Chronic kidney disease is a term referring to the failure of the kidneys to purify the blood from metabolic waste products that normally are eliminated via the urine. This results in an internal intoxication causing malfunctioning of virtually any organ (uremia). Chronic kidney disease is usually caused by inflammatory or toxic damage to the kidneys, resulting in scar tissue (fibrosis). Chronic kidney disease is often the consequence of other chronic conditions, especially hypertension, diabetes mellitus, cardiovascular disease, but also obesity, cancer and liver disease. Chronic kidney disease by itself is in its turn at the origin of multiple complications, most notoriously cardiovascular disease.
Chronic kidney disease affects at least 10% of Europeans. The frequency will rise in the coming years due to ageing and improved survival amongst patients suffering from its causes. It is one of the growing causes of death and will rank death cause number five by 2030.
Although chronic kidney disease in its early stages can be treated conservatively, with drugs and lifestyle measures, more advanced stages require organ replacement therapies such as artificial kidney (dialysis) or transplantation. Especially dialysis causes an additional burden on the patients’ condition. The example below refers to a dialysis patient who is now waiting for his transplantation.
The case of Kidney Disease
Age: 52 year old
Job: Sales-manager in a medium-size company
The Case Of Antonio Who Is Treated By Dialysis
Antonio is a 52-years- old sales manager in a medium-size company in the textile sector. He has been suffering from hypertension for more than 10 years and this together with frequent restaurant meals and business trips has caused chronic kidney disease. Although he stopped smoking a couple of years ago, chronic kidney disease progressed further and he had to start dialysis 6 months ago. He opted for automated peritoneal dialysis, which he hopes will allow him to continue with his job. Yet, he has been on sick leave for a few months before the start of dialysis but also thereafter as he needed some time to adapt to his new situation. Although he will be waitlisted for kidney transplantation, uncertainty about whether he will be able to continue to work is high.
Chronic Kidney Disease
1 What is it
Chronic kidney disease is together with acute kidney injury one of the major types of functional kidney failure. The most important function of the kidneys is to remove metabolic waste products from the blood stream into urine via filtration. Disruption of this function results in the accumulation of these metabolites in the body. Best known is urea which was at the origin of the term uremia, which refers to the gradual intoxication by these solutes as kidney failure progresses. In fact, there are hundreds of such solutes, resulting in the dysfunction of almost every organ, and a large number of potentially fatal complications, the most frequent ones being cardio-vascular disease, bone disease and malnutrition.
One of the main characteristics of chronic kidney disease is that symptoms occur only when it is far advanced. Apart from symptoms related to the causing disorders and the complications of chronic kidney disease, features are atypical but extremely distressing: fatigue, itching, impotence, pain, restless legs, sleeplessness. In addition, in advanced stages and especially when dialysis is initiated, stress, anxiety and depressive symptoms are frequent.
Above all, prevention of the development and progression of chronic kidney disease is of utmost importance. Primarily this consists of lifestyle measures such as healthy diet, exercise, quitting smoking, combating environmental pollution and avoiding medicines that are toxic to the kidneys (e.g. some painkillers). Conditions leading to chronic kidney disease (diabetes mellitus, high blood pressure, obesity, cardiovascular disease) should be optimally treated. Patients with chronic kidney disease are especially prone to retain salt which thus should be restricted in the diet. Likewise phosphate causes cardiovascular and bone disease and intake of phosphate sources (protein, especially cheese and processed meats) should be limited.
In case of far advanced chronic kidney disease, kidney function needs to be replaced by either
dialysis or transplantation. Although some symptoms may persist on dialysis, others improve, helping to recover work skills that were lost in the final pre-dialysis stage of kidney disease. Dialysis can be offered either as hemodialysis (cleaning the blood stream by a machine) or peritoneal dialysis (by instilling fluid into the abdomen). Hemodialysis is performed with intervals, almost always in a hospital. Peritoneal dialysis is usually provided outside the hospital, either on a continuous basis (24/24) or overnight. Dialysis also necessitates surgical interventions, e.g. to create and maintain access to the vascular bed for hemodialysis, or to the abdomen for peritoneal dialysis. Chronic kidney disease requires the intake of many drugs with their own complication profile. After transplantation, the need to suppress the immune system to prevent rejection causes its own specific complications (e.g. infection, diabetes mellitus, bone disease or cancer). However problems due to complications can easily be overcome by adaptations of the work environment, because most of the worker´s capabilities remain intact after transplantation.
4 Psychosocial issues and impact of the disease on employment
Due to the link with many other chronic diseases and the frequent complications provoking sick leaves, hospitalizations and consultations, CKD patients often lose their job during progression of the disease, or during the transition period to dialysis therapy. However, unemployment and the associated risk of depression impose a new health risk to the patient, in addition to a loss of social and economic functions. Therefore, continuing to work is highly recommended for physical and psychological health, also for patients on dialysis. Especially the alternatives to traditional in-hospital hemodialysis like PD, home hemodialysis or overnight dialysis allow patients to continue their activities which increases also their chances to remain at work after the kidney transplantation. However, even if later transplantation often will almost normalize working capacity, many transplanted patients remain unemployed, due to the prolonged jobless period before and on dialysis.
To manage workers with chronic kidney disease and help them continue working or return to their job, the community at large can support a number of interventions
- The medical professionals (nephrologists, nephrology nurses, general practitioners) are to take measures that keep chronic kidney patients at work which include:
- Informing patients that staying at work is beneficial for their mental and financial status, and outcomes;
- Advise employers on the importance of keeping CKD patients at work and on the optimal approaches to realize this;
- Patients should be stimulated to get themselves informed on the best track to remain active. Patient organizations should strive to make this information available, e.g. via weblinks.
- Employers should be stimulated to create conditions that are preventive for kidney disease as well as favoring kidney patients to stay at work. Apart from promoting healthy lifestyle (low sugar, low calory, low salt diet; exercise; smoking ban) and education of workers on healthy lifestyle, these include:
- Create appropriate conditions to keep patients with chronic kidney disease at work, taking into account their capabilities and limitations (avoid strenuous efforts, lifting of heavy weights, brisk shocks or activities that necessitate extreme vigilance);
- Adapt time schedules in function of need for dialysis or consultations;
- Enable chronic kidney disease patients to comply with their dietary needs;
- Provide means and time for chronic kidney disease patients who stayed out of the labor circuit for a long time to catch up with the evolution during their absence.
- Encourage patients to discuss with their fellow workers their disease and how it affects their life and working capabilities.
For further information, see:
Spanish Federation of Kidney Patients (Federación Nacional ALCER) www.alcer.org