Ashelford S, Raynsford J, Taylor V. Pathophysiology and pharmacology in nursing, 2nd edn. London: Sage; 2019

Brochard L, Abroug F, Brenner M An Official ATS/ERS/ESICM/SCCM/SRLF Statement: Prevention and Management of Acute Renal Failure in the ICU Patient: an international consensus conference in intensive care medicine. Am J Respir Crit Care Med. 2010; 181:(10)1128-1155

Chen TK, Knicely DH, Grams ME. Chronic kidney disease diagnosis and management. JAMA. 2019; 322:(13)1294-1304

Clarke AL, Yates T, Smith AC, Chilcot J. Patient's perceptions of chronic kidney disease and their association with psychosocial and clinical outcomes: a narrative review. Clin Kidney J. 2016; 9:(3)494-502

Cooper K, Gosnell K. Adult health nursing, 8th edn. St Louis, MO: Elsevier; 2019

Collister D, Pyne L, Cunningham J Multidisciplinary chronic kidney disease clinic practices: a scoping review. Can J Kidney Health Dis. 2019; 6

Donald M, Kahlon BK, Beanlands H Self-management interventions for adults with chronic kidney disease: a scoping review. BMJ Open. 2018; 8:(3)

Gebreyohannes EA, Bhagavathula AS, Abebe TB, Tefera YG, Abegaz TM. Adverse effects and non-adherence to antihypertensive medications in University of Gondar Comprehensive Specialized Hospital. Clin Hypertens. 2019; 25:(1)

Havas K, Bonner A, Douglas C. Self-management support for people with chronic kidney disease: patient perspectives. J Ren Care. 2016; 42:(1)7-14

Jager KJ, Kovesdy C, Langham R, Rosenberg M, Jha V, Zoccali C. A single number for advocacy and communication—worldwide more than 850 million individuals have kidney diseases. Kidney Int. 2019; 96:(5)1048-1050

Jankowski J, Floege J, Fliser D, Böhm M, Marx N. Cardiovascular disease in chronic kidney disease. Circulation. 2021; 143:(11)1157-1172

Jones M, Tomson C. Acute kidney injury and ‘nephrotoxins’: mind your language. Clin Med (Lond). 2018; 18:(5)384-386

Chronic kidney disease in England: The human and financial cost. 2012. (accessed 10 October 2022)

KDIGO. KDIGO clinical practice guideline for acute kidney injury. 2012. (accessed 10 October 2022)

KDIGO. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. 2013. (accessed 10 October 2022)

McMahon E, Campbell K, Mudge D, Bauer J. Achieving salt restriction in chronic kidney disease. Int J Nephrol. 2012; 2012

Mercado MG, Smith DK, Guard EL. Acute kidney injury: diagnosis and management.: Medline; 2019

Nagalingam K. The renal system and associated disorder. Chapter 11, 4th edn. In: Peate I (ed). : Wiley-Blackwell; 2021

National Institute for Health and Care Excellence. Pyelonephritis (acute): antimicrobial prescribing. NICE guideline NG111. 2019a. (accessed 17 October 2022)

National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. NICE guideline NG148. 2019b. (accessed 17 October 2022)

National Institute for Health and Care Excellence. Acute kidney injury. Scenario: management. Clinical Knowledge Summary. 2021a. (accessed 10 October 2022)

National Institute for Health and Care Excellence. Chronic kidney disease in adults: assessment and management. NICE guideline NG203. 2021b. (accessed 10 October 2022)

NHS England. Update on Quality Outcomes Framework changes for 2022/23. 2022. (accessed 17 October 2022)

NHS website. Better health: Drink less. 2022. (accessed 10 October 2022)

Peng S, He J, Huang J Self-management interventions for chronic kidney disease: a systematic review and meta-analysis. BMC Nephrol. 2019; 20:(1)

Pugh D, Gallacher PJ, Dhaun N. Management of hypertension in chronic kidney disease. Drugs. 2020; 80:(13)1381-1386

Rahman M, Shad F, Smith MC. Acute kidney injury: a guide to diagnosis and management. Am Fam Physician. 2012; 86:(7)631-639

Seidu S, Barrat J, Khunti K. Clinical update: The important role of dual kidney function testing (ACR and eGFR) in primary care: Identification of risk and management in type 2 diabetes. Prim Care Diabetes. 2020; 14:(4)370-375

Seki M, Nakayama M, Sakoh T Blood urea nitrogen is independently associated with renal outcomes in Japanese patients with stage 3–5 chronic kidney disease: a prospective observational study. BMC Nephrol. 2019; 20:(1)

Think Kidneys. Information for the public: Think Kidneys awareness campaign. 2017. (accessed 10 October 2022)

Triozzi JL, Parker Gregg L, Virani SS, Navaneethan SD. Management of type 2 diabetes in chronic kidney disease. BMJ Open Diabetes Res Care. 2021; 9:(1)

Wasung ME, Chawla LS, Madero M. Biomarkers of renal function, which and when?. Clin Chim Acta. 2015; 438:350-357

Waugh A, Grant A. Ross and Wilson anatomy and physiology in health and illness, 13th edn. Edinburgh: Elsevier Health Sciences; 2018

Welch JL, Johnson M, Zimmerman L, Russell CL, Perkins SM, Decker BS. Self-management interventions in stages 1 to 4 chronic kidney disease: an integrative review. West J Nurs Res. 2015; 37:(5)652-678

Zabetian A, Sanchez IM, Narayan KMV, Hwang CK, Ali MK. Global rural diabetes prevalence: A systematic review and meta-analysis covering 1990–2012. Diabetes Res Clin Pract. 2014; 104:(2)206-213

Zamboli P, De Nicola L, Minutolo R Effect of furosemide on left ventricular mass in non-dialysis chronic kidney disease patients: a randomized controlled trial. Nephrol Dial Transplant. 2011; 26:(5)1575-1583

The renal system and associated disorders

27 October 2022
Volume 31 · Issue 19


Disorders of the renal system, including the kidneys and urinary tract, are increasingly recognised as a public health concern, accounting for 830 000 deaths worldwide. Patients often have comorbidities, with many presenting with other diseases. Health professionals require good knowledge of the renal system and associated disorders to create holistic care plans to meet individual patients' needs. This article covers the pathophysiology of some of the most common problems, patient assessment and investigations, and considerations in helping patients with self-management.

Disorders of the renal system, including kidneys and urinary tract, are estimated to account for 830 000 deaths each year worldwide and are the 12th biggest cause of death (Jager et al, 2019). Renal disorders cover a range of diseases with different aetiologies, trajectory, functional severity and treatment options, ranging from minor changes in renal function to more serious conditions including acute kidney injury or, if present, in the long term, chronic kidney disease. These patients also tend to present with other comorbidities such as hypertension, diabetes and cardiovascular disease. These are also predictors for the occurrence of acute kidney injury, further aggravating prognosis and mortality outcomes.

When not managed, renal diseases can progress to end-stage renal disease (ESRD) whereby kidney function must be substituted by renal replacement therapy (RRT): haemodialysis, peritoneal dialysis or, when patients fit the selection criteria, transplantation. However, patients are more likely to die from comorbidities, such as cardiovascular causes, than reach ESRD with dialysis intervention, illustrating the complexity of this cohort of patients and the need to manage comorbidities to allow better renal function (Jankowski et al, 2021). Considering the adverse impact of renal disease on public health, awareness of the severity and risks of these conditions is important for nursing practice. Nursing care for this comorbid cohort of patients is challenging as patients can deteriorate quickly. Understanding the different classifications, interventions and the ability to create tailored care plans, is essential to deliver patient-centered care, aiming to improve health-related outcomes.

The renal system: an overview

The renal system plays an important role in homeostasis and its function is to filter approximately 200 litres of fluid each day and allow excretion of toxins and metabolic waste while keeping essential substances in the blood, supporting electrolyte balance. It is composed of the kidneys, ureters, bladder, and urethra (Figure 1). The kidneys regulate the volume and composition of extracellular fluid, removing waste and extra fluid from the body and assisting control of blood pressure, among other functions (Box 1).

Figure 1. The renal and urinary system

Box 1.Functions of the kidney

  • Fluid homeostasis
  • Excretion of urea and creatinine (nitrogenous waste)
  • Electrolyte homeostasis (potassium and sodium)
  • Secretion of renin (control of blood pressure)
  • Production of red blood cells (erythropoiesis)
  • Acid–base balance
  • Synthesis of vitamin D
  • Detoxification
  • Gluconeogenesis (generation of glucose from certain non-carbohydrate carbon substrates)

The two kidneys are found at the back of the abdomen on the posterior wall (retroperitoneal), usually 5–6 cm wide and 3-4 cm thick. The outer border of the kidneys is convex, and the inner border is known as the hilum. The outer capsule of the kidney, called the renal capsule, protects the kidney from damage (Ashelford et al, 2019). It is here that renal arteries, renal veins, nerves and ureters enter and leave the kidneys (Nagalingam, 2021). The kidneys have a rich blood supply from the aorta via the renal artery with approximately 1200 ml of blood flowing through each kidney every minute. Nephrons are situated within the medulla; their main function is to produce urine, which is drained into the tiny ducts.

Urine concentration is controlled by the hypothalamus and the posterior pituitary gland and when an increase in blood osmolality occurs (increased concentration of blood particles), anti-diuretic hormones are released, causing water reabsorption in the kidneys and more concentrated urine. Characteristics of urine change according to a wide range of factors such as fluid or nutrient intake, age, body mass index, exposure to exercise, and environmental temperature.

Urine leaves the kidneys through the ureters, draining into the bladder. The sensory nerve fibres in the bladder wall signal the brain to trigger the process to expel the urine, which is known as micturition, with the bladder in healthy adults holding an average of 500–600 ml of urine before voiding (Waugh and Grant, 2018).

Measuring normal kidney function

Laboratory tests

Monitoring and establishing kidney function through biomarkers allows health professionals to define the parameter of structural, chemical, or physiological change that suggests the presence, severity or progress of a disease (Wasung et al, 2015). However, evidence suggests these biomarkers are not powerful in detecting the early stages of renal disease as kidney injury starts with biological and molecular changes, evolving into cellular damage at a later stage when these would be able to be measured in the blood (Wasung et al, 2015). Kidney function is usually measured through creatinine levels in the blood, or ‘serum creatinine’ (SCr), and blood urea nitrogen (BUN). Another commonly used test, glomerular filtration rate (GFR), is not a biomarker but an estimation of the clearance of filtrate in the glomerulus (Table 1).

Table 1. Renal function laboratory tests
Serum creatinine level Creatinine is the end product of protein metabolism and wear on muscles, directly affected by muscle mass. The more muscle, the higher the creatinine level in the blood. Normal creatinine levels in adults are 59–104 umol/litre for males and 45–84 umol/litre in females.
Blood urea nitrogen test (BUN) Measures the nitrogen component of urea in the blood, it drops as eGFR drops and can be affected by other factors than renal disease such as malnutrition, sepsis, heart failure, hypovolaemia (Seki et al, 2019)
Estimated glomerular filtration rate (eGFR) Calculation through a formula using serum creatinine, age, gender and body mass index. Generally, normal GFR is above 90 ml/minute/1.73m2

Urine tests

Urine output remains a powerful early indicator of kidney injury as to successfully excrete body wastes, an adult must produce around 1 ml/kg or 0.5 ml/kg/hour of urine in relation to their body weight (Waugh and Grant, 2018). Changes in urine characteristics and output can also inform objective history taking and management plans, as these can suggest renal disease. Urinalysis is performed in two parts. The first, usually done in a quick manner when abnormalities are suspected, consists of dipping a reagent strip into urine and noting color changes in each section of the strip (Figure 2).

Figure 2. Urinalysis reagent strip

Specific gravity indicates the concentrating ability of the kidneys, with low values suggesting urine dilution through excessive diuresis. On the other hand, presence of protein in urine (proteinuria) is likely to be a consequence of damage to the glomeruli, often linked to chronic kidney disease (Table 2). The most common protein found in urine is albumin and the degree of albuminuria is usually assessed with the albumin–creatinine ratio (ACR) test (albumin mg / creatinine g) – this measurement is considered along with the GFR to categorise risk for kidney disease progression, morbidity and mortality (Seidu et al, 2020).

Table 2. Urine composition
Components of urine Normal adult values (usually measured in 24-hour collection specimen)
pH 4.5–8.0
Sodium 27–287 mEq/litre/24 hours
Potassium 25–123 mEq/litre/24 hours
Urea 165–583 mmol/litre/24 hours
Creatinine 500–2000 mg/24 hours
Uric acid 1.4–4.5 mmol/24 hours
Phosphorus 0.9–1.3 g/24 hours
Calcium 100–250 mg/24 hours
Chloride 110–250 mEq/litre/24 hours
Ammonia 10 to 105 mEq in 24 hours
Water 96%
Should not have:
  • Ketones
  • Nitrites
  • Blood
  • Glucose
  • Protein
  • Leukocytes
Source: Waugh and Grant, 2018

The next step for urologic diagnosis is often timed urine collection – which may vary in duration from 2 to 24 hours – providing information on how the kidneys excrete and conserve various solutes.

Kidney biopsy

Biopsy might be required to investigate damage caused to the kidneys and aid diagnosis. A small piece of the kidney is taken away to be analysed under a microscope (Cooper and Gosnell, 2019).

Disorders and causes of renal system diseases

Kidney disease has many potential causes and disorders associated with it and prevalence varies by country, ethnicity, gender and age. The following are some of the most commonly seen in practice.


This is inflammation of the bladder, caused by bacteria (E. coli) entering the bladder through the urethra, in other words a urinary tract infection (UTI). Indicators of this in the physical examination and history taking will be:

  • Frequency
  • Urgency
  • Pyuria (increased presence of white blood cells in urine)
  • Dysuria
  • Haematuria
  • Nocturia
  • Abdominal pain or discomfort
  • Urinary incontinence.

The main investigation would be a midstream urine sample. In some cases a flexible cystoscopy (endoscopy of the urinary bladder via the urethra) may be required to detect abnormalities, and urine cytology to rule out renal cancer. Infection is treated with antibiotics and health education should be provided to reduce the likelihood of reinfection: personal hygiene education, especially in women, and regarding voiding urine before and after sexual intercourse. Patients would be advised to increase fluid intake unless contraindicated.

Renal calculi

Stones in the urinary tract are asymptomatic in the early stages, however, patients report colicky pain, haematuria, nausea and vomiting if stones are in the ureters. There is also a dull pain in the suprapubic region after voiding urine. Investigations would involve:

  • Urine analysis to detect UTI and haematuria
  • Abdominal X-ray (to identify urine obstruction)
  • Intravenous pyelogram (shows position of stone)
  • Blood tests – full blood count, urea and electrolytes
  • Cystoscopy.

Interventions for urinary stones would include dietary modification if they are the result of excessive intake of calcium, protein, oxalates (found in chocolate, rhubarb and nuts) or vitamin D. The patient should be encouraged to drink fluids (2.5–3 litres a day), and to make lifestyle changes to include regular exercise to prevent urinary stasis. Patient education should cover recognising the signs of a UTI as well as advice regarding medication adherence, and providing information to reduce their anxiety. Pain management is another key intervention.

Acute pyelonephritis

This is an infection of the upper urinary tract involving both parenchyma and kidney pelvis. It usually starts as an infection of the lower urinary tract, progressing upwards to the kidneys. Patients who are pregnant, have indwelling catheters, diabetes, genitourinary tract abnormalities or immunosuppression are at increased risk of complications (National Institute for Health and Care Excellence (NICE), 2019a).

Symptoms usually develop within hours or over the course of a day (although it should be noted that in children symptoms can be absent).

  • Flank pain
  • Nausea or vomiting
  • Dysuria and haematuria, especially in women
  • Sudden onset of fever
  • Suprapubic tenderness.

Investigations would be first of all a comprehensive history and physical assessment, including any previous medical history of UTI and kidney stones. Urinalysis is used to confirm diagnosis, with pyuria the most common finding. A urine culture is necessary to identify the micro-organism responsible and inform a decision on antibiotics. Blood tests would be a full blood count – raised white blood cells indicate infection, while renal markers (creatinine and urea) are used to assess any repercussions in kidney function. Imaging may be required: abdominal/pelvic CT scan with contrast for unwell septic patients, and potentally an ultrasound to reveal any renal abnormalities.

Whether the patient is managed as an outpatient or inpatient will depend on comorbidities and risk of deterioration. Inpatient management is usually required for elderly patients, those who are immunocompromised, have poorly controlled diabetes, or have previously had a renal transplant.

Pharmacological interventions would be:

  • Antibiotics, with choice based on urine culture (oral or IV depending on setting) (NICE, 2019a)
  • Analgesia (oral or IV)
  • Antipyretics
  • IV anti-emetics and fluids if there is dehydration due to nausea and vomiting

Non-pharmacological interventions would be the usual patient education regarding fluid intake and personal hygiene, recognising signs and symptoms of UTIs. Patients considered at lower risk and managed as outpatients will still need education on the signs of urosepsis and when to seek urgent assistance.

Acute kidney injury

The term acute kidney injury (AKI) describes an abrupt deterioration (within 48 hours) in filtration marked by increased serum creatinine (from baseline) with or without reduction in diuresis (KDIGO, 2012). AKI replaced outdated terms such as ‘acute renal failure’ or ‘acute renal insufficiency’, staging definitions for AKI are shown in Table 3.

Table 3. Stages of acute kidney injury (AKI)
AKI stages Serum creatinine changes Urine output changes
1 >1.5–1.9 x the baseline <05 ml/kg/hour for 6 hours
2 >2–2.9 x baseline <0.5 ml/kg/hour for 12 hours
3 >3 x baseline <0.3 ml/kg/hour for 24 hours or anuria (no urine production) for >12 hours
Source: KDIGO, 2012

Causes of AKI can be classified as:

  • Prerenal: due to reduced kidney perfusion, often because of hypovolaemia, decreased cardiac output (Mercado et al, 2019)
  • Intrarenal: damage to the kidney parenchyma (where waste excretion takes place) and nephrons usually due to nephrotoxic drugs or nephritis (Mercado et al, 2019)
  • Postrenal: inadequate urine drainage along the ureters, bladder and urethra, commonly secondary to stones or prostate enlargement (Nagalingam, 2021).

Therefore the physical assessment should include assessment of volume status (pulse, blood pressure, including any postural changes, capillary refill time, jugular venous pressure, skin turgor). Peripheral oedema, chest auscultation and weight history will inform fluid status. Any abrupt changes in weight might suggest hyper-or hypovolaemia. Skin rashes can indicate systemic illness. Urine output should be assessed and, if an inpatient, review and monitoring of fluid charts should consider the different stages of AKI (Table 3).

Medication history can provide information on potential underlying causes – such as non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors, or some antibiotics. These are often referred to as ‘nephrotoxic’ drugs; however, Jones and Tomson (2018) argued that it is not helpful to describe ACE inhibitors and angiotensin II receptor blockers (ARBs) in this way, since the effect is reversible and in other contexts they have a protective effect, being used to preserve kidney function in patients with cardiovascular problems, hypertension and diabetes. The latest NICE (2019b) guideline avoids the term, instead referring to ‘drugs that can cause or exacerbate kidney injury’.

Investigations would cover (Rahman et al, 2012):

  • Urinalysis (including ACR level)
  • Full blood count (excluding underlying infection and/or anaemia)
  • Renal profile bloods, including urea, creatinine, eGFR
  • Imaging studies might inform whether obstruction is present (post-renal causes)
  • Postvoid residual urine greater than 100 ml can suggest postrenal AKI.

Generally, AKI requires inpatient admission unless a clear reversible cause has been identified.

Pharmacological interventions for AKI include (Brochard et al, 2010; KDIGO, 2012):

  • Stop any drugs that can cause or exacerbate kidney injury (in particular, metformin should be avoided) and adjustment of medications to renal dosages when applicable. Involve and liaise with pharmacists and prescribers
  • Ensure volume status, which might require intravenous fluid (eg, normal saline)
  • Maintain arterial blood pressure above 65 mmHg, which might require vasopressors if hypotension is present.

Non-pharmacological interventions should cover the following areas (KDIGO, 2012; NICE, 2021a):

  • Avoid and monitor closely electrolyte imbalances (hyperkalemia, hyponatraemia, hypermagnesemia)
  • Avoid and monitor hyperglycaemia closely
  • Avoid radiocontrast procedures (such as angiography, CTCA) (because radiocontrast agents put stress on the kidneys)
  • Patient education would be directed towards adequate hydration, regular follow-up and renal function monitoring, when to seek medical advice and how to avoid UTIs.

Psychosocial assessment should encompass psychological and social support – often this is the first time a patient may have come into contact with specialist health professionals who can provide support.

Chronic kidney diease

CKD refers to a persistent abnormality in the kidney structure or function for more than 3 months (KDIGO, 2013). It is recognised as a global public health problem, with an estimated global prevalence of 13.4% (KDIGO, 2013), representing a total cost to the NHS of around £1.4 billion in 2009/10 (Kerr, 2012; NHS England, 2022)

CKD is defined by GFR below 60 ml/minute/1.73 m2, and albuminuria of at least 30 mg/24 hours. It is classified in stages from 1 to 5 depending on GFR and albuminuria (Table 4)

Table 4. Risk categories for kidney disease progression, morbidity and mortality, based on albuminaria and glomerular filtration rate (GFR)
Albuminuria categories
A1 A2 A3
Normal to mildly increased Moderately increased Severely increased
<30 mg/g<3 mg/mmol 30–299 mg/g 3–29 mg/mmol ≥300 mg/g≥30 mg/mmol
GFR stages G1 Normal or high ≥90*      
G2 Mildly decreased 60–90*      
G3a Mildly to moderately decreased 45–59*      
G3b Moderately to severely decreased 30–44*      
G4 Severely decreased 15–29*      
G5 Kidney failure <15*      


▪ Low risk (if no other markers of kidney disease and CKD)

▪ Moderately increased risk

▪ High risk

▪ Very high risk

▪ Highest risk


Glomerular filtration rate in ml/minute/1.73m2

Urinary albumin–creatinine ratio

Source: Adapted from KDIGO, 2013

During the physical assessment and history taking it is important to determine duration of kidney disease and if GFR has been below 60 for less than 3 months, then AKI on CKD is possible and tests should be repeated (KDIGO, 2013). Review and evaluate volume status; hypovolaemia suggests overdiuresis, whereas hypervolaemia is often linked to liver, heart failure or nephrotic syndrome (Chen et al, 2019)

CKD is usually identified through routine renal profile bloods, although less commonly patients present with the following symptoms (Chen et al, 2019):

  • Lethargy, fatigue
  • Headache
  • Breathlessness
  • Peripheral oedema
  • Proteinuria, hematuria, nocturia
  • ‘Foamy urine’ (sign of albuminuria)
  • Oliguria
  • Anuria
  • Symptoms of anaemia
  • Poor appetite, nausea, or vomiting,
  • Weight loss
  • Pruritus (itchy skin).

Investigations would include renal function blood tests (serum creatinine and GFR, and full blood count to identify the extent of any anaemia. Urine samples would be needed for urine ACR and analysis for specific gravity, as well as a urine culture (to test for UTI). Advanced cases of CKD may require renal biopsy, and renal ultrasound is sometimes needed to determine whether there is an obstruction, or otherwise help in identifying the aetiology of CKD (NICE, 2021b).

Pharmacological interventions for CKD would be, first, to avoid drugs that cause or exacerbate kidney injury (eg ACE inhibitors, NSAIDs and certain herbal remedies). Adjustment of drug dosing is frequently required on medications such as antibiotics, oral anticoagulants, and hypoglycaemic agents, among others (Chen et al, 2019).

Non-pharmacological interventions should consider the following (Think Kidneys, 2017):

  • Referral to specialist teams for regular follow up (nephrology)
  • Promote healthy lifestyle (low salt diet, low potassium diet, regular exercise, avoidance of medications that can damage the kidneys, low alcohol)
  • Encouragement and empowerments towards self-care (such as signs and symptoms of worsening renal function, monitor fluid intake and output)
  • Address co-morbidities such as hypertension, anaemia, low calcium or phosphate and diabetes
  • Offer psychosocial interventions.

Case study

Presenting complaint

Nile presented to his GP surgery for an annual routine renal function review and following assessment, his eGFR result was 65 ml/minute/1.73 m2 and his ACR was 5 mg/mmol. His eGFR result has not changed from his result in the past 2 years.

Social history

Nile is a widowed 70-year-old gentleman, who lives alone in sheltered accommodation, smoking 20 cigarettes a day. He drinks 2 cans of beer a day to help with daily boredom when his friends are not available to meet him. His mobility is mildly reduced, mobilising with support of a stick and ‘furniture walking’ around the house.

Prior medical history

  • Chronic hypertension, managed with losartan 25 mg once daily
  • Chronic kidney disease, diagnosed a year ago
  • Type 2 diabetes, controlled by gliclazide 30 mg once daily
  • Recent urinary tract infections (3 in the last 6 months).

Subjective and objective assessment

  • Recent onset of nocturia in the past few days. Reports urine had a ‘foul’ smell last week
  • Peripheral and bilateral ankle oedema, worse during the day
  • Weight gain of 2 kg in the past 2 days, above his known ‘dry’ and usual weight. (In renal care, dry weight is weight without the excess fluid that builds up between dialysis treatments. This weight is similar to what a person with normal kidney function would weigh after urinating).

Care plan

The nurse involved in Nile's case recognises the complexity of his needs, requiring involvement including psychosocial practitioners, dietitians, pharmacists, social workers, nephrologists, and specialist nurses to provide holistic care. Ultimately this will lead to better health-related outcomes, such as lower hospitalisation rates, slower CKD progression and reduced risk of mortality (Collister et al, 2019).

Causes of CKD, in this case, are multi-factorial, including chronic hypertension, type 2 diabetes mellitus and lifestyle behaviours (such as sedentarism from low mobility and alcohol consumption) (Peng et al, 2019). Fears related to future consequences and disease trajectory are commonly described by renal patients and patients' own illness perceptions should be addressed regularly during routine follow-up (Clarke et al, 2016).

The clinical care plan in Table 5 focuses on interventions that preserve renal function, and prevent adverse effects of comorbidities, however, they come at the cost of requiring several behavioural changes in Nile's daily routine. Effective self-management requires active patient participation; however, the degree of willingness to engage with these strategies can vary (Donald et al, 2018). The emotional burden associated with therapeutic goals and lifestyle changes is known to lead to non-concordance with self-management strategies (Welch et al, 2015).

Table 5. Clinical care plan for Niles
Self-management empowerment
Address mental wellbeing and psychosocial implications
  • Assess Nile's perspectives towards his illness, using open-ended questions such as ‘How do you feel about your symptoms and how well do you feel you understand your condition?’ (Clarke et al, 2016)
  • Assess Nile's willingness to change lifestyle and adhere to self-management intervention, advocating a patient-centred approach (Donald et al, 2018)
  • Assess Nile's mental health and wellbeing routinely, using validated assessment tools such as Patient Health Questionnaire-4 (PHQ4) and distress thermometer
  • Involve any wider family or friends, with Nile's consent, providing practical and emotional support. Investigate if there is any available support for chronic patients in local areas and clinical commissioning groups (Havas et al, 2016)
  • Set realistic and specific goals in Nile's self-management care plan, offering positive reinforcement and help with establishing a routine by using reminders (for example, through dosette box, and phone alarms) (Havas et al, 2016)
Promoting healthy behaviours
  • Encourage Nile to stop smoking and reduce alcohol intake by choosing initially lower alcohol drinks (beer under 4% alcohol by volume (ABV)) or swapping to no-alcohol alternatives, delaying disease trajectory (NHS website, 2022). If in agreement, offer Nile referral to local community for further support
  • Encourage Nile to set a ‘booze budget’, allocating specific money to spend on alcohol weekly. Work together with Nile to overcome boredom, looking for other activities, such as a new hobby, or DIY strategies (NHS website, 2022)
  • Nutritional health: encourage low-potassium and low-sodium diet with less than 3 g/day of salt to halt CKD trajectory and prevent hypertension (McMahon et al, 2012). Assess Nile's ability to cook at home and if help is needed, refer to social services or community support with meals
  • Promote engagement with weight monitoring. Weight loss is effective in reducing blood pressure and proteinuria, slowing CKD progression for overweight patients, but in Nile's case he is not overweight, so focus on positively reinforcing this (Pugh et al, 2020). Monitor Nile's weight at each follow-up, observing whether weight fluctuates due to fluid overload (2–3 kg increase in 2–3 days) or if it reduces progressively, suggestive of disease progression and malnutrition Evaluate whether other symptoms such as nausea, vomiting or reduced appetite could have led to lower calorie consumption and therefore loss of weight
  • Suggest that Nile raises his feet when resting to decrease peripheral ankle oedema
  • Refer to local low-function rehabilitation exercises in the community as available – exercise results in higher functional levels among CKD patients (Peng et al, 2019)
  • Refer to physiotherapy or occupational therapy community services for home assessment and rehabilitation if possible, promoting independence
Recognition of early warning signs
  • Educate Nile towards signs and symptoms suggestive of worsening renal function and when to activate resources in the community, providing safety net. Provide numbers and emails for his specialist renal team and GP surgery
Manage comorbidities
Blood pressure management
  • Aim for blood pressure < 140/90 mmHg; losartan as an ARB has both cardio and renal protective properties in the right context (Pugh et al, 2020)
  • Alert Nile regarding common side effects of medication, and differences between these and effects that are specific to the disease, such as dizziness, fatigue, postural low blood pressure, risk of falls (Gebreyohannes et al, 2019)
Diabetes management
  • Refer Nile to specialist diabetic nurse for tailored HBA1c monitoring and management – HBA1c reflects an average of 90 days blood glucose and in CKD should be done every 3–6 months (Triozzi et al, 2021)
  • Caloric and exercise strategies can improve glycaemic control. Protein intake of 0.8 g/kg body weight/day is recommended for non-dialysis-dependent patients (Triozzi et al, 2021)
  • Sodium–glucose cotransporter-2 inhibitors (SGLT2i), such as empagliflozin, should be considered as associated with slowing CKD progression and reduction in mortality (Zabetian et al, 2014)
Weight gain and peripheral oedema management
  • Refer Nile to continence team due to nocturia
  • Refer Nile to physiotherapy team for high risk of falls secondary to low mobility
  • Educate regarding avoiding caffeinated hot drinks during the evening, reducing fluid intake at this stage
  • Encourage Nile to maintain a record of his daily weight until baseline weight is established (known as dry weight), providing nurse with accurate and relevant information on his fluid status, avoiding excessive diuresis and hypovolaemia
  • Ensure patient is known to nephrology team for specialised follow-up and up-to-date investigations
  • Pre- and post-void bladder scan might be necessary to rule out urinary retention
  • Low-dose diuretic (thiazide such as bendroflumethiazide) might be necessary to prevent further fluid overload. Volume overload is seen in 50% of CKD patients, offering antihypertensive and cardioprotective effects (Zamboli et al, 2011)
Polypharmacy/medication regimens
  • Medication reconciliation (ie compare the patient's medication orders against all medication the patient has been prescribed: name, dosage, frequency) must be done on a regular basis by independent prescribers (either GP, specialist nurses or pharmacists) to ensure nephrotoxic agents are avoided and patients are avoiding inappropriate over-the-counter therapies (Collister et al, 2019)
  • Promote concordance with medication prescribed such as losartan and oral glycaemic control medications. Review blood pressure and blood glucose level/HBA1c and titrate accordingly


Renal biomarkers are essential to guide management plans, prognosis, and disease trajectory. However, good history taking and physical assessment remain essential to differentiate between the wide range of renal disorders. Serum creatinine and GFR are often used and requested in blood tests across clinical practice, therefore nurses must have an understanding of what these results mean and how to plan care accordingly.

Acute kidney injury and chronic kidney disease are public health problems. Care plans require an integrated and multidisciplinary team approach. Interventions should focus equally on both physical health and mental wellbeing. The emotional burden associated with demanding lifestyle changes has been well described in qualitative studies focusing on renal patients. Empowerment towards self-management, and addressing comorbidities, are essential not only to reduce mortality and morbidity but also to achieve better patient-directed outcomes such as quality of life and satisfaction with care. Adequate follow-up requires a patient-centred approach, with careful consideration in the development of tailored and achievable care plans. Active participation is required from both patients and professionals, as patients' needs, and perceptions of illness change throughout the renal disease trajectory.


  • The renal system is an important system in the body and plays a key role in homeostasis
  • When not managed, renal disease can progress to end-stage kidney disease
  • Nursing care for this comorbid group of patients can be challenging as patients can deteriorate rapidly
  • Nurses need an understanding of the different classifications and interventions to be able to provide patient-centered care

CPD reflective questions

  • How is renal disease assessed in your clinical area?
  • What support is in place to promote healthy behaviours for patients with renal disease?
  • What support is provided for patients with end-stage kidney disease