What happens at the end of ESRD?

Sometimes referred to as renal failure, kidney failure is the final stage of chronic kidney disease. The patient’s kidneys gradually lose their ability to filter waste and extra water from the blood, creating a build-up within the body, which is terminal when left untreated.

At this point, the patient needs dialysis or a kidney transplant. If neither of these options are available, or if the patient opts to forgo this treatment, hospice care can help in ensuring the patient’s remaining time is as comfortable as possible by managing pain and other symptoms. Once the patient reaches end stage renal disease (ESRD), death usually occurs within a few weeks. This can be longer or shorter depending on the patient’s overall health, and how much kidney function they have left.

As a family caregiver of someone with kidney failure, it is important that you are able to recognize the signs and symptoms of end-stage kidney failure. By knowing how to identify the signs, you can help your loved one in receiving the right care when it’s needed most.

What are the signs of end-of-life kidney failure?

Some of the most common end-of-life kidney failure signs include:

• Water retention/swelling of legs and feet
• Loss of appetite, nausea, and vomiting
• Confusion
• Shortness of breath
• Insomnia and sleep issues
• Itchiness, cramps, and muscle twitches
• Passing very little or no urine
• Drowsiness and fatigue

End-of-life kidney failure can be painful depending on the patient. While patients may experience symptoms including pain, they can be managed with medication and other hospice care services that are designed to meet all the patient’s physical, mental, and emotional needs.

Tips for managing end-of-life kidney failure symptoms.

There are several different ways you can help a loved one manage their end-stage kidney failure symptoms. Perhaps the most valuable thing you can do is listen to your loved one and try as best you can to address their issues. However, if at any time you are unsure of how you can help, or if the patient is unable to communicate effectively, we recommend contacting their primary care physician.

What you can do for your loved one.

Besides managing symptoms, as a family caregiver you can help by communicating what end-of-life kidney failure signs you are seeing to the patient’s doctor and the hospice care team. Additionally, as a loved one, you can help the patient get their affairs in order. And finally, if it hasn’t been done already, by contacting a hospice services provider as soon as possible.

How hospice can help with end-stage kidney failure.

Besides providing help in recognizing the signs of end-of-life kidney failure, hospice can help the family caregiver in managing their own needs. The team at Crossroads Hospice & Palliative Care includes nurses, volunteers, aides, social workers, and doctors who provide many different services, from personal care like grooming and bathing, to help with managing the patient’s medication.

If you would like to learn more about how Crossroads can help, we recommend you contact us now by selecting one of the “24/7 Help” options from the green bar at the top of this page.

More than 500,000 people in the United States live with end-stage renal disease (ESRD). The development of chronic kidney disease (CKD) and its progression to this terminal disease remains a significant source of reduced quality of life and significant premature mortality. The Kidney Disease Improving Global Outcomes (KDIGO) define CKD using markers of kidney damage, specifically markers that determine proteinuria and glomerular filtration rate. This activity explains when this condition should be considered on the differential diagnosis, articulates how to properly evaluate for this condition, and highlights the interprofessional team's role in caring for patients with this condition.

Objectives:

• Describe the causes of end-stage renal disease.

• Outline the presentation of a patient with end-stage renal disease.

• Summarize the treatment options for end-stage renal disease.

• Outline interprofessional team strategies for improving care coordination and communication to advance care bundle approaches to manage and improve outcomes in end-stage renal disease.

Introduction

More than 500,000 people in the United States live with end-stage renal disease (ESRD). The development of chronic kidney disease (CKD) and its progression to this terminal disease remains a significant source of reduced quality of life and significant premature mortality. Chronic kidney disease (CKD) is a debilitating disease, and standards of medical care involve aggressive monitoring for signs of disease progression and early referral to specialists for dialysis or possible renal transplant. The Kidney Disease Improving Global Outcomes (KDIGO) foundation guidelines define CKD using kidney damage markers, specifically markers that determine proteinuria and glomerular filtration rate. By definition, the presence of both of these factors (glomerular filtration rate [GFR] less than 60 mL/min and albumin greater than 30 mg per gram of creatinine) along with abnormalities of kidney structure or function for greater than three months signifies chronic kidney disease. End-stage renal disease, moreover, is defined as a GFR less than 15 mL/min.

According to KDIGO 2012 clinical practice guideline, CKD is classified into five stages considering the GFR level.

• Stage 1: Kidney damage with normal GFR (greater than 90 ml/min)

• Stage 2: Mild reduction in GFR (60-89 mL/min)

• Stage 3a: Moderate reduction in GFR (45 to 59 mL/min)

• Stage 3b: Moderate reduction in GFR (30 to 44 mL/min)

• Stage 4: Severe reduction in GFR (15 to 29 mL/min)

• Stage 5: Renal failure (GFR less than 15 mL/min)

Etiology

Many chronic diseases can cause end-stage renal disease. In the United States, diabetes mellitus is the leading cause. Other causes include:

• Glomerular disease (primary or secondary)

• Tubulointerstitial disease

• Urinary tract obstruction or dysfunction

• Recurrent kidney stone disease

• Congenital (birth) defects of the kidney or bladder

• Unrecovered acute kidney injury

• Certain medications, including non-steroidal anti-inflammatory drugs (NSAIDs), calcineurin inhibitors, and antiretrovirals

1. Vascular Diseases

   • Cytoplasmic pattern antineutrophil cytoplasmic antibody (C-ANCA)–positive and perinuclear pattern antineutrophil cytoplasmic antibody (P-ANCA)–positive vasculitides

   • ANCA-negative vasculitides

   • Hypertensive nephrosclerosis

2. Primary Glomerular Diseases

   • Immunoglobulin A (IgA) nephropathy

   • Focal and segmental glomerulosclerosis (FSGS)

   • Membranoproliferative glomerulonephritis (MPGN)

   • Complement-related diseases (atypical hemolytic-uremic syndrome [HUS], dense deposit disease)

   • Rapidly progressive (crescentic) glomerulonephritis

3. Secondary Causes of Glomerular Disease

   • Systemic lupus erythematosus

   • Mixed connective tissue disease

   • Granulomatosis with polyangiitis (formerly known as Wegener granulomatosis)

   • Human immunodeficiency virus (HIV) infection

   • Light-chain deposition disease

   • Thrombotic thrombocytopenic purpura (TTP)

   • Shiga-toxin or Streptococcus pneumoniae – related HUS

4. Causes of Tubulointerstitial Disease

   • Drugs (eg, sulfonamides, allopurinol)

   • Infection (viral, bacterial, parasitic)

   • Tubulointerstitial nephritis and uveitis (TINU) syndrome

   • Multiple myeloma cast nephropathy

   • Cystinosis and other inherited diseases

5. Urinary Tract Obstruction

   • Benign prostatic hypertrophy

   • Urolithiasis (kidney stones)

   • Congenital (birth) defects of the kidney or bladder

Epidemiology

According to the United States Renal Data System, in 2015, there were 124,411 new ESRD diagnoses, reflecting an increasing burden of kidney failure. The prevalence of the disease has been rising at a stable number of about 20,000 cases per year. Kidney disease is the ninth leading cause of death in the United States.

Race/Ethnicity

The degree of kidney failure varies widely by race in the US. In 2015, the rate of ESRD was three times higher in African Americans as compared to Caucasians (393.5 versus 139.9 per million population). In that same year, the ESRD prevalence was about ten times higher in American Indians or Alaska Natives and twice as high in Native Hawaiians or Pacific Islanders. Prevalence rates were 1.3 times higher in Asian Americans, as well. Of note, incidence rates in the African American population have been decreasing each year since 2006, leading to an overall decrease of 21%. This reduction has been even more pronounced in American Indians/Alaska Natives.

Age

The prevalence of CKD increases with age with the most rapid growth in people aged 60 years or older. The prevalence is 6.0% at age 18-44 years and 38.1% at age more than 65 years.

Sex

The cumulative incidence of end-stage renal disease is more in males as compared to females.

Pathophysiology

Each nephron in a normal kidney contributes to the total glomerular filtration rate (GFR). The decline of kidney function is gradual and initially may present asymptomatically. The natural history of renal failure depends on the etiology of the disease but ultimately involves early homeostatic mechanisms involving hyperfiltration of the nephrons. The kidney maintains GFR, despite progressive destruction of nephrons, because the remaining normal nephrons develop hyperfiltration and compensatory hypertrophy. As a result, the patient with mild renal impairment can show normal creatinine values, and the disease can go undetected for some time. This nephron adaptability allows for continued normal clearance of plasma solutes. This adaptive mechanism will run its course and eventually cause damage to the glomeruli of the remaining nephrons. At this point, antihypertensives such as ACEs or ARBs may be beneficial in slowing the progress of the disease and preserving renal function. Plasma levels of substances such as urea and creatinine start to show measurable increases only after total GFR has decreased 50%. For example, a rise in plasma creatinine from 0.6 mg/dL to 1.2 mg/dL in a patient, although within the normal range, actually represents a loss of 50% of functioning nephron mass.

Although hyperfiltration and hypertrophy of residual nephrons are beneficial for the maintenance of GFR, it is found to be a major cause of progressive renal dysfunction. The increased glomerular capillary pressure may damage the capillaries, leading to focal and segmental glomerulosclerosis (FSGS) and eventually to global glomerulosclerosis.

Factors that may worsen renal injury include:

Hyperkalemia

Potassium excretion at near-normal levels is generally maintained in CKD, as long as aldosterone secretion and distal flow are maintained. Hyperkalemia develops when GFR falls to less than 20-25 mL/min/1.73 m², at this point, the kidneys have decreased ability to excrete potassium.

Metabolic Acidosis

Metabolic acidosis in stage 5 CKD is high anion gap metabolic acidosis but with the anion gap generally not higher than 20 mEq/L. In CKD, the kidneys cannot produce enough ammonia in the proximal tubules to excrete the endogenous acid into the urine in the form of ammonium. In stage 5 CKD, the accumulation of phosphates, sulfates, and other organic anions is the cause of the increase in the anion gap.

Metabolic acidosis has deleterious effects on protein balance, leading to:

• Negative nitrogen balance

• Increased protein degradation

• The increased essential amino acid oxidation

• Reduced albumin synthesis

• Lack of adaptation to a low-protein diet 

Metabolic acidosis also plays a role in the development of renal osteodystrophy, because bones are buffer for excess acid, with resultant loss of minerals. Acidosis also interferes with vitamin D metabolism.

Salt and Water Handling Abnormalities

Salt and water handling by the kidney is affected in CKD. Volume overload results from failure of sodium and free-water excretion and occur when the GFR falls to less than 10-15 mL/min/1.73 m². This leads to peripheral edema, pulmonary edema, and hypertension. Tubulointerstitial renal diseases often cause fluid loss rather than overload. Thus, despite severe reductions in GFR, tubulointerstitial renal diseases may manifest as polyuria and volume depletion, with the inability to concentrate the urine.

 Anemia

Normochromic normocytic anemia develops from the decreased renal synthesis of erythropoietin, the hormone responsible for bone marrow stimulation for red blood cell (RBC) production. Other causes of anemia in CKD include the following:

• Chronic blood loss: Uremia-induced platelet dysfunction enhances the bleeding tendency

• Secondary hyperparathyroidism

Bone Disease

Renal bone disease is a common complication of CKD. Different types of the bone disease occur with CKD, as follows:

• High-turnover bone disease from high parathyroid hormone (PTH) levels

• Low-turnover bone disease (adynamic bone disease)

• Defective mineralization (osteomalacia)

• Beta-2-microglobulin–associated bone disease 

Secondary hyperparathyroidism develops in CKD because of the following factors:

• Decreased renal synthesis of 1,25-dihydroxycholecalciferol (1,25-dihydroxyvitamin D, or calcitriol)

• Intrinsic alteration in the parathyroid glands, which gives rise to increased PTH secretion and increased parathyroid growth

• Skeletal resistance to PTH

 Hyperphosphatemia and hypocalcemia  

Hyperphosphatemia develops from the inability of the kidneys to excrete excess phosphate. Hyperphosphatemia suppresses the renal hydroxylation of inactive 25-hydroxyvitamin D to calcitriol. Increased phosphate concentration also affects PTH concentration by its direct effect on the parathyroid glands (posttranscriptional effect). Hypocalcemia results from decreased intestinal calcium absorption because of low plasma calcitriol levels.

Increased PTH secretion

Hypocalcemia, hyperphosphatemia, and low serum calcitriol levels stimulate PTH synthesis and secretion. With persistent stimulus in advanced CKD, parathyroid glands become hypertrophic and then hyperplastic.

History and Physical

End-stage renal disease can present with a constellation of signs and symptoms. Some include volume overload refractory to diuretics, hypertension poorly responsive to medication, anemia, mineral and bone disorders, and metabolic derangements including hyperkalemia, hyponatremia, metabolic acidosis, hypo/hypercalcemia, and hyperphosphatemia. Metabolic acidosis in stage 5 CKD presents as protein-energy malnutrition, muscle weakness, and loss of lean body mass. Salt and water retention can cause peripheral edema, pulmonary edema, and hypertension. Anemia manifests as fatigue, impaired cognitive function, and reduced quality of life. Anemia can also lead to heart failure.

Other manifestations of uremia in end-stage renal disease (ESRD) are:

• Anorexia, nausea, vomiting, diarrhea

• Dry skin, pruritus, ecchymosis

• Erectile dysfunction, decreased libido, amenorrhea

Uremic toxicity is an indication for urgent dialysis. In general, ESRD symptoms appear in stages 4 and 5 when the GFR is less than 30 ml/min. Some patients with nephrotic syndrome and cystic renal disease may present earlier. Depression is ubiquitous in patients with ESRD and should be screened for on presentation.

Evaluation

Chronic kidney disease is diagnosed when there is evidence of kidney damage for at least three months or in any patient with a GFR of less than 60 mL/min for that same amount of time.

To calculate GFR, three equations are commonly used (the MDRD [Modification of Diet in Renal Disease Study], CKD-EPI, and Cockcroft-Gault formula). However, the best estimate of GFR is the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation, which adjusts for age, race, and gender. However, it is important to note that the formula tends to underestimate the actual GFR at a GFR greater than 60 mL/min.

Further evaluation of kidney disease can include a renal ultrasound, complete blood count (CBC), basic metabolic panel (BMP), urinalysis, and/or kidney biopsy.

Complete Blood Count

CBC shows normochromic normocytic anemia.

Basic Metabolic Panel (BMP)

The blood urea nitrogen (BUN) and serum creatinine levels are elevated. Hyperkalemia or low bicarbonate levels are usually present. Serum albumin levels are low due to urinary protein loss or malnutrition. Serum phosphate, 25-hydroxyvitamin D, alkaline phosphatase, and intact parathyroid hormone (PTH) levels are obtained to look for evidence of renal bone disease. A lipid profile should be obtained because of the risk of cardiovascular disease.

Urinalysis

To quantitate albuminuria, a spot urine protein/creatinine ratio can be done. A value higher than 30 mg of albumin per gram of creatinine is considered abnormal, while values greater than 300mg/g are considered severely impaired renal function. Additionally, a 24-hour urine protein can also be performed. A value greater than 3.5 g is concerning for nephrotic range proteinuria.

Renal Ultrasonography

Renal ultrasonography should be done to look for hydronephrosis or involvement of the retroperitoneum with fibrosis, tumor, or diffuse adenopathy. Small, echogenic kidneys are observed in advanced renal failure. While in diabetic nephropathy kidneys are normal in size. Structural abnormalities like polycystic kidneys also may be observed on ultrasonograms. An ultrasound can provide data estimating size, obstructions, stones, echogenicity, and cortical thinning.

Radiology

Plain abdominal radiography can detect radio-opaque stones or nephrocalcinosis, while a voiding cystourethrogram (VCUG) is diagnostic for vesicoureteral reflux.

Computed tomography (CT) scanning can help in a better description of renal masses and cysts and is also sensitive for identifying renal stones.

Magnetic resonance angiography (MRA) can accurately diagnose renal artery stenosis.

A renal radionuclide scan with captopril administration can diagnose renal artery stenosis and it also quantitates differential renal contribution to total glomerular filtration rate (GFR).

Renal Biopsy

Percutaneous ultrasound-guided renal biopsy is indicated when the diagnosis is unclear after an appropriate workup.

Specific Tests

• Serum and urine protein electrophoresis for multiple myeloma

• Antinuclear antibodies (ANA), double-stranded DNA antibody levels for systemic lupus erythematosus

• Cytoplasmic and perinuclear pattern antineutrophil cytoplasmic antibody (C-ANCA and P-ANCA) levels for granulomatosis with polyangiitis (Wegener granulomatosis) and microscopic polyangiitis

• Anti–glomerular basement membrane (anti-GBM) antibodies for Goodpasture syndrome

• Hepatitis B and C, Venereal Disease Research Laboratory (VDRL) serology. human immunodeficiency virus (HIV)

Treatment / Management

Treatment of end-stage renal disease involves correcting parameters at the level of the patient's presentation. Interventions aimed at slowing the rate of kidney disease should be initiated and can include:

• Treating the underlying cause and managing blood pressure and proteinuria. Blood pressure should be targeted to a systolic blood pressure less than 130 mmHg and diastolic blood pressure less than 80 mmHg in adults with or without diabetes mellitus whose urine albumin excretion exceeds 30 mg for 24 hours. For diabetic patients with proteinuria, an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin 2 receptor blocker (ARB) should be started in cases where urine albumin values range between 30 and 300 mg in 24 hours and greater than 300 mg in 24 hours. These drugs slow the disease progression, particularly when initiated before the GFR decreases to less than 60 mL/min or before plasma creatinine concentration exceeds 1.2 and 1.5 in women and men, respectively.

• Other targets in preventive care and monitoring should include tight glycemic control, cardiovascular risk reduction, and general lifestyle recommendations such as smoking cessation and dietary restriction. Glycemic control is critical. A hemoglobin A1C of less than 7% is generally recommended to prevent or delay microvascular complications in this population. Management with sodium-glucose transporter 2 (SGLT-2) inhibitors may reduce the disease burden in those with type 2 diabetes mellitus.

• Treatment of chronic metabolic acidosis with supplemental renal bicarbonate also may slow the progression of end-stage renal disease.

• Patients with CKD tend to have dyslipidemia, particularly hypertriglyceridemia. Monitoring fasting lipid panels and initiation of cholesterol-lowering agents such as HMG-CoA reductase inhibitors should be done early in the course of the disease.

• Volume overload or pulmonary edema should be treated with loop diuretics or ultrafiltration.

• For uremic manifestations, long-term renal replacement therapy (hemodialysis, peritoneal dialysis, or kidney transplantation) is needed.

• Anemia is treated with an erythropoiesis-stimulating agent (ESA) such as erythropoietin.

• Hyperphosphatemia is treated with phosphate binders (calcium acetate, sevelamer carbonate, or lanthanum carbonate) and dietary phosphate restriction.

• Lifestyle modification and dietary restrictions are routinely recommended. Adhering to a low salt diet (less than 2 g/day), a renal diet (avoiding foods that are high in phosphorus), and restricting daily protein to 0.8 g per kg body weight per day is essential to managing disease burden.

• Hypocalcemia should also be monitored. A 25-OH vitamin D level less than 10 ng/mL warrants initiation of ergocalciferol 50,000 IU weekly for 6 to 8 weeks before switching to cholecalciferol 800 to 1000 IU daily.

• Hyperparathyroidism should be treated with calcitriol, vitamin D analogs, or calcimimetics.

Planning for Long-term Renal Replacement Therapy

Early patient education should be initiated regarding natural disease progression, different modalities for dialysis, and renal transplantation. For patients in whom transplantation is not imminent, a primary arteriovenous fistula should be created in advance of the anticipated date of dialysis. Every patient with end-stage renal disease should be timely referred for renal transplantation.

Indications for renal replacement therapy in patients with CKD include the following:

• Severe metabolic acidosis

• Intractable volume overload

• Failure to thrive and malnutrition

• Intractable gastrointestinal symptoms

• Glomerular filtration rate (GFR) of 5-9 mL/min/1.73 m², irrespective of the symptoms or the presence or absence of other comorbidities

Differential Diagnosis

The clinical features of end-stage renal disease mimic many other disorders and also there are many diseases that lead to end-stage renal disease. Therefore the following differentials should be considered whenever assessing a patient with end-stage renal disease.

• Chronic glomerulonephritis

• Rapidly progressive glomerulonephritis

• Nephropathy of pregnancy/pregnancy toxemia

• Polycystic kidney disease

• Systemic lupus erythematosus nephritis

• Renal failure due to a congenital abnormality of metabolism

• Renal/urinary tract tuberculosis

• Renal/urinary tract calculus

• Renal/urinary tract tumor

• Obstructive urinary tract disease

Prognosis

End-stage renal disease is a progressive disorder, and timely renal replacement therapy is necessary to prevent death. The disorder is associated with numerous hospitalizations, increased healthcare costs, and numerous metabolic changes. The mortality rates for patients with end-stage renal disease are significantly higher than those without the disease. Even with timely dialysis, the death rates vary from 20% to 50% over 24 months. The most common cause of death is hyperkalemia, followed by adverse cardiac events. Mortality rates are higher for men than for women, similarly, Blacks are more prone to death due to ESRD than Whites. The highest mortality rate is within the first six months of starting the dialysis. The 5-year survival rate for a patient undergoing long-term dialysis in the United States is approximately 35% and approximately 25% in patients with diabetes.

In children, puberty is delayed in both genders, and low levels of vitamin D are common, which is an independent risk factor for death.

Complications

Complications of end-stage renal disease are divided into two groups. Complications due to ESRD and complications due to vascular access or dialysis.

Complications Due to ESRD

• Coronary heart disease is a significant complication of chronic kidney disease and is the most common cause of death in this population. Patients on dialysis have a 10 to 30 times higher cardiovascular mortality risk than in the general population.

• Peripheral vascular disease is also commonly seen.

• Mineral and bone disorders (secondary to hyperparathyroidism, vitamin D deficiency)

• Decreased libido, erectile dysfunction

Complications Due to Vascular Access/Dialysis

• Local or disseminated intravascular infection

• Electrolyte abnormalities after dialysis

• Dialysis disequilibrium syndrome

Consultations

The management of end-stage renal disease requires a dedicated interprofessional healthcare team comprising of the following:

Deterrence and Patient Education

The U.S. Preventive Services Task Force (USPSTF) does not recommend screening of asymptomatic individuals for CKD. However, for those at higher risk for the disease, such as those with diabetes or hypertension, USPSTF recommends ongoing screening for CKD with proteinuria testing. However, it is important to note that a patient who is already on ACEI or ARB therapy screening for proteinuria is not necessary.

Patients with end-stage renal disease should be educated about the following:

• Avoidance of nephrotoxic drugs like non-steroidal anti-inflammatory drugs

• Advanced counseling for renal replacement modalities, including peritoneal dialysis, hemodialysis, and transplantation

• Timely placement of vascular access for hemodialysis

• Pregnancy could be fatal in ESRD

• Avoid phosphate-rich foods

• Potassium restriction in diet

• Sodium and water restriction to avoid volume overload

• Protein restriction to delay the onset of uremic symptoms

• Reduction in salt intake may slow the progression of diabetic CKD

Pearls and Other Issues

• ESRD is a terminal illness defined as having a glomerular filtration rate of less than 15 mL/min.

• The most common cause of ESRD in the US is diabetic nephropathy, followed by hypertension.

• Other etiologies can include glomerulonephritis, cystic kidney disease, recurrent kidney infection, chronic obstruction, etc.

• The disease can present with nausea, vomiting, metabolic, hematologic, electrolyte derangements, seizures, coma, bleeding diathesis, refractory fluid overload, and hypertension unresponsive to pharmacotherapy, uremic pericarditis, etc.

• Vigilant monitoring of GFR and proteinuria in diabetics and non-diabetics is essential for managing disease progression in patients with chronic kidney disease.

• Early referral to specialists is necessary for timely dialysis or renal transplant planning.

Enhancing Healthcare Team Outcomes

Once a patient has been diagnosed with ESRD, a significant number of them will require dialysis, and the lucky few may be eligible for a renal transplant. End-stage renal failure significantly increases morbidity and mortality; it also leads to enormous costs to the healthcare system. Thus, the disorder is best managed by an interprofessional team that is dedicated to adequate disease control and improving outcomes for these patients.

There is no cure for end-stage renal disease, and all the available treatments are short-term. Thus, the key to improving long-term outcomes is in preventing the progression of the disease.

A dedicated interprofessional healthcare team should be comprised of a nurse educator, a specialized pharmacist, a nutritionist, a social worker, and a team of clinical providers, including a primary care provider and a trained nephrologist.

The specialized nurse educator plays a vital role in educating the patient about lifestyle modifications necessary to prevent the progression of CKD. In patients with advanced CKD, the dedicated nurse's role become crucial in protecting an arm for future fistula placement. During hospitalizations, the clinical nurse should place limb restrictions on that arm to ensure venipunctures and blood pressure readings are not taken on that arm.

The pharmacist should identify those patients who carry a diagnosis of CKD and provide specialized instructions to these patients, particularly concerning avoiding nephrotoxic agents and medications. The pharmacist plays a crucial role in communicating and guiding the providers about the patient's medications to limit those that can adversely affect the kidneys.

A trained nutritionist should also be involved in the care of these patients to guide an appropriate diet plan specific to their needs.

A social worker should be involved in the care to ensure that the patient has a support system and the financial resources to continue therapy.

To improve outcomes, each interprofessional team member should communicate with the providers and act collaboratively to ensure that the patient is receiving optimal care resulting in the best outcomes. [Level 5]

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What happens in the final stages of kidney failure?

What is the main problem during end

What happens in end

How does end