Jane Davis, DNP

(Left to Right) Jane Davis, DNP, and Kim Zuber, PA-C
Credit: Self

 (managing medications when not eating or drinking) are frequently applied in medicine. 

Chart 1: Signs and symptoms for activation of 

It is routine to adjust medications when patients are ill or undergoing procedures, but the ‘formal’ adoption of 

 is unusual in the US. However, outpatient 

 are common in Canada, Australia, New Zealand, and many European countries. The local pharmacist often adjusts outpatient medications to decrease acute kidney injury (AKI) incidence.

 When sick day guidelines were originally conceived in 2013, they were part of a worldwide effort to decrease the incidence of AKI.

 Yet, as is often the case in medicine, there are more nuances to 

Chart 2: Need for Immediate Medical Intervention

The National Institute for Health Care Excellence (NICE) convened an international expert panel in late 2022 to develop a consensus on 

 The panel included a multidisciplinary group of 26 experts from 4 countries and 10 medical disciplines. The panel listed 42 specific recommendations: 5 that are signs or symptoms of dehydration (Chart 1), 6 that require immediate medical interventions (Chart 2), and 14 scenarios for patient self-management (Chart 3). Although some scenarios had less than 100% agreement, most recommendations were close to unanimous. The expert panel also agreed on which medications qualify under the ‘

Chart 4: Medications to be adjusted for sick day rules

Educating and involving patients in adjusting medications to fit circumstances is essential for successful self-management. Up to 50% of Americans are estimated to have at least chronic disease, which requires management and, often, medication adjustment.

 Self-management techniques have proved to be successful for patients with diabetes, asthma and hypertension.

 represent a new frontier in medication management. The guidelines establish categories for intervention based on severity ranging from complete self-management to a 911 call. While most sick day guidelines focus on diabetes management, the newer guidelines include SGLT2 inhibitors, anti-hypertensive medications, and diuretics. The focus is to address complications related to either volume depletion, hypo or hyperglycemia, or ketoacidosis.

Any guideline has its supporters and detractors; however, the concept of holding medications while 

 is postulated to decrease the incidence of iatrogenic AKI and thus save nephrons. However, only time will tell.

National Institute of care and Excellence (NICE) Acute kidney injury: prevention, detection and management, NICE guideline. December 18, 2019, 

, guideline 1.2.13 pg 12. Accessed June 17, 2023

Lea-Henry TN, Baird-Gunning J, Petzel E, Roberts DM. Medication management on sick days. 

Sick day guidance - think kidneys. Think Kidneys NHS. January 2018. Accessed June 17, 2023. https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2018/01/Think-Kidneys-Sick-Day-Guidance-2018.pdf.

Watson KE, Dhaliwal K, Robertshaw S, et al for PAUSE (Preventing Medication Complications During Acute Illness Through Symptom Evaluation and Sick Day Guidance) Medication Safety Advisory Panel. Consensus Recommendations for Sick Day Medication Guidance for People With Diabetes, Kidney, or Cardiovascular Disease: A Modified Delphi Process. 

Watson KE, Dhaliwal K, McMurtry E, et al. Sick Day Medication Guidance for People With Diabetes, Kidney Disease, or Cardiovascular Disease: A Systematic Scoping Review. 

Kwong YD, Tuot DS. Optimizing Self-Management Programs in Kidney Disease: Implementation of Sick-Day Protocols. 

Articles

In their latest column, Kim Zuber, PA-C, and Jane Davis, DNP, break down the concept of "sick day rules" and what this means for providers caring for those with kidney disease. 

Sick Day Rules in Nephrology, with Kim Zuber, PA-C, and Jane Davis, DNP

Expert guidelines for evaluation, testing and management of hepatitis C (HCV) in chronic kidney disease (CKD) have gone through 2 major iterations in the last decade. The first discussion of how to treat the CKD patient was published in 2008.

 In 2018, the introduction of new oral direct acting antiviral (DAA) therapies necessitated a new guideline.

However, Kidney Disease Improving Global Outcomes (KDIGO), the nephrology ‘gold standard’, has decided that an update is needed with new DAA protocols and the increasing use of HCV+ organ transplants.

 There is no update on who to screen nor how to screen, no update on transmission in dialysis units but there are changes in how to treat HCV in CKD (Chapter 2) and how to manage HCV in kidney transplant patients. (Chapter 4).

KDIGO recommends treating all patients with CKD, Stage 1 through Stage 5D (on dialysis), with DAA therapy (Figure 1) Of course, as is standard for all HCV protocols, patients should be tested for hepatitis B prior to treatment.

Hepatitis C treatment Regimen by CKD Stage

Source: Kidney Disease: Improving Global Outcomes (KDIGO) Hepatitis C Work Group. KDIGO 2022 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease

Treatment is condensed in the figure with the caveat that the order of treatments in the figure does not indicate a ranking or preferential order. Note is made that sofosbuvir is safe for all stages of CKD.

The biggest change in the guidelines is in the kidney transplant patient. While there have been concerns of drug-drug interactions with the medications used for immunosuppression, recent trials have shown the DAA medications are safe in this population. We know that if left untreated, HCV will decrease patient survival after kidney transplant. For patients who are HCV+, the timing of treatment depends on the transplant plan and the level of liver fibrosis (

high liver fibrosis means a liver/kidney transplant is recommended, rather than kidney only

). If the HCV+ patient has a living donor and is expected to be transplanted quickly (defined as less than 24 weeks), then the recommendation is to treat with DAA therapy after the transplant. If the wait time for the living donor is less than 24 weeks, the recommendation is to treat as soon as possible with a DAA.

If the patient does not have a living donor and a deceased donor HCV+ kidney is used, then treatment is after transplant. Transplant with HCV+ kidneys is encouraged by KDIGO due to the excellent outcomes with these organs. Treatment for HCV+ should occur as soon as possible post-transplant with DAA therapy. However, due to the more frequent relapse rate, treatment should be for the full 12 weeks no matter which protocol is used.

KDIGO’s new guidelines for the treatment of CKD patients place a special emphasis on the kidney transplant patient. As more and more of our patients are transplanted with HCV+ organs, experience with DAA regimens has shown them to be a safe and effective treatment in all stages of CKD. Dialysis is a bridge to transplant for patients able to qualify and tolerate transplant surgery. Survival on dialysis is limited and survival with a transplant is statistically much better. HCV+ organs will allow better long-term survival in kidney failure patients and the use of these organs is encouraged by the entire nephrology community.

Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO clinical practice guidelines for the prevention, diagnosis, evaluation, and treatment of hepatitis C in chronic kidney disease. 

Gordon CE, Balk EM, Francis JM. Summary of the 2018 Kidney Disease Improving Global Outcomes (KDIGO) Guideline on hepatitis C in chronic kidney disease. 

Kidney Disease: Improving Global Outcomes (KDIGO) Hepatitis C Work Group. KDIGO 2022 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease. 

Kim Zuber, PA-C, and Jane Davis, DNP, provide perspective on guideline recommendations for the management of hepatitis C in people with chronic kidney disease from the Kidney Disease Improving Global Outcomes. 