older age has been acknowledged as a risk factor for development of Chronic Kidney Disease, but as it has been argued by Coresh et al.
(2007) age-related decline in GFR can lead to overestimation of the actual rates of elderly patients with Chronic Kidney Disease, as these people have impaired but stable kindey function. Usually a reduced residual kidney function, manifested by low GFR, could be an indicator of other co-existing conditions, such as hypertension, cardiovascular or cerebrovascular disease and/or Diabetes Mellitus. In regards to gender, data are inclusive.
The United States Renal Database System (USRDS) (2013) reports a 22% lower rates of Chronic Kidney Disease in females, which is a bit lower than Greece’s rates as females reach the 36.5% of the total Chronic Kidney Disease patients (Ioannidis & Papadaki, 2013). Another trend regarding Chronic Kidney Disease is that higher incidences have been found among African and Latin Americans than in Caucasians in the USA (USRDS 2013). Couser et al.
(2011) reports that eventhough Chronic Kidney Disease patients of African origin present higher rates internationaly, those treated in Europe and Africa are, proportionally, less than in the USA, highlighting the modifiable risk factors’ contribution in the progression of the disease.
2.2 STAGES OF CHRONIC KIDNEY DISEASE (CKD)
The progression of Chronic Kidney Disease is often slow, as the appearance of symptoms and the onset of complications. A variety of sings and symptoms can be present during the various stages of Chronic Kidney Disease. Its diagnosis may require extensive investigations (blood and urine tests, as well as imaging), and may be set only by specially trained physicians and nurses. It is divided in five stages depending on the glomerular filtration rate.
• Stage 1: eGFR of ≥90mL/min/1.73m2 indicates minor kidney damage with proteinuria and/or haematuria. The above value of eGFR has to be positively diagnosed in two repetitive measurements with a time distance of two weeks. Co-morbid conditions, such as hypertension, diabetes mellitus and hyperlipidaemia, should be treated as well. Modification in life style (exercise and smoking cessation) along with medication therapy can slow progression. Once annually testing is advised.
• Stage 2: GFR of 60-89mL/min/1.73m2 indicates mild kidney damage and demands more close and frequent monitoring with blood and imaging tests. In this stage kidney function varies from 60-90% and the, presented above, sings and symptoms persist.
Stage 2, as well as 1, is usually treated in primary care settings.
• Stage 3: GFR of 30-59 mL/min/1.73m2 indicates moderate kidney damage (30-60% of kidney function) and need for every six months evaluation. Treatment of complications, such as hypertension or hypelipidaemia, has to be more efficient.
Patients have to be immunised for influenza and pneumonococcal. Regular review of the medication administered is needed in order to minimise use of nephrotoxic agents and ensure dosage adjustment according to renal disease status. Sings and symptoms like fatigue, oedema in the lower extremities, shortness of breath, urine changes (foamy and dark urines), low back pain, muscle cramps and restless legs can appear.
If deterioration of kidney function is rapid then the patient has to be refered to specialised renal team within a hospital setting.
• Stage 4: GFR of 15-29 mL/min/1.73m2 reflects severe kidney damage (15-30% of kindey function) and the need to take the necessary steps in oreder to prepare the patient for initiation of renal replacement therapy. Previous described tests are recommended every three months. Sings and symptoms of stage 3 can be accompanied by nausea and vomiting, metallic taste in the mouth, uraemic breath, loss of appetite, difficulty
