Kidney palliative care

z
Renal
Supportive
care Dr Pankaj Singhai
MBBS,MD
Assistant Professor
Department of Palliative Medicine,
Sri Aurobindo Medical College and PG Institute, Indore

z
Learning Objectives (what you learn at the end of this
session)
 Basic Nephrology: All should know
 Suffering in patients with CKD?- Suffering burden,
 How to manage patients with CKD? – Symptom Control
 How to identify patients for Kidney supportive care?
 Conservative Management for patients not on Dialysis.
 Is dialysis is absolutely for all ESKD patients? – withdrawl from
HD.

z
Classification of CKD
What is End stage renal disease?

z
Drugs affecting renal functions
 NSAIDS
 Aminoglycosides
 Bisphosphonates*
 CHEMOTHERAPIES
 Anti HTN- ACEi/ARBs/ Diuretics
 Herbal Medications/ Heavy
metals

z
Drugs that “do” and “do not” depend on
renal functions
Dependent on renal function Independent on renal function
Morphine, Tramadol, Tapentadol Fentanyl, Methadone,
Ciprofloxacin, levofloxacin Moxifloxacin
Glibenclamide, glimepride,
Sitagliptine
Pioglitazone
Gabapentin < pregabalin Carbamazepine, phenytoin,
valproate
Lithium, mirtazapine citalopram , haloperidol, risperidone

z
Epidemiology
India is the Diabetes capital of world.
Most common reason for CKD is Diabetes.
Patients with CKD has high symptom burden
Around 15 % patients on dialysis dies every year.
While in patients aged more than 75: mortality is more than 25 %

z
CKDs are 16th most common cause of
deaths, expected to be 5th leading cause of
death by 2040 worldwide

z
Holley J L CJASN 2012;7:1033-1038
Trajectories of Illness

z
Treatment options
 Slowing progression:
 early diagnosis,
 t/t of comorbidity (Diabetes, HTN, Proteinuria)
 Protein restriction (0.6-0.75g/kg/day),
 Medication dose adjustment
 Treatment of complications
 Renal Replacement Therapy
 Adequate symptom control
 End of life care
Jha V. Developing supportive care
services for patients with kidney failure:
An idea whose time has come. Indian J
Palliat Care 2021;27, Suppl S1:3-5

z
 ……..about 188 million people experience catastrophic health
expenditure annually as a result of kidney diseases across
LMICs, the greatest of any disease group.
Essue, B.M., et al.,
Economic Burden of Chronic Ill Health and Injuries for Households in Low-and
Middle-Income Countries.
2018, World Bank

z
 Advanced kidney disease is not asymptomatic.
 Potential complications of dialysis are longer than those of
chronic kidney disease alone.
 Clinicians often assume a more favourable prognosis than is
justified.
 For many patients dialysis is not the bridge to renal
transplantation.
 Dialysis doesn’t transform lives – it is often palliative
treatment. (Brown et al 2007)

Clinical Abnormalities in Uremia
Fluid and electrolyte disturbances Neuromuscular disturbances Dermatologic disturbances
Volume expansion (I) Fatigue (I) Pallor (I)
Hyponatremia (I) Sleep disorders (P) Hyperpigmentation (I, P, or D)
Hyperkalemia (I) Headache (P) Pruritus (P)
Hyperphosphatemia (I) Impaired mentation (I) Ecchymoses (I)
Endocrine and metabolic
disturbances
Lethargy (I) Nephrogenic fibrosing dermopathy (D)
Secondary hyperparathyroidism
(I/P)
Asterixis (I) Uremic frost (I)
Adynamic bone (D) Muscular irritability Gastrointestinal disturbances
Vit D deficient osteomalacia (I) Peripheral neuropathy (I or P) Anorexia (I)
Carbohydrate resistance (I) Restless legs syndrome (I or P) Nausea and vomiting (I)
Hyperuricemia (I/P) Myoclonus (I) Gastroenteritis (I)
Hypertriglyceridemia (I/P) Seizures (I or P) Peptic ulcer (I or P)
Increased Lp(a) levels (P) Coma (I) Gastrointestinal bleeding (I, P, or D)
Decreased HDL levels (P) Muscle cramps (P or D) Idiopathic ascites (D)
PEM (I/P) Dialysis disequilibrium syndrome (D) Peritonitis (D)
Impaired growth & development
(P)
Myopathy (P or D) Hematologic and immunologic
disturbances
Infertility & sexual dysfunction (P) Cardiovascular and pulmonary disturbances Anemia (I)
Amenorrhea (I/P) Arterial hypertension (I or P) Lymphocytopenia (P)
B2 microglobulin amyliodosis (P/D) Congestive heart failure or pulmonary edema (I) Bleeding diathesis (I or D)

z
Illness beyond Kidney…….
Progressive disease
 Multiple complications:
 Stroke- ischemic/hemorrhagic
 IHD, Pericardial D,Heart Failure,
 Recurrent sepsis
 Fistula failure
 Pancreatitis
 Crisis – pre transplant/during
transplant/ post transplant
 DVT
 Peripheral Neuropathy (severe)
 Peripheral vascular disease
 Ischemic ulcers/ Gangrene
 Bone disorders, calciphylaxis
 Bleeding disorders
PAIN
Total Pain
• Multiple Symptoms
• DEPRESSION
• Cachexia/ facial edema
• Loss of taste/ Anorexia
• NAUSEA/ vomiting
• Breathing difficulties
(Pulmonary edema)
• Recurrent abdominal
pain
• Itching,
• Restless leg
• FINANCIAL Toxicity

z
Complications during Dialysis
 Hypotension (25-55%)
 Cramps (5-20%)
 Nausea and vomiting (5-15%)
 Headache (5%)
 Chest pain (2-5%)
 Back pain (2-5%)
 Itching (5%)
 Fever and chills (<1%)
• Financial Toxicity
• Caregiver Burnout
• Complications of
AV fisula/ Access

z
Palliative care
Outcome Score
iPOS Renal
No. of patients interviewed:
85
Avg Age : 59Years
Average Duration of dialysis :
4 years

z
Symptom
Burden
• Mild: 30% of patient
• Moderate to severe Pain 20%
Pain: 50%
• Mild: 45%
• Moderate to Severe: 22%
fatigue: 67%
• Mild: 31%
• Moderate to Severe: 25%
Lack of Apetite: 56%
• Mild: 21%
• Moderate- severe: 22%
Restless leg: 43%
• Mild: 34.5%
• Moderate to severe: 22.6%
Poor mobility: 57%
• Mild: 27%
• Moderate to severe: 19%
Sleep disturbances 46%
• Mild: 20%
• Moderate– severe: 21.5 %
Pruritus – 41.5%
• Mild 20.3%
• Moderate to Severe: 10.6%
Breathing discomfort- 31%

z
Psychosocial
Need
Communication gap:
• 40% of people felt they were able to express what
they felt
• 60% patients could not share their feelings
• 37% Patients did not had enough information as
they wanted
Financial/ Practicals needs:
• Not addressed: 27%
• Partly addressed: 20%
• No financial issues: 53%
80% of patients felt that they were wasting
significant amount of time in healthcare
facility.

z
Case story
 Mr 66 year old, Ex-businessman, Diabetes, diagnosed with CKD
5 years ago, now on twice weekly dialysis, complains of
persistent itching all the time, sometime very severe. Also he
had severe diabetic neuropathy and complains of burning
sensation in both feets,

z
Causes of Pain
 Musculoskeletal
pain:
 Osteoarthritis.
 Osteoporosis.
 Renal osteodystrophy.
 Diskitis/osteomyelitis.
 Carpal tunnel syndrome.
 Related to dialysis
procedure.
 Neuropathic pain from
peripheral neuropathy.
 Ischemic pain from
peripheral vascular disease.
 Angina.
 Other:
 Polycystic kidney disease.
 Malignancy.
 Calciphylaxis.
 Trauma.

z
Pain management
 Pain is most common symptom in dialysis patients
(50% of patients).
 Undertreatment is widespread and negatively
impacts quality of life.
 May occur for any number of causes at any time.
 Patients often won’t admit to nor seek relief from it
Rao SR, Vallath N, Siddini V, Jamale T, Bajpai D, Sancheti NN, Rangaswamy D. Symptom
management among patients with chronic kidney disease. Indian J Palliat Care 2021;27, Suppl
S1:14-29

z
General Principles of Pain Management
 Assess pain fully.
 Use WHO ladder.- Validated
 Avoid codeine, morphine, - active metabolites -renally excreted.
 Use adjuvant analgesics as needed.
 NSAIDs may actively worsen renal function.
 If this is the only option to achieving good symptom control, discuss with
renal physicians and ensure that patient and carers are aware of the
potential harm.

z
Uremic Pruritus
Look for and correct Non Pharmacological Pharmacological
Adequacy of Dialysis, PTH,
Calcium / Phosphorus
management
Hydration, education on Pruritus
general care
Moisturising cream with 0.3%, menthol,
Pramoxine 1%; menthol/camphor/phenol
0.3% - alone or together
Drug reactions, Iron
deficiency
Phototherapy - UV B 400-
4800J/m2 3 times / week for 3
weeks trial
Capsaicin 0.025% or 0.03% ; Gamma
Linoleinic Acid cream 2.2%
Allergy, dry skin, Infestations,
inflamation
Complimentary therapies?
Acupressure, Transcutaneous
electrical acupoint stimulation
Gabapentin 50 mg after HD, titrated as
required to 50 mg HS and post HD, increase
by 100 mgs weekly max -300mg HS
Minimize scratching
Avoid hot water baths
Use gentle soaps
Aggressive moisturisation
Pregabalin 25 mg after HD, increasing to
HS and post HD, titrated as required, by 25
mgs weekly max -75mg HS
Evening Primrose oil 100 mg capsule 1 BD
or 2 BD
sertraline 50 mg /D; Doxepin 10 mg HS
Lignocaine infusion -100-max upto 350 mg
SC infusion
UP is non-histamine dependant -Anti Histamines ineffective.
https://www.jpalliativecare.com/text.asp?2021/27/5/14/317222

z
Restless Leg Syndromes
Iron deficiency anemia or If
serum ferritin < 50-75 g/mL
then treatment with oral /
intravenous iron (IVI 1000mg
Iron Dextran)
Abstinence -alcohol, caffeine,
nicotine
Gabapentin 50 mg HS, titrated
as required, by 100 mgs weekly
max -300mg HS
Hyperphosphatemia Mental alert activities like
solving puzzles, board games
Pregabalin 25 mg HS, titrated
as required, by 25 mgs weekly
max -75 mg HS
Adv . Reactions of Drugs eg
Dopamine antagonists –
Haloperidol, metoclopramide,
respiridone, quetiapine,
olanzepine, anti depressants –
SSRIs, SNRIs, TCAs, opioids,
Ca blockers, Carbamazepine,
Lithium
Exercises, pedals during
dialysis
Vitamin C and E
Pramipexole 0.125 mg HS
titrated to Max 0.75 mg/D
Rotigotine, Tab / patch
not > 3 mg/D
Ropinirol 0.25 mg Hs titrated to
Max 2 mg/D
Rule out:
Leg cramps, Osteoarthritis
Peripheral neuropathy
Pruritus
Akathisia

z
Nausea/ Vomiting
Control Uraemia,
dyselectrolemia
Relaxation, imagery,
Acupressure
Metoclopramide 2.5 mg P.O or
S/C q4H if gastric paresis
suspected
Ondansetron 4 mg TDS upto 8
mg TDs (avoid if constipated)
s/e-opioids, SSRIs Ginger If predominant Nausea
1. Haloperidol 0.5 mg q 12H to
upto 2 mg q4H
2. Olanzepine 2.5 mg q8H upto
q4H
Delayed Gastric Emptying, due
to uraemia or diabetic
autonomic peripheral
neuropathy
Constipation
Avoid spicy, greasy,
excessive sweet
foods, patient choice
w/f – EPS, RLS

z Dyspnoea
Anxiety, anemia,
infection
Propped up Position,
Abdominal breathing,
pursed lip breathing,
exercise to capacity
If Pulmonary edema:
Furosemide
, Metolazone,
SCUF
Respiratory
secretions
Glycopyrrolate,
Hyoscine, restrict
intake
When distressed with
breathlessness - Open
windows, Hand-held
Fan, Shoulder/ back
massage, Relaxation
Fentanyl SC/SL/ / Intra-
nasal (? OTFC)
Morphine dose - 1 mg
SC/PO
Oxygen if Hypoxemic

z
Depression
Look for and correct Non
Pharmacological
Pharmacological
Screen during
vulnerable periods- 1st
year of HD, failed
transplant, not listed for
transplant
Psychotherapy -
Expressive, cognitive
behavioural,
1st L -Sertraline 50-
200mg/D; Escitalopram 10-
20 mg/D
Mirtazepine 15-45 mg/D in
CKD 1-4,
CKD 5 - 50% dose
reduction Venlafaxine,
Electro-convulsive
Therapy
Cognitive behavioural
Therapy
Exercise therapy
Optimize cardiac
medications, dialysate

z
Identifying a patient for renal supportive care

z
CASE:2
 85 year old female, known case of hypertension, ischemic heart
disease with heart failure, CKD on dialysis since 5 years.
 Poor socioeconomic status- cant afford an extra dialysis per
week.
 c/o Chronic pain, persistent breathless before dialysis
 Limited mobility, fully dependent for activities of daily living.
(Does not wanted to be burden on her daughter)

z
 Aims to enable the earlier identification of people with chronic suffering who may
need additional supportive care.
 Earlier recognition of decline leads to earlier anticipation of likely needs, better
planning, fewer crisis hospital admissions and care tailored to peoples’ wishes
 3 steps

z
Surprise Question:“Would you be surprised if the patient
were to die in the next year, months, weeks, days?
 The answer to this question should be an intuitive one, pulling together a
range of clinical, social and other factors that give a whole picture of
deterioration.
If you would not be surprised,
 what measures might be taken to improve the patient’s quality of life now
and in preparation for possible further decline?
Step 1

z
General indicators of decline and increasing needs?
 General physical decline, increasing dependence and need for support.
 Repeated unplanned hospital admissions.
 Advanced disease - unstable, deteriorating,
 Presence of significant multi-morbidities.
 Decreasing activity – functional performance status declining (e.g. KPS) limited self-care
 Decreasing response to treatments, decreasing reversibility.
 Patient choice for no further active treatment and focus on quality of life.
 Progressive weight loss (>10%) in past six months.
 Sentinel Event e.g. serious fall, bereavement, transfer to nursing home.
 Serum albumin <2.5g/dl.
Step 2
Modified Charlson’s score (MCS) > 8
Karnofsky Performance scale of < 40 (Bedridden)

z Specific Clinical Indicators related to CKD
 Stage 4 or 5 Chronic Kidney Disease (CKD) whose condition is
deteriorating with at least two of the indicators below:
 Patient for whom the surprise question is applicable.
 Repeated unplanned admissions (more than 3/year).
 Patients with poor tolerance of dialysis with change of modality.
 Patients choosing the ‘no dialysis’ option (conservative), dialysis withdrawal
or not opting for dialysis if transplant has failed.
 Difficult physical or psychological symptoms that have not responded to
specific treatments.
 Symptomatic Renal Failure in patients who have chosen not to dialyse –
nausea and vomiting, anorexia, pruritus, reduced functional status,
intractable fluid overload.
Step 3

z
Risk factors Points
Body mass index (kg/m
2
)
<18.5 2
Diabetes *
Presence 1
Congestive heart failure stage III or IV*
Presence 2
Peripheral vascular disease stage III or IV
Presence 2
Dysrhythmia
Presence 1
Active malignancy *
Presence 1
Severe behavioural disorder
Presence 2
Totally dependent for transfers
Presence 3
Initial context for HD
Unplanned 2
Score > 9 has 70
% 6-month
mortality
Prognostic score
for 6-month
mortality in elderly
patients (>75 years)
Couchoud,et al, A clinical
score to predict 6-month
prognosis in elderly patients
starting dialysis for end-stage
renal disease, Nephrology
Dialysis Transplantation,
Volume 24, Issue 5, May
2009, Pages 1553–
1561, https://doi.org/10.1093/n
dt/gfn698

z
WITHHOLDING / WITHDRAWL from DIALYSIS

z
Is dialysis is absolutely for all ESKD patients?
“Will I live longer if I start dialysis ?”
For a long time the assumption was –
“Yes, you will always live longer if you commence dialysis than if you do not.”
Conclusions. In CKD stage 5 patients over 75 years, who receive specialist nephrological
care early, and who follow a planned management pathway, the survival advantage of
dialysis is substantially reduced by comorbidity and ischaemic heart disease in particular

Murtagh et al. NDT. 2007;22:1955-62
Overall
Survival benefit lost if Co-
morbidities include IHD
AGE- >75 years

z
Kidney Supportive Care
Symptom
Control
Communication
Psychosocial
support

z
Key points
 Primary supportive care should be available to all throughout the entire course of their illness.
 Provision of supportive care should be based on need rather than solely an estimation of survival.
 Identify those patients who are most likely to benefit from supportive care interventions.
 Assess and manage symptoms effectively.
 Estimate and communicate prognosis (survival and future illness trajectory) to the best of their
ability.
 Develop appropriate goals of care that address individual patients’ preferences, goals, and values.
 Assist with care coordination including referral to specialist supportive care and hospice service
as available and appropriate
 Education: supportive care should be recognized as a core competency and therefore constitutes an
essential component of continuing medical education for practicing nephrologists, as well as the
nephrology curriculum for trainees.

z
FURTHER READ……
 Oxford textbook of Palliative Medicine, Chapter 15.6- ESKD

z
Further Reading
https://jpalliativecare.com/issue/2021-27-supplement/

z
Thank Doctorpsinghai@gmail.com
+91 9920828452

Kidney palliative care

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Kidney palliative care

Similar to Kidney palliative care (20)

Recently uploaded

Recently uploaded (20)

Kidney palliative care