Care Of Chronic Kidney Disease Patients Research Articles

SAT-219 IMPROVEMENT OF UNHEALTHY BEHAVIORS AND KEY PERFORMANCE INDICATORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE 3-4 AT 1-YEAR FOLLOW-UP OF ESCORT-2 STUDY

In the ESCORT-2 study, we have designed multidisciplinary integrative care team (MDIC) to take care of stages 3 and 4 chronic kidney disease (CKD) patients among community hospitals in Kamphaeng Phet province, Thailand. In this study, key performance indicators (KPIs) and individual lifestyle pattern that affecting CKD progression were enlisted for serial monitoring, we presented herein the baseline results of KPIs achievement and incidence of unhealthy behaviors of the study. The ESCORT-2 study was a quasi-experimental study which was designed to evaluate the effect of MDIC approach to delay CKD progression in routine clinical care at five district hospitals in Kamphaeng Phet province, Thailand. It comprised hospital-based multidisciplinary team approach and community-based home visit. Clinical characteristics, blood and urine parameters were monitored during hospital visit every 3 months. Unhealthy behaviors were evaluated annually. 914 patients with CKD stages 3 and 4 were enrolled. In the KPI aspects, the patients at the first year of follow-up who achieved office BP less than 140/90, Hb A1c < 7, Hct > 30%, serum bicarbonate > 22 mEq/L and took ACEI or ARB were 773(84.7%), 153(35.3%), 567(95%), 660(72.2%) and 633(72.9%) compared with 681(74.8%), 240(49.9%), 774(91.8%), 583(63.8%) and 604(66.4%) at the beginning of study, in order as table 1. In the unhealthy behavior aspects, the CKD patients who took NSAIDs or herb in the first year of follow-up were 54(6.2%) and 15(1.7%) compared with 327(35.8%) and 209(23.1%) at the beginning of study, respectively as table 1. After 1-year follow-up, the MDIC approach can facilitate improvement in most of KPIs and unhealthy behaviors among community care for CKD patients.

Patient and provider experience and perspectives of a risk-based approach to multidisciplinary chronic kidney disease care: a mixed methods study

BackgroundThe Kidney Failure Risk Equation (KFRE) predicts risk of progression to kidney failure and is used to guide clinical decisions for patients with chronic kidney disease (CKD).MethodsThe KFRE was implemented to guide access to multidisciplinary care for CKD patients in Alberta, Canada, based on their 2-year risk of kidney failure. We used a mixed methods approach to investigate patients’ and providers’ perspectives and experiences 1 year following KFRE implementation. We conducted post-implementation interviews with multidisciplinary clinic providers and with low-risk patients who transitioned from multidisciplinary to general nephrology care. We also administered pre- and post-implementation patient care experience surveys, targeting both low-risk patients discharged to general nephrology and high-risk patients who remained in the multidisciplinary clinic, and provider job satisfaction surveys.ResultsTwenty-seven interviews were conducted (9 patients, 1 family member, 17 providers). Five categories were identified among patients and providers: targeted care; access to resources outside the multidisciplinary clinics; self-efficacy; patient reassurance and reduced stress; and transition process for low-risk patients Two additional categories were identified among providers only: anticipated concerns and job satisfaction. Patients and providers reported that the risk-based approach allowed the clinic to target care to those most likely to experience kidney failure and most likely to benefit from multidisciplinary care. While some participants indicated the risk-based model enhanced the sustainability of the clinics, others expressed concern that care for low-risk patients discharged from multidisciplinary care, or those now considered ineligible, may be inadequate.Overall, 413 patients completed the care experience survey and 73 providers completed the workplace satisfaction survey. The majority of patients were satisfied with their care in both periods with no overall differences. When considering the responses “Always” and “Often” together versus not, there were statistically significant improvements in domains of access to care, caring staff, and safety of care. There were no differences in healthcare providers’ job satisfaction following KFRE implementation.ConclusionsPatients and healthcare providers reported that the risk-based approach improved the focus of the multidisciplinary CKD clinics by targeting patients at highest risk, with survey results suggesting no difference in patient care experience or healthcare provider job satisfaction.

Recording blood pressure and eGFR in primary care after the Belgrade screening study

Background: In 2009, Belgrade nephrologists and general practitioners from thirteen health centers carried out screening for chronic kidney disease (CKD). Three years later, medical records of patients from four health centers participating in the screening study were retrospectively analyzed in order to check whether general practitioners had continued to control patients at risk for CKD in accordance with the recommendations provided.Methods: The study included 460 patients who visited their doctor at least once in the three-year period. Data on blood pressure, ACEI use, estimated glomerular filtration rate (eGFR) and comorbidities were taken from patients’ medical records.Results: Blood pressure was not recorded in any of the three years in 42.8% and eGFR in 36.7% of the patients, but blood pressure was registered every year in 7.8% and eGFR in 4.3% of them. Over the three years, the relative number of patients with recorded blood pressure decreased from 41.7% to 17.8%, and with recorded eGFR from 41.7% to 21.5%. Multivariate linear regression found that Health Center, systolic and diastolic blood pressure and presence of hypertension were negatively associated with number of years with recorded blood pressure. Health Center, systolic blood pressure and sum of years with recorded eGFR below 60 ml/min/1.73m2 were associated with number of years with recorded eGFR.Conclusions: Under-recording of blood pressure and eGFR in primary care health centers suggests lack of adherence to current guidelines and insufficient care of CKD patients. This implies the necessity for continuous education of physicians.

Perceived Benefits and Challenges of a Risk-Based Approach to Multidisciplinary Chronic Kidney Disease Care: A Qualitative Descriptive Study.

Background:The kidney failure risk equation (KFRE) provides an estimate of risk of progression to kidney failure, and may guide clinical care.Objective:We aimed to describe patient, family, and health care provider’s perspectives of the perceived benefits and challenges of using a risk-based approach to guide care delivery for patients with advanced chronic kidney disease (CKD), and refine implementation based on their input.Methods:We used qualitative methodology to explore perceived benefits and challenges of implementing a risk-based approach (using the KFRE) to determine eligibility for multidisciplinary CKD care in Southern Alberta. We obtained perspectives from patients and families through focus groups, as well as input from health care providers through interviews and open-ended responses from an online survey. Twelve patients/family members participated in 2 focus groups, 16 health care providers participated in an interview, and 40 health care providers responded to the survey.Results:Overall, participants felt that a KFRE-based approach had the potential to improve efficiency of the clinics by targeting care to patients at highest risk of kidney failure; however, they also expressed concerns about the impact of loss of services for lower risk individuals. Participants also articulated concerns about a perceived lack of capacity for adequate CKD patient care in the community. Our implementation strategy was modified as a result of participants’ feedback.Conclusions:We identified benefits and challenges to implementation of a risk-based approach to guide care of patients with advanced CKD. Based on these results, our implementation strategy has been modified by removing the category of referral back to primary care alone, and instead having that decision made jointly by nephrologists and patients among low-risk patients.

Non-proteinuric rather than proteinuric renal diseases are the leading cause of end-stage kidney disease.

Proteinuria is a distinguishing feature in primary and secondary forms of chronic glomerulonephritis, which contribute to no more than the 20% of the end-stage kidney disease (ESKD) population. The contribution of non-proteinuric nephropathies to the global ESKD burden is still poorly focused and scarce research efforts are dedicated to the elucidation of risk factors and mechanistic pathways triggering ESKD in these diseases. We abstracted information on proteinuria in the main renal diseases other than glomerulonephritides that may evolve into ESKD. In type 2 diabetes, non-proteinuric diabetic kidney disease (DKD) is more frequent than proteinuric DKD, and risk factors for non-proteinuric forms of DKD now receive increasing attention. Similarly, proteinuria is most often inconspicuous or absent in the most frequent cause of ESKD, i.e. hypertension-related chronic kidney disease (CKD), as well as in progressive cystic diseases like autosomal dominant polycystic kidney disease and in pyelonephritis/tubulo-interstitial diseases. Maintaining a high degree of attention in the care of CKD patients with proteinuria is fundamental to effectively retard progression toward kidney failure. However, substantial research efforts are still needed to develop treatment strategies that may help the vast majority of CKD patients who eventually develop ESKD via mechanistic pathways other than proteinuria.

Assessing key cost drivers associated with caring for chronic kidney disease patients

BackgroundTo examine key factors influencing chronic kidney disease (CKD) patients’ total expenditure and offer recommendations on how to reduce total cost of CKD care without compromising quality.MethodsUsing the 2002–2011 Medical Expenditure Panel Survey (MEPS) data, our cross-sectional study analyzed 197 patient records—79 patients with one record and 59 with two entries per patient (138 unique patients). We used three patient groups, based on international statistical classification of diseases version 9 code for condition (ICD9CODX) classification, to focus inference from the analysis: (a) non-dialysis dependent CKD, (b) dialysis and (c) transplant. Covariate information included region, demographic, co-morbid conditions and types of services. We used descriptive methods and multivariate generalized linear models to understand the impact of cost drivers. We compared actual and predicted CKD cost of care data using a hold-out sample of nine, randomly selected patients to validate the models.ResultsTotal costs were significantly affected by treatment type, with dialysis being significantly higher than non-dialysis and transplant groups. Costs were highest in the West region of the U.S. Average costs for patients with public insurance were significantly higher than patients with private insurance (p < .0743), and likewise, for patients with co-morbid conditions over those without co-morbid conditions (p < .001).ConclusionsManaging CKD patients both before and after the onset of dialysis treatment and managing co-morbid conditions in individuals with CKD are potential sources of substantial cost savings in the care of CKD patients. Comparing total costs pre and post the United States Affordable Care Act could provide invaluable insights into managing the cost-quality tradeoff in CKD care.

Perspectives on optimizing care of patients in multidisciplinary chronic kidney disease clinics.

Purpose of reviewTo summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), the Canadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) entitled “Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease (CKD) Clinics” that was held on April 24, 2015, in Montreal, Quebec.Sources of informationThe panel consisted of a variety of members from across Canada including a multidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. Josee Verdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin).FindingsThe objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2) to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examine the components required for optimal care including education strategies, structures, and tools, and (4) to describe a framework and metrics for CKD care which respect patient and system needs. This article summarizes the key concepts discussed at the symposium from a patient and physician perspectives. Key messages include (1) understanding patient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinary CKD clinic and provincial renal program models, (2) barriers to effective communication and education are common in the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shared decision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practice variability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful in approaching variability as well as measuring and improving patient outcomes.LimitationsThe perspectives provided may not be applicable across centers given the differences in patient populations including age, ethnicity, culture, language, socioeconomic status, education, and multidisciplinary CKD clinic structure and function.ImplicationsKnowledge transmission by collaborative interprovincial and interprofessional networks may play a role in facilitating optimal CKD care. Validation of system and clinic models that improve outcomes is needed prior to disseminating these best practices.

An observational study of the quality of care for chronic kidney disease: a Buffalo and Albany, New York metropolitan area study.

BackgroundThe database of a major regional health insurer was employed to identify the number and frequency of covered patients with chronic kidney disease (CKD). We then examined the characteristics of their care as defined, in part, by the frequency of physician visits and specialty referral, the characteristics of laboratory testing and total costs as indices of the quality of care of the subject population.MethodsThis retrospective, cross-sectional study analyzed insurance claims, laboratory results and medication prescription data. Patients with two estimated glomerular filtration rate readings below 60 ml/min/1.73 m2 (n = 20,388) were identified and classified by CKD stage.ResultsThe prevalence of CKD stages 3a and above was 12 %. Vascular comorbidities were common with prevalence increasing steadily from stage 3a through stage 5. Only 55.6 % of stage 4 CKD patients had claims for nephrology visits within one year of their index date. Fifty-nine percent of patients had claims for renin-angiotensin system (RAS) blockers. Twenty-five percent of patients in stage 3a CKD filled a prescription for non-steroidal anti-inflammatory drugs. Fifty-two percent of patients who developed end-stage renal disease received their first dialysis treatment as inpatients.ConclusionsThe pattern of medical practice observed highlights apparent deficiencies in the care of CKD patients including inappropriate medication use, delayed nephrology referral, and a lack of preparation for dialysis. This study shows the potential value of using large patient databases available through insurers to assess and likely improve regional CKD care.

Chronic Kidney Disease Guideline Implementation in Primary Care: A Qualitative Report from the TRANSLATE CKD Study.

Primary care physicians (PCPs) are optimally situated to identify and manage early stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national, mixed-methods, cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. As part of the mixed-methods process evaluation, semistructured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the 4 domains of Normalization Process Theory (NPT). Identified themes illuminated the complex work undertaken to manage CKD in primary care practices. Barriers to guideline implementation were identified in each of the 4 NPT domains, including (1) lack of knowledge and understanding around CKD (coherence), (2) difficulties engaging providers and patients in CKD management (cognitive participation), (3) limited time and competing demands (collective action), and (4) challenges obtaining and using data to monitor progress (reflexive monitoring). Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care.

An adsorbent monolith device to augment the removal of uraemic toxins during haemodialysis

Adsorbents designed with porosity which allows the removal of protein bound and high molecular weight uraemic toxins may improve the effectiveness of haemodialysis treatment of chronic kidney disease (CKD). A nanoporous activated carbon monolith prototype designed for direct blood contact was first assessed for its capacity to remove albumin bound marker toxins indoxyl sulphate (IS), p-cresyl sulphate (p-CS) and high molecular weight cytokine interleukin-6 in spiked healthy donor studies. Haemodialysis patient blood samples were then used to measure the presence of these markers in pre- and post-dialysis blood and their removal by adsorbent recirculation of post-dialysis blood samples. Nanopores (20–100 nm) were necessary for marker uraemic toxin removal during in vitro studies. Limited removal of IS and p-CS occurred during haemodialysis, whereas almost complete removal occurred following perfusion through the carbon monoliths suggesting a key role for such adsorbent therapies in CKD patient care.

Renal rehabilitation: the benefits, barriers and exercise options

This article discusses the benefits of well-designed exercise provision, appropriate for chronic kidney disease (CKD), such as enhanced functional capacity, improvements in quality of life, and weight maintenance. However, these things are not usually provided as part of routine care for CKD patients.

New models of chronic kidney disease care including pharmacists: improving medication reconciliation and medication management.

Patients with chronic kidney disease (CKD) are complex, have many medication-related problems (MRPs) and high rates of medication nonadherence, and are less adherent to some medications than patients with higher levels of kidney function. Nonadherence in CKD patients increases the odds of uncontrolled hypertension, which can increase the risk of CKD progression. This review discusses reasons for gaps in medication-related care for CKD patients, pharmacy services to reduce these gaps and successful models that incorporate pharmacist care. Pharmacists are currently being trained to deliver patient-centred care, including identification and management of MRPs and helping patients overcome barriers to improve medication adherence. A growing body of evidence indicates that pharmacist services for CKD patients, including medication reconciliation and medication therapy management, positively affect clinical and cost outcomes, including lower rates of decline in glomerular filtration rates, reduced mortality and fewer hospitalizations and hospital days, but more robust research is needed. Team-based models including pharmacists exist today and are being studied in a wide range of innovative care and reimbursement models. Opportunities are growing to include pharmacists as integral members of CKD and dialysis healthcare teams to reduce MRPs, increase medication adherence and improve patient outcomes.

ADVANCE CARE PLANNING AND END-OF-LIFE CARE IN ADVANCED RENAL FAILURE

People with advanced chronic kidney disease (CKD) have high mortality; substantial physical, emotional and spiritual suffering; and tremendous end-of-life (EOL) care needs. However, their illness trajectories and needs differ from...

Motivational Interviewing for Patients with Chronic Kidney Disease

Successful management of chronic kidney disease (CKD) typically involves consideration of several lifestyle changes and treatments that could improve patients' health outcomes. The complexity of behavioral changes and treatment decisions that must be made by patients, with the support of their treatment team, could diminish their motivation to address CKD and lead to poorer treatment outcomes. Hence, motivational enhancement, in the context of patient education and shared decision-making with the treatment team, is a critical issue in CKD patient care. This article describes how motivational interviewing can be used with patients to enhance their motivation to address CKD and participate in treatment.

Efficacy of an internet-based tool for improving physician knowledge of chronic kidney disease: an observational study

BackgroundEarly recognition and management of chronic kidney disease (CKD) are associated with better outcomes. Internal medicine residency should prepare physicians to diagnose and manage CKD.MethodsTo examine whether residency training and program characteristics were associated with CKD knowledge and investigate the effectiveness of an internet-based training module in improving CKD knowledge, we analyzed data from CKD training modules administered annually to U.S. internal medicine residents from July 1, 2005 to June 30, 2009. Baseline CKD knowledge was assessed using pre-tests. The modules’ effectiveness was evaluated by post-tests. Comparisons were performed using X2 tests and paired t-tests.ResultsOf 4,702 residents, 38%, 33%, and 29% were program year (PGY)-1, PGY-2, and PGY-3, respectively. Baseline CKD knowledge was poor, with mean pre-test scores of 45.1-57.0% across the four years. The lowest pre-test performance was on CKD recognition. Pre-test scores were better with higher training levels (P-trend < 0.001 except 2005–2006 [P-trend = 0.35]). Affiliation with a renal fellowship program or program location within a region of high end-stage kidney disease prevalence was not associated with better baseline CKD knowledge. Completion of the CKD module led to significant improvements from pre- to post-test scores (mean improvement 27.8% [SD: 21.3%] which were consistent from 2005 to 2009.ConclusionsKnowledge of diagnosis and management of CKD improves during residency training but remains poor among graduating residents. Web-based training can be effective in educating physicians on CKD-related issues. Studies are needed to determine whether knowledge gained from such an intervention translates to improved care of CKD patients.

Use of administrative databases for health-care planning in CKD

Good-quality information is required to plan healthcare services for patients with chronic diseases. Such information includes measures of disease burden, current care patterns and gaps in care based on quality-of-care indicators and clinical outcomes. Administrative data have long been used as a source of information for policy decisions related to the management of chronic diseases including cardiovascular disease, diabetes and hypertension. More recently, chronic kidney disease (CKD) has been acknowledged as a significant public health issue. Administrative data, particularly when supplemented by the use of routine laboratory data, have the potential to inform the development of optimal CKD care strategies, generate hypotheses about how to slow disease progression and identify risk factors for adverse outcomes. Available data may allow case identification and assessment of rates and patterns of disease progression, evaluation of risk and complications, including current gaps in care, and an estimation of associated costs. In this article, we use the example of the Alberta Kidney Disease Network to describe how researchers and policy makers can collaborate, using administrative data sources to guide health policy for the care of CKD patients.

Evaluating the illness perception questionnaire on patients with chronic kidney disease in Sweden

The Revised Illness Perception Questionnaire (IPQ-R) measures illness perception according to the Common Sense Model of Self-Regulation. Illness perception relates to coping, health management, treatment outcomes and health-related quality of life. IPQ-R has been used in many contexts. However, there is yet no Swedish version evaluated for validity, reliability and usability in the context of a Swedish, adult population with Chronic Kidney Disease (CKD). To evaluate usability and psychometric properties of a Swedish translation of IPQ-R on a group of adults in different stages of CKD. Usability evaluation was carried out through cognitive interviews and psychometrics was assessed by internal consistency, test-retest, inter-correlations, correlations to health-related quality of life and coping and testing for concurrent validity. Content validity was strongly supported, but an uncertainty assessing symptoms attributed to CKD was indicated. All dimensions showed internal consistency, except the treatment control dimension. The IPQ-R showed good stability over time except the personal control dimension. Most IPQ-R dimensions distinguished illness representations between groups of different disease stages and symptom burden. The most supported IPQ-R dimensions for inter-correlations and convergent validity were identity, timeline cyclical, consequences and emotional representations. The evaluation of the Swedish version of IPQ-R on patients with CKD showed support for construct validity, except for the dimensions controllability, illness coherence and timeline, which were less supported. These dimensions should therefore be interpreted with care in CKD patients. There is a need to capture uncertainty regarding illness identity. IPQ-R should be interpreted with care in earlier stages of CKD or if few symptoms are reported. IPQ-R may be applicable and useful as a tool in nursing practice to support healthy behaviour as well as assessing clinical interventions in patients with CKD.

Pharmaceutical care in chronic kidney disease: experience at Grenoble University Hospital from 2006 to 2010

Clinical pharmacists (CPs) specifically manage lab-test follow-up, adapt drug dosage according to guidelines and evaluate cardiovascular risk factors and decline in renal function. The aim of this study was to assess the impact of clinical pharmacy services in outpatient nephrology clinics. For each patient, medical history and current treatment were obtained. Each intervention was classified according to the Act-IP document of the French Society of Clinical Pharmacy. This tool contains identifications and guidelines for prevention and resolution of drug-related problems (DRPs). From January 2008 until April 2009, 42 patients seen by the CP on at least 2 visits were included in the study. We observed 350 pharmaceutical consultations and 263 interventions. The pharmaceutical interventions concerned: untreated indication (30%), underdosage (25.9%) and overdosage (18.3%). The CP interventions consisted of: adapting doses (42.2%) and adding treatments (31.9%). The main drugs involved concerned the cardiovascular (33.1%), digestive-metabolic (28.6%) and hematopoietic (21.6%) systems. The inclusion of a CP in the management of chronic kidney disease (CKD) patients is necessary for identification and prevention of DRPs. Besides the medical improvement of CKD patients, the CP participates in the development of prescription recommendations and therapeutic education programs for patients. Moreover, redefining roles and practices of members of a clinical team proved its efficiency in optimizing the medical care of CKD patients. Furthermore, patient entry into dialysis is postponed, which leads to a reduction in costs for health care insurance.

Chronic Kidney Disease Progression and Outcome According to Serum Phosphorus in Mild-to-Moderate Kidney Dysfunction

Several factors might alter serum phosphate homeostasis and induce hyperhosphatemia in patients with chronic kidney disease (CKD) not requiring dialysis. However, whether and to what extent hyperphosphatemia is associated with a poor prognosis in different CKD patient groups remain to be elucidated. We utilized the "Prevenzione Insufficienza Renale Progressiva" (PIRP) database, a large project sponsored by the Emilia-Romagna Health Institute. PIRP is a collaborative network of nephrologists and general practitioners located in the Emilia-Romagna region, Italy, aimed at increasing awareness of CKD complications and optimizing CKD patient care. We identified 1716 patients who underwent a GFR and serum phosphorous assessment between 2004 and 2007. We tested whether phosphate levels ≥4.3 mg/dl are associated with the risk of CKD progression or all causes of death. Older age and male sex were associated with lower phosphate levels. Instead, higher phosphate levels were noted in patients with diabetes. Patients with phosphate levels ≥4.3 mg/dl were at an increased risk of starting dialysis or dying (hazard ratio 2.04; 95% confidence interval [1.44, 2.90]). Notably, subgroup analyses revealed that the magnitude of the risk associated with hyperphosphatemia varied depending on age, sex, diabetes, and different stages of CKD. These analyses lend support to the hypothesis that phosphorous abnormalities might have a negative effect on the residual renal function and prognosis in different groups of CKD patients. However, the risk associated with hyperphosphatemia might vary in specific CKD patient subgroups.

CE: Continuing Education Article MANAGEMENT OF ANAEMIA IN CHRONIC KIDNEY DISEASE

SUMMARY Anaemia is an almost universal issue that develops in the later stages of chronic kidney disease (CKD) primarily due to a lack of erythropoietin (EPO) and the depressed EPO response in bone marrow. This can have a profound effect on the patient's lifestyle and quality of life. Knowledge of both the psychosocial and clinical areas of CKD is imperative for healthcare professionals so that they can be at the forefront of improvements of CKD patient care.