What is the treatment approach for a moderately frail older adult patient with Acute on Chronic Kidney Disease (AoCKD) in a Skilled Nursing Facility (SNF)?

Treatment of Acute on Chronic Kidney Disease in Skilled Nursing Facilities

For a moderately frail older adult with acute on chronic kidney disease (AoCKD) in a skilled nursing facility, treatment should focus on volume management, medication optimization with close monitoring, and individualized goals of care that prioritize quality of life over aggressive disease-specific interventions. 1

Initial Assessment and Goals of Care

Establish clear goals of care immediately upon recognition of AoCKD, as this fundamentally determines the treatment approach. 1

• Clarify whether the patient is in the "rehabilitation group" (expected to return home), "uncertain prognosis group," or "long-term group" (expected to remain in SNF until death), as each requires different treatment intensity 1
• Document advance care planning preferences regarding hospitalization, dialysis, and intensive interventions before clinical deterioration occurs 1
• Recognize that frail elderly patients with CKD often lose renal function slowly and may die from comorbidities before requiring dialysis 2

Volume Status Management

Monitor daily for volume overload through systematic assessment of weight, edema, lung sounds, and symptoms. 1

• Weigh patient at the same time daily, after voiding, in same clothes, using the same scale (standing or wheelchair) 1
• Look specifically for: any degree of edema, abnormal lung sounds, cough (especially when lying down), dyspnea, orthopnea, jugular vein distension, poor appetite, nocturia, and fatigue 1
• Initiate or adjust diuretic therapy in the SNF setting for volume overload rather than automatically transferring to hospital 1

Medication Management

Blood Pressure Control

Continue ACE inhibitors or ARBs if already prescribed, but monitor renal function and potassium closely. 3, 4

• Check serum creatinine and potassium within 1-2 weeks of any dose adjustment 3
• Accept creatinine increases of 10-25% as acceptable hemodynamic effects; investigate increases >30% for volume depletion, nephrotoxic agents, or other causes 3
• Target blood pressure <130/80 mmHg, but individualize to 130-139 mmHg systolic in frail patients to minimize treatment-related harms including falls 4
• Avoid reducing diastolic BP below 70-80 mmHg, as excessive lowering increases cardiovascular risk in elderly patients 4

Diuretic Therapy

Use diuretics to achieve euvolemia, adjusting doses based on daily weights and clinical assessment. 1

• Thiazide-like diuretics remain effective with eGFR >30 mL/min/1.73 m² 3
• Monitor sodium levels weekly for the first month after initiating thiazide diuretics due to hyponatremia risk 4
• Monitor potassium every 2-4 weeks initially when using diuretics 4

Nephrotoxin Avoidance

Immediately discontinue or avoid NSAIDs, which worsen kidney function and should never be used in patients with CKD. 5

• Review all medications for nephrotoxic potential, including over-the-counter agents 5
• Adjust doses of renally cleared medications based on current eGFR 4
• Monitor for drug-drug interactions, particularly with diuretics, ACE inhibitors/ARBs, and other antihypertensives 5

Monitoring Parameters

Establish a systematic monitoring schedule to detect deterioration early. 1, 4

• Check serum creatinine and eGFR within 2-4 weeks after any medication change 4
• Monitor electrolytes (sodium, potassium) every 2-4 weeks initially, then at least quarterly 3, 4
• Measure orthostatic blood pressures regularly (sitting and standing) to detect orthostatic hypotension 3, 4
• Assess for symptoms of uremia: altered mental status, nausea, poor appetite, fatigue 1

Infection Prevention and Management

Prioritize surveillance and early treatment of infections, as these are common precipitants of AoCKD and hospitalization. 1

• Monitor for respiratory infections, urinary tract infections, and sepsis, which are leading causes of rehospitalization 1
• Treat infections promptly with renally-dosed antibiotics 1
• Ensure appropriate immunizations are current 1

Common Precipitants to Address

Systematically evaluate and manage factors that commonly trigger acute kidney injury in chronic kidney disease. 1

• Assess for: dietary sodium excess, medication nonadherence, excess fluid intake, infections (pneumonia, UTI, sepsis), anemia, arrhythmias (especially atrial fibrillation), and uncontrolled hypertension 1
• Review for medication reconciliation errors, which are common provider/system factors contributing to AoCKD 1

Decision to Transfer vs. Manage in Place

Base hospitalization decisions on goals of care, functional status, and whether medical optimization has been attempted in the SNF. 1

• Initial management of worsening kidney function is appropriate in the SNF setting 1
• Transfer to hospital only if: symptomatic refractory volume overload despite diuretic adjustment, severe electrolyte abnormalities requiring urgent correction, or uremic symptoms requiring urgent dialysis 1
• In the absence of advance care planning, use shared decision-making between the healthcare team and patient/family to determine transfer 1

Dialysis Considerations

For older adults with AoCKD in SNFs, dialysis decisions must weigh survival benefit against quality of life impact. 1, 2

• Recognize that observational data suggests dialysis does not provide survival benefit for older adults with poor mobility and high comorbidity burden 2
• In the US, 20.6% of older adults die within 6 months of dialysis initiation 2
• If continuous renal replacement therapy (CRRT) is needed, it is favored over intermittent dialysis due to hemodynamic instability concerns 1
• Consider conservative management without dialysis as a valid option, incorporating symptom management, psychosocial support, and less intensive lab monitoring focused on quality of life 2

Conservative Management Approach

For patients prioritizing quality of life over survival, conservative kidney management is an evidence-based alternative to dialysis. 6, 2, 7

• Continue all CKD treatments except dialysis: BP control, volume management, anemia management, bone-mineral disorder treatment 2
• Provide active symptom management targeting nausea, pruritus, fatigue, and pain 6
• Incorporate palliative care principles with focus on patient preferences and functional outcomes rather than lab parameters 2, 7
• Recognize that this approach is appropriate for patients with multimorbidity, limited life expectancy, or those who prioritize comfort over life prolongation 7

Nursing Staff Education Requirements

Ensure SNF nursing staff receive specific training on recognizing and managing kidney disease complications. 1

• Train staff on signs/symptoms of volume overload and decreased cardiac output 1
• Educate on proper weighing procedures and when to notify the physician 1
• Teach recognition of precipitants: infections, arrhythmias, metabolic disturbances 1
• Provide education on common CKD medications: ACE inhibitors/ARBs, diuretics, and their monitoring requirements 1

Multidisciplinary Coordination

Implement a coordinated care approach involving nursing, pharmacy, social work, and physician oversight. 1, 8

• Pharmacy review of all medications for appropriateness, dosing, and nephrotoxicity is required in SNFs 1
• Nurse practitioner involvement improves renal outcomes through strict implementation of CKD guidelines and closer monitoring 8
• Social work involvement for advance care planning discussions and family education 1