13th International Conference on Health Promoting Hospitals,
“Empowering for Health: Practicing the Principles”
Dublin, May 18-20, 2005
Virtual Proceedings
Complex rehabilitation strategies in patients with chronic renal
failure
Liidia Kiisk, Ülle Pechter [1], Mai Ots [1]
Centre for Physical Anthropology, 1- Department of Internal Medicine, University of
Tartu, Estonia,
Keywords:
Medical practice, collaboration between specialists, nutrition, rehabilitation
Background
Chronic renal failure (CRF) represents a progressive, irreversible decline in the
glomerular filtration rate (GFR). Most chronic nephropathies lack a specific treatment
and progress relentlessly to end-stage renal disease which prevalence is increasing
worldwide posing a large morbidity, mortality and financial burden. The need for renal
replacement therapy rises ~ 7% a year [1]. The most common causes of progressive
CRF are diabetic nephropathy, chronic glomerulonephritis and hypertensive
nephrosclerosis [2]. A primary disease eventually leads to secondary glomerular injury
and nephron loss that is clinically characterised by proteinuria, hypertension, a gradual
elevation in the plasma creatinine concentration and a progressive decline in GFR [3].
Early protective measures
Protective therapy may have the greatest impact if initiated early in the course of renal
failure development. Good collaboration between various specialists – family
physicians, nephrologists, dieticians, rehabilitation team-specialists, dialysis nurses,
transplantologists is a cornerstone in health promotion strategies for patients with
chronic renal failure.
Family physicians play an important role in early recognising patients with potential for
renal failure. Especially early intervention in patients with hypertension and diabetes is
necessary. Regular blood pressure control and anti-hypertensive therapy can effectively
reduce the risk for the development of kidney damage [4]. The extent to which lowering
blood pressure reduces proteinuria is a possible measure for the effectiveness of therapy
in slowing the progression of renal disease [5, 6]. Patients at risk merit regular renal
assessment with serum creatinine tests and urine analysis for existing microalbuminuria.
Population screening is even advisable [7]. The level of proteinuria must be controlled
regularly in diabetic patients because it gives the most valuable hint at progression of
kidney injury [8, 9].
Collaboration between specialists
RAS-blocking agents are prescribed not only for anti-hypertensive but also for vasoand renoprotective purposes in diabetic nephropathy and in chronic glomerular
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13th International Conference on Health Promoting Hospitals,
“Empowering for Health: Practicing the Principles”
Dublin, May 18-20, 2005
Virtual Proceedings
diseases with and without systemic hypertension [10]. Because of its complexity, the
integrated combined nephroprotective and cardioprotective therapy requires early and
sustained guidance by a nephrologist throughout the whole CRF period [11].
Exercise therapy
Aquatic environment is an ideal one for exercising for chronic renal patients. Regular,
long-time provided exercising, even 2–3 times per week, produces a beneficial effect
[12]. The intensity of exercise should be low, with a prolonged warm-up and exercise
adaptation period and time allowance for adequate cool-down. Exercise therapy should
be supervised by physiotherapist and based on comprehensive plan by a physical
specialist.
Nutritional management and dietician systematic review
Nutritional status, body composition, anthropometrical monitoring, food intake and
biochemical analysis and dietician systematic review is necessary in the complex
rehabilitation. Obesity is noticed as a significant risk factor for the development of
proteinuria [13]. Lowering excess weight is advisable for patients with CRF and
motivation to change the dietary habits should result from education. It is shown that
protein restriction slows the progression of renal disease both in clinical [14, 15] and
experimental studies [16].
The catering service of Tartu University Clinic in Estonian provides food for special
needs to 17 clinics with ~ 1000 patients every day. The share of diet food is about 25–
28%. The names and indications of the nomenclature of diets and the respective
recommendations for consumption of daily energy and basic nutrients are given in
Estonian handbook published by Liidia Kiisk, Treatment diets, Tartu, 2002 [17].
The normative values of the basic nutrients are in accordance with Estonian
nutritional recommendations, the nutrition guidelines of the WHO Regional Office for
Europe and with Regulation no. 131 Health Protection Requirements for Nutrition in
Health Care and Social Welfare Institutions, issued on 14 November 2002 by the
Estonian Minister of Social Affairs.
Systematized anthropometrics
Patients with CRF need to undergo nutritional assessment and their nutritional status
should be followed at frequent intervals. Systematized anthropometrics should
become an obligatory procedure in everyday medical practice.
Lifestyle counselling
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13th International Conference on Health Promoting Hospitals,
“Empowering for Health: Practicing the Principles”
Dublin, May 18-20, 2005
Virtual Proceedings
Systematic lifestyle counselling and education of patients offer many potential
benefits including improved treatment outcomes, reduced anxiety, greater prospect for
continued employment, improved timing for the start of dialysis, and a greater
opportunity for intervention to delay disease progression [18]. Various studies of the
benefits of patient education programmes have shown that educated patients have a
reduced incidence of emergency dialysis compared with control patients [19, 20].
Dialysis nurse as a routine part of work could make systematic assessment of quality
of life with professional questionnaires for CRF patients already in the pre-dialysis
state.
Smoking cessation
Smoking is one of the most important remediable renal risk factors. Discontinuation
of smoking has been shown to improve both renal and cardiovascular prognosis in the
renal patient and is probably the single most effective measure to retard progression
of CRF [21]. For all the above reasons, cessation of smoking should be advised for
renal patients - a recommendation, which should be given by all specialists more
frequently.
Patient-based management
Rehabilitation of patients with CRF should encompass all aspects of the patient's well
being and include vocational, physical, and medical therapies. As patients with
chronic renal disease are considered in the highest risk group of premature
atherosclerotic cardiovascular events, all beneficial rehabilitation strategies should be
included in their management [22]. Each patient's condition should be taken into
account individually when suggesting complex therapies. Careful management of the
patient by healthcare professionals can retard the development of risk factors for CVD
and stabilise renal functioning for a longer period of time.
Acknowledgements
The preparation of the manuscript was supported by scientific grants TARSK 0472
and DARCA 1880.
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13th International Conference on Health Promoting Hospitals,
“Empowering for Health: Practicing the Principles”
Dublin, May 18-20, 2005
Virtual Proceedings
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“Empowering for Health: Practicing the Principles”
Dublin, May 18-20, 2005
Virtual Proceedings
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