Transcript Supportive Care for the Renal Patient – A Review”

“Transition to Palliative
Care for the Renal
Patient”
Helen Hoffman
Predialysis/Vascular Access Coordinator
Renal Unit, Wellington Hospital
28 August 2009
Trichomenes Reniform – Kidney fern
Objectives:

Four treatment options facing a patient with a
diagnosis of End Stage Renal Disease (ESRD)

Changing population of people with End Stage
Renal Disease

Co morbidities and the Symptom Burden in
ESRD

Describe a model of “Supportive Care”

Two case studies and their outcomes
Haemodialysis – minimum 3 x 5 hrs/wk
at home or in-centre
Peritoneal Dialysis – home only therapy
Uses peritoneal
membrane as a semipermeable membrane for
removal of wastes and
toxins in the blood.
Kidney Transplantation
•Big operation – from live or
cadaver donor
•Life time of anti rejection drugs
•Greater chance of infection and
cancers
•Always the risk of rejection
Conservative Management or choosing
not to do dialysis

It is a decision for active
disease management to
preserve and maintain kidney
function for as long as
possible.

It involves ongoing
monitoring by a nephrologist.

Referral to palliative care as
they die from ESRD.
Changing population of people with
ESRD in NZ...
1984
2007
Start
Dialysis
109
461
Over 65
yrs
5%
31%
Diabetes 22%
41%

Those who never start dialysis
-20% of low clearance clinic patients in the
UK (Murtagh 2006).

This data not collected in NZ at present.
“Clinical Guidelines for the Appropriate
Initiation and Withdrawal of Dialysis”
RPA/ASN – 2000
•Shared decision making, patient autonomy, and informed consent - the
patient is central in the decision to start or withdraw from dialysis.
•Treat many patients that 10-20 yrs ago were never offered dialysis.
•Challenge -how to maintain some QOL for these patients.
•“The benefit of dialysis must outweigh the burden” (Perkins 1998)
.....the burden of treatment and the symptoms of disease.
CKD/ESRD+comorbidities
Calcium and phosphate
imbalance – Pruritus,
Dry Skin, calciphylaxis
Anaemia LVH, CVD, lethargy,
SOB, inability to
concentrate
Vitamin D Deficiency
Bone Disease,
pathological fractures
Loss appetite/anorexia
Nausea/vomiting Weight loss, GI bleeds
Fluid overload Oedema, SOB, CVD,
Hypertension
Electrolyte Imbalance
High serum potassium
Confusion, cramps
Cardiovascular Disease
LVH, MI, CHF
Pericarditis
Acidosis
Poor cell function
Malnutrition
Poor healing,
increased risk of
infection
Renal Replacement Therapy –
The ultimate palliative therapy

Dialysis and transplantation are non-curative.

Prolong life and reduce symptoms of renal failure.

Underlying pathophysiology and existing co morbidities
continue to progress.

Problems develop that are consequences of dialysis or
immune suppression after transplantation.
Palliative Care input – 3 groups

Those who never start or forego Renal Replacement
Therapy (RRT) – Conservative Management.

Those on RRT who withdraw from active dialysis
management
(ANZDATA 2008 - 23% dialysis pts withdrew).

Those on RRT who need palliation for co morbidities
and complications caused by ESRD
(ANZDATA 2008 - 51% dialysis pts died CV causes).
Dialysis vs Conservative Management
in over 75 year olds

Burns et al, 2006 – 129 pts CKD stage 5,
from eGFR 15ml/min to death or study
end point

Huge difference in hospital free days

80% CM group died at home or hospice –
more likely to have planned for their death

80% dialysis group died in hospital
Model of Supportive care
(Reiter and Chambers 2002)
Restorative
Care
Palliative Care
Bereavement
Disease Trajectory → → → → → → →

Overlapping or integration of both palliative and
restorative care.

Restorative Care – strategies to reverse, halt or minimise
the underlying pathophysiology of a specific disease
process.
Supportive Care cont...

Over time fewer restorative measures are effective.
example: Ca/PO4 imbalance leads to renal osteodystrophy
– bone pain, pathological fractures, tumoural calcinosis,
calciphylaxis.

A move to more palliative interventions needs to occur

The good of dialysis must always be balanced with good
psychosocial support, symptom management as well as
preparing patients for the end of their life.
Case Study 1 – 31 year old Maori man

Type DM since 1 year old

Retinopathy now blind, autonomic and peripheral neuropathy,
hypertension, chronic diarrhoea, chronic back pain

Lives with partner and 2 children (2 and 7 yrs old)

Home visited July 2007 (eGFR 25ml/min)

Options PD or Hospital HD (100 km travel each way)

Did not want dialysis - decision supported by partner and mother

Admissions for RBC, 2nd visit by me, OPA with physician

Died February 2008 in hospital after being cared for at home until
could not be managed.
Mrs T – 82 yr old Maori lady

Diabetic nephropathy – eGFR 8 mls/min at referral

Retinopathy, hypertension, gout, history of GI haemorrhage sec.
to peptic ulcer disease, GI malignancy – colostomy and
subsequent reversal, Congestive Heart Failure, osteoarthritis

Difficulties mobilising - ?peripheral vascular disease

Lives 35 km each way from DU

Unable to do PD – abdo surgery, general frailty, age is an issue
Some issues:





Hospital based HD or conservative
management only options
Started dialysis via tunnelled IJ
line in May 2007
Feb 2008 -#NOF, pain and poor
mobilising – no surgical options,
for rehab.
May 2008 – bed bound, wants to
stop dialysis, family do not want
her to.
June 12 – last dialysis – withdrew
from dialysis and died 22 June
(13 mths on dialysis).
Some thoughts to finish

Patients foregoing or withdrawing from dialysis
experience a heavy symptom burden.

Due to underlying renal disease but also comorbid conditions.

The constraints on the use of medication in
severe kidney failure make good symptom control
challenging.

Need to improve collaboration between palliative
and renal specialists.

The key to chronic care is building good
relationships, getting to know the person......
William Ostler (1849 – 1919)

“It’s more important
to know what sort of
person this disease
has than what sort of
disease this person
has”
References

Brick, N. et al,“A Renal Collaborative Approach”, EDTNA/ERCA
Journal 2005, XXXI2.

Chambers, E.J., Germain, M., Brown,E., “Supportive Care for
the Renal Patient”, Oxford University Press 2004.

Noble, H. et al, “The Cessation of Dialysis in Patients With
End Stage Renal Disease: Developing an Appropriate
Evidence Base for Practice”, EDTNA/ERCA Journal 2005,
XXXI4.

Noble, H. et al, “Patient Experience of Dialysis Refusal or
Withdrawal – A Review of the Literature”, Journal of Renal
Care 34(2), 94-100.

Murtagh, F.E.M. et al, “Symptom Management in Patients
with Established Renal Failure Managed Without Dialysis”,
EDTNA/ERCA Journal 2006, XXXII2, page 93.

ANZDATA – www.anzdata.org.au