Renal

Supportive
care DR PANKAJ SINGHAI
ASSISTANT PROFESSOR
DEPARTMENT OF PALLIATIVE AND
SUPPORTIVE MEDICINE
SRI AUROBINDO MEDICAL COLLEGE
AND PG INSTITUTE, INDORE
  Basic Nephrology: All should know
Learning  Suffering in patients with CKD?-
Suffering burden,
Objectives  How to manage patients with CKD? –
(what you learn at the end of Symptom Control
this session)  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.
Basic
nephrology
What is End stage renal disease?

Classification of CKD
Trajectories of Illness

Holley J L CJASN 2012;7:1033-1038

 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 %
Most dialysis centres managed by
Dialysis technicians and General
physicians
 ……..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
CKDs are 16th most common cause of deaths, expected to be
5th leading cause of death by 2040 worldwide
Symptom burden
CASE

 85 year old, AJJI, 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)
Kidney is not just a filter
Clinical Abnormalities in Uremia
Fluid and electrolyte
disturbances
Volume expansion (I)
Hyponatremia (I)
Hyperkalemia (I)
Hyperphosphatemia (I)
Endocrine and metabolic
disturbances
Secondary hyperparathyroidism
(I/P)
Adynamic bone (D)
Vit D deficient osteomalacia (I)
Carbohydrate resistance (I)
Hyperuricemia (I/P)
Hypertriglyceridemia (I/P)
Increased Lp(a) levels (P)
Decreased HDL levels (P)
PEM (I/P)
Impaired growth &
development (P)
Infertility & sexual dysfunction
(P)
Neuromuscular disturbances Dermatologic disturbances
Fatigue (I) Pallor (I)
Sleep disorders (P) Hyperpigmentation (I, P, or D)
Headache (P) Pruritus (P)
Impaired mentation (I) Ecchymoses (I)
Lethargy (I) Nephrogenic fibrosing dermopathy
(D)
Asterixis (I) Uremic frost (I)
Muscular irritability Gastrointestinal disturbances
Peripheral neuropathy (I or P) Anorexia (I)
Restless legs syndrome (I or P) Nausea and vomiting (I)
Myoclonus (I) Gastroenteritis (I)
Seizures (I or P) Peptic ulcer (I or P)
Coma (I) Gastrointestinal bleeding (I, P, or D)
Muscle cramps (P or D) Idiopathic ascites (D)
Dialysis disequilibrium syndrome (D) Peritonitis (D)
Myopathy (P or D) Hematologic and immunologic
disturbances
Cardiovascular and pulmonary Anemia (I)
disturbances
Complications during Dialysis

 Hypotension (25-55%) • Financial Toxicity

 Cramps (5-20%) • Caregiver
 Nausea and vomiting (5-15%) Burnout
 Headache (5%) • Complications
 Chest pain (2-5%) of AV fisula/
 Back pain (2-5%) Access
 Itching (5%)
 Fever and chills (<1%)
Measuring Symptom
burden…..
 No. of patients
Palliative interviewed: 85
care
Outcome
Score Avg Age : 59Years
iPOS Renal

Average Duration of
dialysis : 4 years
 Pain: 50%
•Mild: 30% of patient
•Moderate to severe Pain 20%

fatigue: 67%
•Mild: 45%

Sympto •Moderate to Severe: 22%

Lack of Apetite: 56%

m •Mild: 31%
•Moderate to Severe: 25%
Restless leg: 43%

Burden •Mild: 21%

•Moderate- severe: 22%

Poor mobility: 57%

•Mild: 34.5%
•Moderate to severe: 22.6%

Sleep disturbances 46%

•Mild: 27%
•Moderate to severe: 19%
Pruritus – 41.5%
•Mild: 20%
•Moderate– severe: 21.5 %

Breathing discomfort- 31%

•Mild 20.3%
•Moderate to Severe: 10.6%
 Communication gap:

• 40% of people felt they were able to express what

Psychosocial they felt
• 60% patients could not share their feelings
Need • 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.
CLINICAL MANAGEMENT
 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
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,
 Causes of Pain
 Musculoskeletal peripheral vascular
disease.
pain:
 Angina.
 Osteoarthritis.
 Osteoporosis.
 Other:
 Polycystic kidney disease.
 Renal osteodystrophy.
 Malignancy.
 Diskitis/osteomyelitis.
 Calciphylaxis.
 Carpal tunnel syndrome.
 Trauma.
 Related to dialysis
procedure.
 Neuropathic pain from
peripheral neuropathy.
 Ischemic pain from
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
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.
Uremic Pruritus UP is non-histamine dependant -Anti Histamines
ineffective.
Look for and correct Non Pharmacological Pharmacological
Adequacy of Dialysis, PTH, Hydration, education on Moisturising cream with 0.3%, menthol,
Calcium / Phosphorus Pruritus general care Pramoxine 1%;
management menthol/camphor/phenol 0.3% - alone
or together
Drug reactions, Iron Phototherapy - UV B 400- Capsaicin 0.025% or 0.03% ; Gamma
deficiency 4800J/m2 3 times / week for 3 Linoleinic Acid cream 2.2%
weeks trial
Allergy, dry skin, Complimentary therapies? Gabapentin 50 mg after HD, titrated as
Infestations, inflamation Acupressure, Transcutaneous required to 50 mg HS and post HD,
electrical acupoint stimulation increase by 100 mgs weekly max -300mg
HS
Minimize scratching Pregabalin 25 mg after HD, increasing to
Avoid hot water baths HS and post HD, titrated as required, by
Use gentle soaps 25 mgs weekly max -75mg HS
Aggressive moisturisation Evening Primrose oil 100 mg capsule 1 BD
or 2 BD
https://dx.doi.org/10.4103/ijpc.ijpc_69_21 sertraline 50 mg /D; Doxepin 10 mg HS
Lignocaine infusion -100-max upto 350
mg SC infusion
Restless Leg Syndromes
Look for and correct
Iron deficiency anemia or If
serum ferritin < 50-75 g/mL
then treatment with oral /
intravenous iron (IVI 1000mg
Iron Dextran)
Hyperphosphatemia
Adv . Reactions of Drugs eg
Dopamine antagonists –
Haloperidol,
metoclopramide,
respiridone, quetiapine,
olanzepine, anti depressants
– SSRIs, SNRIs, TCAs, opioids,
Ca blockers,
Carbamazepine, Lithium
https://dx.doi.org/10.4103/ijpc.ijpc_69_21
Non Pharmacological Pharmacological
Abstinence -alcohol, Gabapentin 50 mg HS,
caffeine, nicotine titrated as required, by 100
mgs weekly max -300mg HS
Mental alert activities like Pregabalin 25 mg HS, titrated
solving puzzles, board games as required, by 25 mgs
weekly max -75 mg HS
Exercises, pedals during Vitamin C and E
dialysis
Pramipexole 0.125 mg HS
Rule out: titrated to Max 0.75 mg/D
Leg cramps, Osteoarthritis
Rotigotine, Tab / patch
Peripheral neuropathy not > 3 mg/D
Pruritus
Akathisia Ropinirol 0.25 mg Hs titrated
to Max 2 mg/D
 Nausea/ Vomiting https://dx.doi.org/10.4103/ijpc.ijpc_69_21

Look for and correct Non Pharmacological

Pharmacological
Control Uraemia, Relaxation, imagery, Metoclopramide 2.5 mg P.O
dyselectrolemia Acupressure 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, Avoid spicy, greasy, w/f – EPS, RLS
due to uraemia or diabetic excessive sweet
autonomic peripheral foods, patient
neuropathy choice
Constipation
 Dyspnoea

Look for and correct Non Pharmacological Pharmacological

Anxiety, anemia, Propped up Position, If Pulmonary edema:
infection Abdominal breathing, Furosemide
pursed lip breathing, , Metolazone,
exercise to capacity SCUF
Respiratory When distressed with Fentanyl SC/SL/ / Intra-
secretions breathlessness - Open nasal (? OTFC)
Glycopyrrolate, windows, Hand-held Morphine dose - 1 mg
Hyoscine, restrict Fan, Shoulder/ back SC/PO
intake massage, Relaxation
Oxygen if Hypoxemic
https://dx.doi.org/10.4103/ijpc.ijpc_69_21
Identifying a patient for renal
supportive care
 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
Step 1
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 2
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. Modified Charlson’s score (MCS) > 8
 Decreasing activity – functional performance status declining (e.g. KPS) limited self-care
 Decreasing response to treatments, decreasing reversibility.
Karnofsky Performance scale of < 40 (Bedridden)
 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 3
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.
Risk factors Points
Body mass index (kg/m )
2 Prognostic score for
<18.5 2 6-month mortality in
Diabetes * elderly patients (>75
Presence 1 years)
Congestive heart failure stage III or IV*
Presence 2
Peripheral vascular disease stage III or IV
Score > 9 has 70
Presence 2 % 6-month
Dysrhythmia mortality
Presence 1
Active malignancy * Couchoud,et al, A clinical
Presence 1 score to predict 6-month
Severe behavioural disorder prognosis in elderly patients
starting dialysis for end-
Presence 2
stage renal
Totally dependent for transfers disease, Nephrology Dialysis
Presence 3 Transplantation, Volume 24,
Initial context for HD Issue 5, May 2009, Pages
1553–
Unplanned 2 1561, https://doi.org/10.109
COHEN et al (2009)

A mortality score obtained from combining the answer to the Surprise

Question with four routine variables –
 age,
 serum albumin,
 presence of dementia
 peripheral vascular disease
WITHHOLDING / WITHDRAWL from
DIALYSIS
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
 Survival benefit lost if Co-
morbidities include IHD
Overall

AGE- >75 years

Murtagh et al. NDT. 2007;22:1955-62

 COMPREHENSIVE CONSERVATIVE CARE

Definition
„A planned holistic patient-centered care for patients with ESKD that includes :
 Interventions to delay the progression of kidney disease and minimize risk of adverse
events or complications
 Shared decision making
 Active symptom management
 Detailed communication including advance care planning
 Psychological support
 Social and family support
 Cultural and spiritual domains of care
 Kidney Supportive Care

Symptom
Control

Communicati
on

Psychosocial
support
 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: Kidney 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.
FURTHER READ……

 Oxford textbook of Palliative Medicine, Chapter 15.6- ESKD

Further Reading

https://jpalliativecare.com/issue/2021-27-supplement/
doctorpsinghai@gmail.com
+91 9920828452