Principles of Nursing in Kidney Care: Under the Auspices of EDTNAERCA and EKPF 9783031303197, 9783031303203

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Principles of Specialty Nursing Under the Auspices of the European Specialist Nurses Organisations (ESNO) Series Editor: Ber Oomen

Afra Masià-Plana Anastasia Liossatou Editors

Principles of Nursing in Kidney Care

Under the Auspices of EDTNA/ERCA and EKPF

Principles of Specialty Nursing Under the Auspices of the European Specialist Nurses Organisations (ESNO) Series Editor Ber Oomen, Executive Director, European Specialist Nurses Organisation, Arnhem, The Netherlands

The role of the specialist nurse in Europe is still not clearly defined. Despite the fact that there have been formal training programs – e.g. for nurse anaesthetists, operating room nurses, intensive care and mental health nurses – for years now, the practices, status, duration and content of training can vary greatly from country to country. Some other specialist roles, e.g. for Diabetes, Dialysis, Urology and Oncology, have successfully been established in Europe with the help of professional transnational collaborations. Moreover, advances in medical technologies and more sophisticated treatment will not only require specialist nurses in order to ensure quality and safety of care, but will also call upon them to assume new roles in their professional field to compensate for physician shortages. Most of the available literature on specialty nursing practice currently comes from the USA, Canada, and Australia, and accordingly reflects evidence-based nursing in these countries. Therefore, there is a need to establish European evidence-based practice on the basis of different clinical experiences. This series, which encompasses textbooks for each specialty, shapes evidence-based practice in Europe, while also integrating lessons learned from other continents. Moreover, it contributes to clarifying the status of the specialist nurse as an advanced practice nurse. Each volume is dedicated to a specialty such as Mental health and Pyschiatry, firstly published, Oncology, Gastroenterology/Endoscopy, Anesthesia, Kidney Care, Critical Care etc. and for most of them, textbooks are supported by ESNO member societies.

Afra Masià-Plana  •  Anastasia Liossatou Editors

Principles of Nursing in Kidney Care Under the Auspices of EDTNA/ERCA and EKPF

Editors Afra Masià-Plana Faculty of Nursing University of Girona Girona, Spain

Anastasia Liossatou Haemodialysis Unit The General Hospital of Kefalonia Argostoli, Kefalonia, Greece

ISSN 2366-875X     ISSN 2366-8768 (electronic) Principles of Specialty Nursing ISBN 978-3-031-30319-7    ISBN 978-3-031-30320-3 (eBook) https://doi.org/10.1007/978-3-031-30320-3 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

Foreword

Dear Readers, dear Colleagues, I take great pleasure in welcoming you to the new book Principles of Nursing in Kidney Care, born from the collaboration between the EDTNA/ERCA (European Dialysis Transplant Nurse Association/European Renal Care Association) and ESNO (European Specialist Nurse Organization). The increasing prevalence of chronic kidney disease and the rising demand for renal replacement therapy have made the role of renal nurses more important than ever. Renal nursing requires a combination of specialized knowledge, skills, and compassion for people who are suffering from kidney disease. The aim of this publication is to give value once more to the EDTNA/ERCA mission “achieving the best level of education, standards and research for all renal care professionals caring and supporting their patients and families around the world.” This book describes all the aspects of nursing interventions toward people with kidney disease, both acute and chronic, in adults and children. It includes some contributions from experienced renal nurses and other healthcare professionals such as dieticians, psychologists, and nephrologists, who all have extensive knowledge in the field of renal care. They have shared their expertise to provide practical insights, case studies, and examples to help nurses develop the skills and knowledge needed to provide the highest quality of care. The book also includes some insights from people with kidney disease, as the research and knowledge in kidney care are always multidisciplinary and inclusive. I hope that this book will serve as a valuable resource for nurses who work in renal care, and that it will help to improve the care provided to people affected by kidney disease. I would like to thank all the contributors for their hard work in creating this book, and we hope that it will be of benefit to nurses worldwide. Sincerely, EDTNA/ERCA President Hergiswil, Switzerland

Ilaria de Barbieri,

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Preface

My motivation for this book lies at the intersection of my passion for the nursing profession and my interest in the dynamic processes involved in the specialties of the kidney. I am proud of this profession, in which nurses have developed a wide range of proficiencies, including management, leadership, care, decision making, and technical skills. During the time of editing and writing this book, I have learned much. Collaborating with experts around the world has bolstered my knowledge and encouraged me to develop a wider understanding of kidney nursing. The purpose of this book is to provide updated content relating to renal care in nursing, so that future nurses and multidisciplinary health professionals may develop their understanding of kidney care for people suffering from kidney failure. This book also operates as a good foundation for nurses who wish to refresh their knowledge in kidney care. Each chapter is written by experts in their specific field, and data has been provided using the latest evidence available. The book examines new areas arising in the field of nursing in kidney care. These new areas include sexual health, considered another pillar of health and quality of life, and patient partnership in management and decision making, which is proven to have excellent outcomes not only for the health system but also for the design of new standards. We always wanted to put the person/patient in the center of care and not only to focus on the disease but also on the person who suffers it as well as their families. My hope is that this book encourages both kidney nurses and all multidisciplinary health care teams that care for people suffering from kidney failure to adopt a holistic perspective when providing care. This will support an approach that considers the complexity of each case, and armed with the latest evidence, can achieve good outcomes for individuals, their families, and the health care system. Girona, Spain

Afra Masià-Plana

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Acknowledgments

The edition of this book has given us great strength in believing once again in the crucial work that nursing professionals are capable of, especially in the kidney field. It has been a valuable journey where we have not only learned but also enjoyed during the process of creating and revising this book. We would like to express our appreciation and thank all the authors of this publication for their time, effort, and knowledge in writing their chapters. Also, we would like to recognize the assistance of Mrs. Susan Rogers, EDTNA/ERCA English language proof-reader, who has supported the linguistic checks for this book. We are grateful to Springer Nature’s editorial team for giving us the opportunity to be part of this international project. All their unconditional support throughout the process has been impeccable, so a big “thank you” goes to Mrs. Nathalie Lhorset-Poulain and all the editorial team. Furthermore, we would like to give special gratitude to the ESNO society for supporting and encouraging us to build this project, especially to Mr. Ber Omer, ESNO Executive Director. This book would not have been possible without the support from the EDTNA/ ERCA Executive Committee. EDTNA/ERCA, as a leading international association in nephrology, has been a key element in advancing kidney nursing science and knowledge for renal nurses and other healthcare professionals. Moreover, this book is endorsed by the European Kidney Patients Federation (EKPF), and we would like to give a big thank you to the president Mr. Daniel Gallego, who has supported and encouraged this project. Finally, we would like to acknowledge with gratitude the support and love of colleagues and family. We are very lucky to be surrounded by amazing people. Thank you all. Afra Masià-Plana Anastasia Liossatou

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Contents

 Introduction to Kidney Functions and Pathophysiology��������������������������������   1 Debbie Fortnum  Management of Chronic Kidney Disease��������������������������������������������������������  13 José Jesús Broseta and Diana Rodríguez-Espinosa  Oral Care for Adults with CKD������������������������������������������������������������������������  33 Tai Mooi Ho and Navdeep Kumar  Pharmacological Management of CKD ����������������������������������������������������������  49 Michael Corr  Nutrition and Chronic Kidney Disease������������������������������������������������������������  61 Kalliopi-Anna Poulia Acute Kidney Injury������������������������������������������������������������������������������������������  81 Fiona Murphy Kidney Replacement Therapies: Hemodialysis���������������������������������������������� 115 Afra Masià-Plana and Reem Alhameedi  Dialysis Fluid for Hemodialysis and Associated Treatments ������������������������ 139 José Jesús Broseta, Diana Rodríguez-Espinosa, and Francisco Maduell Vascular Access Management and Care: Arteriovenous Fistula (AVF)������������������������������������������������������������������������������������������������������ 151 Donato Leopaldi, Annalisa di Pasquale, and Maurizio Gallieni Vascular Access Management and Care: Arterio-Venous Grafts (AVG)������������������������������������������������������������������������������������������������������ 165 Vasiliki Zoi and Ruben Iglesias  Vascular Access Management and Care: CVC ���������������������������������������������� 175 Afra Masià-Plana and Massimo Fontò  Use of the Ultrasound in Hemodialysis������������������������������������������������������������ 189 Ruben Iglesias, Silvia Corti, Rossella Esposto, and Giuseppe Fenoglio

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 Kidney Replacement Therapies: Peritoneal Dialysis�������������������������������������� 205 Sotiroulla C. Gliki and Maria Arminda Tavares  Infection Prevention and Control: The Importance of Hygiene in Dialysis Care������������������������������������������������������������������������������������������������������ 225 Candice Halinski General Vaccination Scheme for Patients with CKD: Management of Kidney Care During the COVID-19 Pandemia-­Vaccination for COVID-19�������������������������������������������������������������� 243 Faith Lynch  Management of Conservative and Palliative Care in CKD���������������������������� 251 Claire Carswell Kidney Transplantation������������������������������������������������������������������������������������ 265 Jen Lumsdaine  Management of the Elderly Patient with Kidney Disease������������������������������ 281 Sofia Zyga and Victoria Alikari Psychosocial Approach in People with CKD: Psychosocial Implications�������������������������������������������������������������������������������������������������������� 293 Mike Kelly  Quality of Life in People Receiving Kidney Replacement Therapy�������������� 299 Afra Masià-Plana and Miquel Sitjar-Suñer  Sexual Health and Kidney Failure ������������������������������������������������������������������ 313 Clare McKeaveney and Sandra M. Dumanski  CKD Care for Pediatric and Adolescent Patients ������������������������������������������ 323 Ana Grilo, Kalliopi Anna Poulia, and Enas Hussein Mohammed  Patient Education in Kidney Care�������������������������������������������������������������������� 333 Jeanette Finderup  Patient Partnership in Kidney Care���������������������������������������������������������������� 347 Jeanette Finderup, Henning Søndergaard, and Daniel Gallego Multidisciplinary Approach of Care and Management of Kidney Disease. Evidence-Based Nursing Practice and Different Nursing Roles in the Management of Kidney Care���������������� 359 Ann Bonner and Leanne Brown

About the Editors

Afra  Masià-Plana  Registered Nurse since 2002, Psychologist, master’s in psychology and research, postgraduate on health management and PhD on quality of life in patients undergoing chronic hemodialysis (2019). She worked as a registered nurse since 2002 in Spain and 5 years in Brisbane (Australia) and specify on hemodialysis. Currently she is a Scientific Board Member of EDTNA/ ERCA, full time lecturer at the faculty of nursing in University of Girona, Spain.

Anastasia  Liossatou  Head Nurse at the Hemodialysis Unit, General Hospital of Kefalonia, Argostoli, Kefalonia, Greece has 26 years experience of which 23 in the nephrology field. Anastasia was trained as a nephrology nurse at the General Hospital of Papageorgiou, Thessaloniki, Greece. Her background is in hematology and hypertension while she was working at The Royal Liverpool University Hospital, Liverpool & St Georges Hospital, London, UK. She holds a master’s degree in Nursing from the University of Liverpool, UK and a Diploma in Education. Anastasia has been an EDTNA/ ERCA volunteer since 2003, serving the Association from various roles such as an EDTNA/ ERCA Newsletter & Journal Co-Editor and the Chair of the EDTNA/ERCA Scientific Programme Committee. In 2018, she joined the EDTNA/ERCA Executive Committee (EC), where she has undertaken the role of the Publications Coordinator. She has also contributed as an Editor and author to several guidebooks published by EDTNA/ERCA, and has presented many times at the EDTNA/ERCA conferences. Currently, Anastasia is undertaking her PhD at the Department of Nursing, The University of Peloponnese, Tripoli Greece.

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Introduction to Kidney Functions and Pathophysiology Debbie Fortnum

Learning Objectives • • • • •

To review the key anatomical structures of the kidney To identify the main functions of each section of the nephron To understand the excretory and homeostasis processes of the kidney tubules To explain the exogenous functions of the kidney To link pathophysiology with understanding symptoms of kidney dysfunction

1 Introduction Kidney and nephron functions are complex. This chapter examines the basic aspects of renal physiology and pathophysiological processes that underpin renal disease. The reader should then be able to understand the impact of a disease on kidney functions and the subsequent symptoms that are generated. With this approach the reader will be able to determine the specific care that is required.

2 Basic Anatomy of the Kidney The kidneys lie behind the peritoneum, adjacent to either side of the vertebral column, and are paired organs. A healthy kidney is approximately 11 cm long, weighing about 150 g. The renal artery and vein (left and right) provide the blood supply to the kidneys. Each kidney has an outer cortex and inner medullary region (Fig. 1). Approximately one million nephrons are found in each kidney. The filtering and re-absorptive part of the nephrons sit in the cortex region and the concentrating and D. Fortnum (*) EDTNA/ERCA Brand Ambassador, Perth, Australia © The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 A. Masià-Plana, A. Liossatou (eds.), Principles of Nursing in Kidney Care, Principles of Specialty Nursing, https://doi.org/10.1007/978-3-031-30320-3_1

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D. Fortnum

Fig. 1  Anatomy of the kidney. (Reproduced with permission from Springer Nature. Buffi et al. [1])

diluting components mainly sit in the medullary region (Fig.  2). The urine then drains via the collecting ducts into the pelvis of the kidney, via the ureter and into the bladder [3, 4].

3 Nephron Structure and Functions The nephron is the functional unit of the kidney, of which 85% are cortical nephrons and 15% are juxtamedullary nephrons. The nephrons are supported by the cortex and medullary interstitial cells which also supports the peritubular capillaries [3–5]. The structure of the nephron is related to its complex functions and contains five components which each performs a distinct process (Table 1).

4 Blood Supply The renal artery and vein (left and right) deliver blood to the arcuate arteries. The arteries then feed arterioles which deliver blood to the Bowmans capsule. There is a tiny knot of capillaries in each Bowmans capsule. The arteriole delivering blood is known as the afferent arteriole and leaving the capsule is the efferent arteriole.

Introduction to Kidney Functions and Pathophysiology

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Fig. 2  Anatomy of a nephron. (Reproduced with permission from Springer Nature. Rayner et al. [2])

Within the kidney are peritubular capillaries surrounding each section of the nephron and reabsorbing or secreting electrolytes depending on concentration gradient levels and the active pumps which are controlled by hormonal messengers. The specific capillary surrounding the loop of Henle is known as the vasarecta. The final stage of the capillary network are the venous capillaries returning filtered and cleaned blood to the renal vein to enter the systemic circulation [5].

5 Fluid Regulation Kidneys can vary the volume of urine excretion per day from as little as 300 mls up to 23 L, depending on the fluid input and insensible output of the body, which is influenced by other external conditions. The average urine output is 1.5 L in 24 h. The concentration of urine is measured in units of osmolality (mOsmol/kg water). The average range of urine osmolality in people with normal kidneys is between 300 and 500 mOsmol/kg water. Serum osmolality is usually tightly maintained at

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D. Fortnum

Table 1  Description and function of each part of the nephron [5] Functional part Bowman’s capsule (in cortex or medulla)

Description Capsule that surrounds the glomerulus (knot of capillaries). Blood enters via afferent arteriole and leaves via efferent arteriole

Function Filtration of blood. Low molecular weight solutes filter through endothelial cells into Bowman’s space from glomerulusa Filtration rate dependent on concentration gradient between afferent and efferent arteriole. 180 L filtrate per day at 125 ml/ min Proximal First section; pars convoluta High level of reabsorption of water and convoluted (about 14 mm). Epithelial cells electrolytes into capillaries (85%). Active tubule (in cortex are full of mitochondria and transport and diffusion (by mitochondria). or medulla) have brush border. Blood supply Water moves by osmosis is from peritubular capillaries Loop of Henle Descending and ascending thin Descending loop filtrate concentrated by (in medulla) limb (shorter in cortical passive osmosis of water. Ascending loop nephrons). Thin permeable cells. impermeable to water but pumps out more Vasa recta provides blood chloride and sodium ions to keep supply osmolality high in interstitium Distal Thick ascending limb, pars Active fine tuning of urine and correcting convoluted convoluta (1 mm long) and of electrolytes. Feedback from hormones tubule (in connecting distal tubule. regulates these functions. That is, cortex) Epithelial cells with less aldosterone regulates potassium and mitochondria sodium. Parathyroid hormone regulates calcium and phosphate Collecting duct Final part of nephron from Collects urine, site of action to further (medulla) connecting distal tubule to the retain water (presence of antidiuretic ureter hormone) and transfers urine to pelvis then into the ureter The healthy glomerular basement membrane barrier is highly restrictive to larger molecular weight proteins including albumin but when damaged it becomes leaky leading to proteinuria [6] a

290 mOsmol/kg (+/−5mosm/kg) [5]. A number of mechanisms control fluid balance including: • The Loop of Henle facilitates urine volume variance with its complex counter-­ current concentration mechanism. This is facilitated by the ability of the ascending limb to pump sodium chloride into the interstitium while being impermeable to water. This increased medullary tissue osmolality allows additional water to be reabsorbed into the vasa recta capillaries, via the interstitium, from the water permeable descending limb of the loop of Henle. • In response to dehydration the posterior pituitary gland releases antidiuretic peptide (ADH) (also known as vasopressin) which increases collecting tube permeability, thereby increasing body water reabsorption. Urine can concentrate up to 1200 mosm/kg if required. • The distal tubule macula densa contact point with the glomerulus triggers the renin–angiotensin aldosterone system (RAAS) to retain fluid and increase blood pressure (as above). • Thirst mechanism (osmoreceptors in the hypothalamus) is stimulated when serum osmolality increases by 2–3%. Dehydration or excess sodium intake can trigger thirst [7].

Introduction to Kidney Functions and Pathophysiology

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• Atrial natriuretic peptide is released from stretch receptors in cardiac atrial cells to inhibit aldosterone, renin and ADH release, thereby increasing urine output. Without ADH urine can have an osmolality as low as 50 mOsmol/kg [3, 5]. Urine specific gravity is a measure that defines the ratio of the density of urine compared to the density of water. Dark urine that is concentrated, specific gravity >1.030, indicates extreme dehydration. Urine, specific gravity  30 mg/g, or nondiabetic CKD with a UACR >300 mg/g [1]. In the American Association of Clinical Endocrinology’s last guidelines, finerenone, a new mineralocorticoid receptor antagonist, has been pointed out as a treatment option for patients with CKD and type 2 diabetes in combination with an ACEi or ARB [12]. Persons with concomitant heart failure with reduced ejection fraction (HFrEF) should be treated with a mineralocorticoid receptor antagonist and

Management of Chronic Kidney Disease

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sacubitril/valsartan when tolerated [13]. Their main adverse events are hypotension and hyperkalemia, the most limiting factors to dose titration. But more infrequent ones, such as dry cough and angioedema, should also be identified.  yperkalemia H Considering the increased risk of hyperkalemia is crucial, and close monitoring of blood potassium at baseline is recommended, especially in double-blockade cases. High potassium levels interfere with the membrane potential, electrical impulse production, and propagation in myocytes and other muscle cells. Hence, severe hyperkalemia can induce deadly cardiac arrhythmias and flaccid paralysis [14]. Additionally, patients may also experience non-life-threatening side effects such as dizziness, palpitations, or leg weakness [15]. Given the increased risk, classically, physicians recommend patients with CKD adhere to a potassium-restricted diet, recent data show that dietary potassium sources that come from whole fruits (not juices) and vegetables rich in fiber are not associated with a risk of severe hyperkalemia, but on the contrary, are linked to a better nutritional status [16, 17]. Therefore, their strict restriction is not necessary. In refractory cases, potassium binders may be prescribed. Among the commercially available potassium binders are the classic sodium polystyrene sulfonate and calcium polystyrene sulfonate, which are characterized by bothersome side effects like constipation, diarrhea, vomiting, nausea, flatulence, indigestion, abdominal pain, and heartburn. Two more recent binders, patiromer and sodium zirconium cyclosilicate, are effective, safe, and better tolerated. The latter has a faster onset of action, making it useful in acute hyperkalemia cases [18, 19]

2.1.2 Sodium-Glucose Cotransporter-2 Inhibitors (SGLT2i) The SGLT2i or glycosurics have appeared as a new therapeutic tool for treating type 2 diabetes and its comorbidities, with demonstrated cardiovascular and renal benefits. However, its therapeutic effects go beyond glycemic control, and, in fact, they have been shown to maintain this benefit in nondiabetic patients with CKD and heart failure [20–22]. In the context of CKD, these drugs proved to achieve a significant reduction in albuminuria and the risk of progression of CKD by 30–40%, delaying the entry into renal replacement therapy (Fig. 2). Particular caution should be taken when this drug family is initiated in persons on concomitant diuretic treatment, in which volemia status, blood pressure reduction, kidney function, electrolytes, and weight changes have to be checked at baseline and monitored at 2–3 weeks after initiation to avoid adverse events. Regarding its potential adverse effects, the following should be considered: –– There is an increased risk of fungal genitourinary infections (especially in patients with very poor glycemic control) that only in a few cases would justify its suspension, assessing risk-benefit. In the event of such an infection, treatment would be a single dose of fluconazole 150 mg.

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J. J. Broseta and D. Rodríguez-Espinosa

Fig. 2  Comparison of estimated glomerular filtration slope between those treated with placebo versus dapagliflozin and the consequent delay in entering in end-stage kidney disease of the latter. Self-construction with DAPA-CKD data

–– Acute kidney injury can occur in patients taking several diuretics or in episodes of dehydration (common to RAASi). To avoid these, the patient should be instructed to temporarily discontinue the drug in diarrhea, vomiting, or hypotension episodes. However, a decline in eGFR by up to 30%, or greater when initiated in combination, is expected when SGLT2 and RAASi drug classes are initiated. Still, it must be considered a hyperfiltration correction rather than a kidney injury in the absence of dehydration. Indeed, the more significant the initial decline in the eGFR, the higher the kidney protection. In the case this increase persists for more than 4 weeks or is not correlated with a UACR reduction, it is necessary to reduce doses or stop treatment and evaluate other concomitant drugs and the patient’s clinical situation (use of non-steroidal anti-inflammatory drugs (NSAIDs), excess diuretics, volume depletion), in addition to considering bilateral renal artery stenosis. –– Diabetic ketoacidosis, although infrequent, should be suspected in patients with intolerance to ingestion, vomiting, and ketonuria. Hyperglycemia is not necessary, as there is euglycemic ketoacidosis in these cases. It is associated with certain risk factors such as alcohol abuse or in patients whose insulin secretion deficit rather than insulin resistance predominates as the cause of diabetes.

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2.2 Hypertension 2.2.1 Therapeutic Target In patients with CKD, the blood pressure target has evolved toward stricter control as the guidelines have been updated, especially since the publication of the SPRINT study [23]. The 2021 blood pressure in CKD KDIGO guidelines, which are the most recent, recommend a target below 120/80 mmHg as long as it is well tolerated [24]. 2.2.2 Blood Pressure Measurement Patient preparation and a standardized blood pressure measurement technique are vital for the diagnosis and follow-up of hypertension. The following recommendations should be followed in order to have an excellent management of blood pressure [24]. Patients should: 1. Be seated in a chair, relaxed, with both feet on the floor and back supported, for at least 5 min. The patient’s blood pressure (BP) should not be measured sitting or lying on a stretcher. 2. Not have smoked, exercised, or consumed caffeine at least 30 min before the measurement. 3. Have emptied their bladder. 4. Not talk during measurement or rest times. 5. Have BP measured in both arms and then use whichever arm gave the higher value. A difference of 15 mmHg or more between the two arms is associated with increased mortality risk. 6. Have the pressure cuff placed on the arm, at the level of the right atrium (approximately the midpoint of the sternum), with the cuff resting on a surface. In addition, it should be of adequate size. 7. Have their blood pressure estimated from the average of two or more readings on two or more occasions, separated by at least 1 min. 8. Have their study complemented with self-measurement of blood pressure (AMPA) at home or ambulatory blood pressure monitoring (ABPM) if a high blood pressure is measured at the medical visit. The latter is also useful for confirming the diagnosis of hypertension, identifying phenotypes of white coat hypertension, masked, diurnal or nocturnal pattern, etc., and is especially recommended in patients with CKD.

2.2.3 Treatment of Hypertension Nonpharmacologic therapy should be the first step in the treatment and management of hypertension, especially among patients with CKD [24]: –– Daily sodium intake