Health Pathway Assignment Help | action Evidence for action

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Step 2: Choosing a HealthPathway (to critique) 

HealthPathway: Chronic Kidney Disease

Chronic kidney disease (CKD) is an important public health concern, one in three Australians are at risk of developing CKD. (1) The health pathway about CKD identifies red flags to recognize acute kidney injury over CKD. In CKD assessment the HealthPathway lists investigations to assess kidney function and diagnose CKD. Furthermore, under management it provides a guideline to categorize chronic kidney disease in stages using GFR and recommends management accordingly. Finally, under the referral section it warns about immediate nephrology assessment if red flags are identified or the patients are at high risk according to the list of criteria’s mentioned in the HealthPathway.

Step 3 Critique of the pathway and new actions 500 words, 40 marks

a. Outline the existing prevention actions or gaps within the pathway (is there a step or steps in the pathway that help prevent progression of the disease? If none, outline what is missing)

The existing prevention action in the HealthPathway includes lifestyle modifications such as smoking cessation, weight reduction, low salt diet and regular physical activity. These are conservative recommendations which are ideal first line strategies however the HealthPathway fails to provide details or step based approaches required to implement these strategies in CKD patients. Moreover, the HealthPathway includes actions suchas managing chronic conditions; hypertension, hyperlipidemia and diabetes and also toreplace and avoid nephrotoxic drugs. Both these actions are good suggestions to prevent the progression of CKD but are less likely to be classified as primary prevention to prevent the onset of CKD within the population.

b. Describe two additional actions to prevent further progression of the disease and/or to strengthen existing prevention actions in the pathway (i.e. what other actions are required?)

The first additional action to prevent further progression of chronic kidney disease among that population that can be included in the HealthPathway is preventing psychological distress and depression in patients. (2) One in four patients diagnosed with CKD struggle with depression at anytime. (3) Patients with CKD suffer from severe psychological distress especially during the early period of their diagnosis. (4) There are biological, psychological and social factors identified in the context of CKD causing depression that impacts the patient’s quality of life. (4) Using multidisciplinary intervention, depression and psychological distress should be managed in CKD patients to improve clinical outcomes and their overall quality of life. (5)

The second prevention action to add in the HealthPathway guideline for CKD is nutrition in the context of CKD. There is evidence that a detailed nutritional plan with a control of protein intake, is effective in correcting metabolic disorders including proteinuria. (6) Inflammation is a common disorder in CKD and it can cause anorexia and catabolism and with reduced or inadequate nutritional intake it can result in increased mortality risk among CKD patients. (7)

c. Comment on likely impact of the two additional actions on population health indicators: progression of the disease; disability rate; mortality; morbidity etc.

In literature there is an association between depression and morbidity and mortality in patients with chronic kidney disease. (2) Studies show that CKD patients with moderate to severe depression requiring kidney transplant have poor clinical outcomes, requiring dialysis or having an increased risk of death during kidney transplants. (2) CKD patients with depression have poor prognosis of their disease due to behavioral and medical factors. (8) Identifying and treating psychological distress and depression in CKD patients on an individual level can improve behavioral factors such as adhering to strict fluid and dietary restrictions, compliance with medications, cooperating with the medical team to manage their condition, etc. (2) All of which lead to better clinical outcome. On a population level, treating for depression can result in overall improvement of the elderly patients since CKD patients may have other comorbid conditions such as cardiovascular disease. (9)

Nutrition plays a vital role in the disease progression of CKD patients. (6) Studies show low protein diets can significantly decrease the decline of mild and moderate disease. (10) Moreover, there are recommendations that therapeutic diets such as using protein from plant sources over animal sources can have additional benefits for CKD patients. (11) This indicates that prescribing appropriate nutritional guidelines can have a significant impact on progression of CKD. The demographic at high risk of chronic kidney disease are of older age who are otherwise at high risk of malnutrition and frailty hence improved nutrition will have beneficial impact on the health of the population in this demographic. (12)

Step 4 Evidence to support preventive actions and recommendations for integrating preventive actions into the pathway 400 words, 40 marks

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Preventive action

List the action Evidence for action

Find 3 papers Quality of Evidence

Critique the paper Recommendations for integration into HealthPathways
1. Screening and management of depression in patients with chronic kidney disease 1. This paper(2) discusses the prevalence of depression among CKD patients. It urges the importance of screening and managing depression in routine care of CKD. The paper looks into data suggesting the benefit of SSRI and psychotherapy in treating depression among this population and improving their overall outcome. The study identified biological, psychological and socio-economic factors that contribute to depression in patients with CKD. Hence, the paper tries to link that the high prevalence of depression in CKD patients and association of psychosocial distress with outcomes indicate screening and management of these conditions in caring for CKD patients.
1. This is a systematic review published in 2012 by the Department of Psychology, Ryerson University, Canada. According to NHMRC designation the level of evidence is I since the paper looks into 28 studies on the prevalence of depression among CKD patients. The paper aimed at eliminating bias by discussing the difference in the questionnaires used in the different discussed studies to assess depression in CKD patients. However, eliminating bias is not explicitly discussed in the paper and other attempts to eliminate bias like identifying impact of depression on CKD among different demographics was not touched. Recommending doctors to consider screening for depression in patients who present with CKD symptoms and consider referral to the Geelong hospital psychiatric team.
2. Improving nutrition and tailoring diet to slow down progress of the decline in kidney function 1. This paper (6) suggests that there is good evidence that a comprehensive nutritional plan with reduced protein intake can improve metabolic disorders suffered in CKD like proteinuria, which improves overall clinical outcome.
2. This second paper (7) found that malnutrition among individuals with CKD resulted in rapidly developing atherosclerosis which is recognized as a leading cause of morbidity and mortality in CKD due to the atherosclerotic cardiovascular disease. This was done by studying 109 patients with CKD by using ultrasound to detect carotid plagues and assessing nutritional status using subjective global assessments and several tests including serum albumin and urea. 1. This is a review published in 2011 by the International society of Nephrology.According to NHMRC guidelines the level of evidence is III-3 since evidence is obtained from a wide range of historical studies with interrupted time series and not details about parallel control groups.To eliminate bias, the studies compared were adjusted for age, gender, serum albumin, BMI, CVS history and diabetes.

2.This is a cross-sectional study with its latest updated published on 2015. According to NHMRC guidelines the level of evidence is III-2 since 109 patients with CKD were studied and compared to twenty-two healthy subjects. The statistical data was presented as MEAN +- SEM and P < 0.05 was indicated as statistically significant. The P-value of the end result that malnourished CKD patients having high prevalence of atherosclerosis and worse clinical outcomes excluded chance. Furthermore, to eliminate bias the paper adjusted age and gender. The limitations of this study is that it’s a cross-sectional study and also due to the analysis method used minor elevations in tests results like CRP was not detected. Adding guidelines in the HealthPathway around the importance of nutrition for CKD patients and include specific recommendations such as adhering to a low protein diet.

Step 5 Feedback 250 words, 10 marks

A. Summarize your actions, evidence for action and recommendation for integration from above into 250 words. Place this summary into your report here!

The two actions I recommended to be included in the HealthPathway for chronic kidney disease patients is screening and managing depression and including nutritional recommendations that slow down the progression of decline in kidney function. Being diagnosed with chronic kidney disease has a significant impact on quality of life, having to be compliant with a long list of medications and be required to frequently visit hospitals. Evidence shows this has an affect on the mental health of patients and treating patients with a CKD diagnosis can help with better clinical outcomes. Chronic kidney disease causes a wide range of dysregulation in the body including fluid and electrolyte imbalance, hence the management for CKD requires strict monitoring of input and output to ensure good outcomes. Especially CKD patients on dialysis required diet control to limit buildup of waste in the body which cannot be eliminated due to declining kidney function. Evidence discusses the adverse outcomes in CKD patients with inadequate nutrition and also the positive clinical outcome of controlled diet. Hence adding nutritional guidelines in the HealthPathway for CKD is recommended.

References

• 1. 4364.0.55.001 – National Health Survey: First Results, 2014-15 [Internet]. Abs.gov.au. 2015 [cited 15 October 2017]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/PrimaryMainFeatures/4364.0.55.001?OpenDocument
• 2. Zalai D, Szeifert L, Novak M. Psychological Distress and Depression in Patients with Chronic Kidney Disease. Seminars in Dialysis. 2012;25(4):428-438.
• 3.Palmer S, Vecchio M, Craig JC, Tonelli M, Johnson DW, Nicolucci A, Pellegrini F, Saglimbene V, Logroscino G, Fishbane S, Strippoli GF. Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies. Kidney international. 2013 Jul 31;84(1):179-91.
• 4. Bautovich A, Katz I, Smith M, Loo CK, Harvey SB. Depression and chronic kidney disease: A review for clinicians. Australian & New Zealand Journal of Psychiatry. 2014 Jun;48(6):530-41.
• 5. Hedayati SS, Yalamanchili V, Finkelstein FO. A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney international. 2012 Feb 1;81(3):247-55.
• 6. Fouque D, Pelletier S, Mafra D, Chauveau P. Nutrition and chronic kidney disease. Kidney International. 2011;80(4):348-357.
• 7. Stenvinkel P, Heimbürger O, Paultre F, Diczfalusy U, Wang T, Berglund L et al. Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney International. 1999;55(5):1899-1911.
• 8.Wuerth D, Finkelstein SH, Finkelstein FO. Psychosocial factors in patients with chronic kidney disease: the identification and treatment of depression in patients maintained on dialysis. InSeminars in dialysis 2005 Mar 4 (Vol. 18, No. 2, pp. 142-146). Blackwell Science Inc.
• 9. Lee Y, Kim M, Cho S, Kim S. Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease. International Journal of Clinical Practice. 2013;67(4):363-368.
• 10.Knight EL, Stampfer MJ, Hankinson SE, Spiegelman D, Curhan GC. The impact of protein intake on renal function decline in women with normal renal function or mild renal insufficiency. Annals of internal medicine. 2003 Mar 18;138(6):460-7.
• 11. .Gretz N, Meisinger E, Strauch M. Does a low protein diet really slow down the rate of progression of chronic renal failure?. Blood purification. 1989;7(1):33-8.
• 12Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. American journal of kidney diseases. 2003 Jan 31;41(1):1-2.

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