Dyslipidemia in patients with chronic kidney disease (CKD) is not uncommon and increases overall risk for cardiovascular disease (CVD). Of incident patients with ESRD:

• 46% had total cholesterol levels well over 160 mg/dL and
• 40% exceed the desired threshold for triglycerides (150 mg/dL) (1).

While complex to manage, there are several resources available. In 2003, KDOQI released its Clinical Practice Guidelines for Managing Dyslipidemias in CKD (2). To summarize, the guidelines state for all adults and adolescents with CKD:

• Assessment should include a complete fasting lipid profile with total cholesterol, low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), and triglycerides.
• Dyslipidemias should be evaluated upon presentation (when the patient is stable), at 2–3 months after a change in treatment or other conditions known to cause dyslipidemias; and at least annually thereafter.

Nephrology Nursing Standards of Practice and Guidelines for Care offers guidelines for assessment, intervention, and patient education to achieve these outcomes (3). In part, the stated desired patient outcomes in the management of dyslipidemia are, the patient will:

• Achieve lipoprotein levels within targeted ranges
• Demonstrate a reduction in modifiable risk factors that contribute to the development of CVD.

All of this is informative, but how can we implement this in a simple and sustainable manner? How do we create an action plan that will achieve the desired patient outcomes?

Clinical Solutions offers a three-pronged approach to Triglycerides (TG) and HDL management.
“Assessment, Treatment, and Evaluation of the Patient with Elevated Triglycerides and Low HDL” from the Preventive Cardiovascular Nurses Association (PCNA), includes:

1. A professional course, “Assessment, Treatment, and Evaluation of the Patient with Elevated Triglycerides and Low HDL”, provides an overview of triglycerides and HDL. Invited speaker, Carol M. Mason, ARNP, FAHA (USF Heart Health, University of South Florida) reviews current clinical practice guidelines, assessment of risk including clinical assessment and laboratory testing, treatment options, and patient education including nutrition, exercise, weight loss, lifestyle changes, and medications. This program is offered free of charge and offers one hour of continuing education for registered nurses.
2. Clinical reference tool, “Elevated TG and Low HDL: A Quick Look at Patient Evaluation”, free to download, is a unique pocket guide providing for clinicians:
• ATP III Guidelines
• Risk Factors and Common Causes
• Clinical Assessment Guide
• Supporting Lifestyle Changes
• Pharmacologic Therapy
3. “What you need to know: Triglycerides and HDL” – a patient focused information handout that is applicable to patients with CKD, may be download at no cost. It describes TG and HDL, laboratory values, and risk factors, as well as advice on how to lower TG with an emphasis on nutrition, activity, weight and lifestyle changes. Over-the-counter and prescribed medications are discussed, and is followed by an action plan to be customized for each patient.

Start Now! Use the checklist. Let us know how you have reduced lipid levels in your practice. Contact us at Sallybh@nephrologyclinicalsolutions.com

TRIGLYCERIDES AND HDL PROGRAM CHECK LIST
OBJECTIVE: Achieve lipoprotein levels within targeted ranges

Steps	Start Date	Target Completion	Progress Date	Progress/Comments
1. Log into www.pcna.net/members/exams/Triglycerides/
2. Attend professional educational program (online or download). Complete the evaluation and print your CE certificate
3. Download and print Clinical Reference Tool Distribute copies to colleagues with direct clinical responsibilities. As a group, review the pocket guide asking and seeking answers to questions. Use laboratory-reporting system to identify patients who exceed the TG target range and those who have low HDL. Assign specific staff members to these patients. e. Include dietitian, social worker, physician, and others.
4. Download and print patient handout Photocopy for patients with high levels of TG and/or low levels of HDL. Review the content with the patient. Include interactive education; encourage questions, comments, and discussion about current and potential changes in self-management activities. Complete the action plan section. Tailor interventions to patient need. Assure that goal setting identifies barriers, and provides patient skill building and problem solving. For those patients with normal levels, use the handout as a preventative teaching opportunity.
5. Follow-up activities include reviewing with patient progress toward agreed upon goals. Include discussion of current laboratory results, nutritional intake, lifestyle changes, and medications. Support self-monitoring through dietary and exercise logs and review of laboratory test results.

References:

1. U.S. Renal Data System, USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2007. www.usrds.org
2. National Kidney Foundation. Clinical practice guidelines for managing dyslipidemias in chronic kidney disease. Am J Kidney Dis 2003 Apr;41(4Suppl 3):S1-91. [452 references] www.kidney.org
3. Burrows-Hudson, S. & Prowant, B. [Eds.] Nephrology nursing standards of practice and guidelines for care, 2005. Pitman, NJ:ANNA. www.annanurse.org