Symptom Management in Patients With Established Renal Failure Managed Without Dialysis

Abstract

Increasing numbers of patients with chronic kidney disease Stage 5 (GFR <15ml/minute) are being managed without dialysis, either through their own preference or because dialysis is unlikely to benefit them. This growing group of patients has extensive health care needs. Their overall symptom burden is high, and symptom prevalence matches or exceeds that in other end of life populations, both with cancer and other non-cancer diagnoses. These symptoms may often go unrecognised and under-treated. Regular symptom assessment is necessary, together with pro-active management of identified symptoms. Pain can be managed using the principles of the World Health Organisation analgesic ladder. Not all opioid medications are recommended for these patients. Paracetamol, tramadol, and fentanyl are the most appropriate medications for steps 1, 2 and 3 respectively. There is limited evidence on the use of buprenorphine, oxycodone and hydromorphone. Methadone is safe but should only be prescribed by a clinician experienced in its use. Morphine and diamorphine are not recommended because of metabolite accumulation. Pruritus is also challenging to manage. The evidence for pharmacological interventions to alleviate pruritus is summarized, and a pragmatic approach to management suggested. Emollients, capsaisin cream, antihistamines, thalidomide and ondansetron may be helpful, according to the extent and pattern of pruritus. Symptoms may frequently be due to co-morbid conditions, not renal disease itself, and managing them is difficult because of the constraints on the use of medication which kidney failure imposes. Collaboration between renal and palliative specialists can help identify ways to achieve best care for these patients.

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

“…Overall, RRT patients spent on average 6.9% of the days they survived (25 d per patient per year) as hospital inpatients, which is similar to three studies that described incident 90-d survivor RRT patients who were aged Ͼ80 yr (20), incident peritoneal dialysis patients who were aged Ͼ75 yr (21), and RRT patients who were aged Ն70 yr; had survived Ͼ90 d (22); and were hospitalized for 35,19, and 20 d per patient per year, respectively.…”

“…The growing literature surrounding end-of-life care in renal patients has been largely centered around advanced care planning for patients who are established on dialysis and symptom control in palliative care of patients who have withdrawn from dialysis (19,(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40). The next step in improving care for patients with kidney failure is to discuss initiation of dialysis (versus MCM) earlier.…”

A concept analysis of renal supportive care: the changing world of nephrology

“…Although it has been known for some time that renal patients have shortened life expectancy and many carry a high symptom burden (Cohen et al. 2006, Murtagh et al. 2006, Saini et al.…”

Science supporting the art of medicine: improving the management of breathlessness

“…3 There are now a number of breathlessness services working with respiratory departments (Cambridge Breathlessness Intervention Service, Breathlessness Support Service at King's, The Breathing Space at St Joseph's Hospice, London, 'Inspired', Nova Scotia), which have led to improved access to palliative care for all patients with respiratory disease. These services work with the patient, family and referring team until there is no further improvement possible, accepting re-referral from respiratory medicine if needed or ensuring excellent continuing links with palliative care.…”