Symptom Management in Patients with Stage 5 CKD Opting for Conservative Management

Abstract

Chronic kidney disease (CKD) stages 3–5 now affects 8.5% of adults in the United Kingdom; with 4% of patients expected to reach stage 5 CKD. Increasing numbers of older patients are contributing to the growth of demand of kidney services. With the exception of transplantation, dialysis has been the main form of renal replacement therapy (RRT) for advanced CKD. This elderly population is usually too frail and has many other co-existing medical complaints or co morbidities to undergo transplantation. Dialysis is an invasive treatment, and some frail elderly patients can experience many dialysis related symptoms. An alternative option for these patients is to choose conservative management (CM) of their stage 5 CKD. These patients often have complex supportive and palliative care needs. The frequency, severity and distress caused by symptoms related to stage 5 CKD are often under recognized and under treated. There is a need for early identification and management of symptoms as they present in patients with stage 5 CKD being managed conservatively. Symptom assessment should be focused on anticipating, identifying and alleviating any symptoms. This needs to be incorporated into the regular practice of those managing CM patients.

Conservative management for patients with chronic kidney disease refusing dialysis

“…The progression of CKD is tied to the deterioration of metabolic parameters and consequently to the onset of symptoms. 24 - 26 Interventions aimed at correcting metabolic alterations may reduce symptoms and improve the quality of life of patients off dialysis.…”

“…The most common complaints made by patients managed conservatively include weakness, malaise, lethargy, prostration, somnolence, trouble sleeping, attention deficit, depression, inappetence, dry mouth, metallic taste in the mouth, nausea, pruritus, dry skin, dyspnea, edema, cramps, restless legs syndrome, and pain. 24 - 26…”

“…Methadone is relatively safe, since it is metabolized in the liver and the accumulation of metabolites is minimal in patients with CKD. 24 - 26…”

“…When needed, the usual initial dose is 1.5 mg - administered subcutaneously or orally - and the maximum dose is 10 mg/day. 24 Subcutaneous metoclopramide 10 mg, three times a day, at a maximum of 60 mg/day, may be attempted in cases of stasis or obstruction impeding gastric emptying, a frequent event in diabetic patients. 24 , 25 Dose reductions may be required, since metoclopramide may accumulate and produce extrapyramidal side effects.…”

“…Patients with significant anxiety may benefit from the prescription of low-dose therapy with benzodiazepines, midazolam or opioids. 24 , 25 Patients on these drugs have to be closely monitored to avoid toxicity and excessive somnolence. Patients with hypoxia may be offered intermittent or continuous administration of oxygen.…”