15.7 (15.6) end stage kidney disease

Question 1

List THREE clinical scenarios in ESRD that results in the need for PC involvement

Answer 1

1. those who choose or who are advised not to embark on dialysis (conservative mgmt)
2. those who are failing to thrive on dialysis, experiencing worsening QOL and increasing symptom burden despite dialysis
3. those who discontinue dialysis

Question 2

What is the median survival after dialysis discontinuation (with what exception)

Answer 2

◆ 8-10 days
◆ If residual renal function, survival in months

Question 3

Name TWO validated renal disease symptom assessment tools.

Answer 3

◆ Dialysis Symptom Index
◆ Renal version of the Patient Outcome Scale (symptom module)
◆ Integrated Patient Outcome Scale - Renal version (IPOS-Renal)

Non renal specific: ESAS

Question 4

List FIVE symptoms commonly experienced by patients with ESRD

Answer 4

◆ anxiety & depression
◆ pain
◆ pruritus
◆ restless legs
◆ sleep disturbance
◆ fatigue

◆ other symptoms
- n/v
- drowsiness
- breathlessness
- leg edema
- dry mouth
- lack of appetite
- altered taste
- poor concentration
- dry skin
- constipation

◆ symptoms due to comorbid conditions

Question 5

List THREE general causes of symptoms in patients with ESRD

Answer 5

◆ uremia
◆ dialysis
◆ comorbidity

Question 6

List TWO opioids that can be safely used in ESRD

Answer 6

◆ fentanyl
◆ alfentanil
◆ buprenorphine
———–
◆ methadone
———–

Note on Hydromorphone: use carefully if mild or mod renal impairment (avoid in severe renal impairment)

Question 7

List THREE causes of fatigue in ESRD

Answer 7

◆ Renal Disease
- anemia, hyperparathyroidism, uremia may contribute
◆ Dialysis
◆ Comorbid conditions

Question 8

How to treat fatigue in ESRD?

Answer 8

◆Exercise and rehab
◆Treat anemia with erythropoietin stimulating agents (EPO)

Question 9

What 1 metabolic derangement contribute to pruritus in ESRD and how to treat?

Answer 9

High PO4 - tx with phosphate binder and dietary advice

Question 10

List FOUR systemic treatments for pruritus in ESRD

Answer 10

◆ Xerosis (dry skin) relieving agents
- emollients (dry skin)

◆ Immune modulators
- ultraviolet B light
- tacrolimus
- thalidomide

◆ Antihistamines

◆Neuropathic agents
- gabapentin
- capsaicin

◆ Opioid antagonists (limited use per uptodate)
- nalfurafine (Kappa agonist)
- butorphanol (Kappa agonist/mu antagionist)

◆ Anti-depressant (per uptodate)

Question 11

List the FOUR diagnostic criteria for RLS

Answer 11

◆ urge to move legs, usually with unpleasant sensation
◆ worse during periods of rest or inactivity
◆ worse symptoms in evening or night
◆ partial or total relief by physical activity

Question 12

List TWO drugs that can be used to manage RLS

List TWO non-pharmacological interventions to manage RLS

Answer 12

◆ Dopamine agonist (levodopa, ropinirole, pramipexole)
◆ Gabapentin
◆ Benzo (clonazepam)

◆ Avoid exacerbating agents (e.g. ETOH, caffeine, nicotine)
◆ Exercise

Note: huge change from 5th E. due to new systematic review (Sinclair, 2018)

Question 13

List THREE drugs which may worsen RLS

Answer 13

Dopamine antagonist (e.g. maxeran)
Anti-depressants (e.g. SSRI, TCAs)
Anti-histamine
Lithium

FS:
Anti D
Anti H
Anti 5HT

Same meds that lower seizure threshold

Question 14

List FOUR non-pharm approaches to managing dyspnea in ESRD

Answer 14

◆ sitting upright
◆ use of fan, stream of cool air
◆ calm, settled environment

◆ PT/OT (appropriate aids)

◆ mgmt of anxiety

◆ inhaled O2 if hypoxic

FS: think general SOB strategies
Breathlessness management
Self care
Equipment
Education, rehab, support group
Meds
Interventions (surgery, dialysis)

Question 15

Under what conditions is active treatment with erythropoietin-stimulating agents likely to improve fatigue when anaemia is due to kidney disease?

Answer 15

◆ IF:
- glomerular filtration rate is less than 30 mL/min/1.73 m2 (<45 mL/min/1.73 m2 in diabetics)

• no other cause (such as blood loss, or folic acid or vitamin B12 deficiency) is identified

FS: GFR<30 ( <45 for diabetics)

Question 16

What are three indications for dialysis for a patient with chronic kidney disease?

Answer 16

a. Volume overload
b. Signs or symptoms of uremia
c. eGFR (if <15 with symptoms, or <5)

FS: Acute = AEIOU
Acidosis
Electrolyte
Ingestion
Overload
Uremia

Question 17

List 5 complications associated with dialysis.

Answer 17

a. Line infection / complicated infections
b. Fistula bleeding
c. Increased fatigue
d. Depressed mood
e. Decreased quality of life
f. Discomfort / pain
g. Hypotension
h. Calciphylaxis
i. Itch

Question 18

What are the symptoms of uremia?

Answer 18

Symptoms of uremia:
pain
agitation
myoclonus/muscle twitching
dyspnea
pruritis
nausea