ESRD Flashcards
1
Q
Epidemiology of ESRD
A
- Increasing acceptance of dialysis, particularly in the elderly population
- Increased survival on dialysis
2
Q
Prognosis on dialysis
A
- Life expectancy is poor
- Overall 1 year survival 23%, 5 year survival 60%
- Mortality of patients over the age of 75 with comorbidities approaches 50% within 6 months!
- Increased age, low serum albumin, poor functional status, and comorbidities are poor prognostic factors
3
Q
Conservative management for ESRD
A
- Active disease management (anemia, metabolic bone disease, electrolyte abnormalities) and aggressive palliative care
- Appropriate for any patient who decides risks/burdens of dialysis outweigh benefits
- May remain stable for long periods of time rather than imminent death (contrast with high rates of decline or death before and after initiating dialysis)
- Some patients may have improved quality of life and a survival advantage as compared to on dialysis
4
Q
Pain and ESRD
A
- Common in ESRD patients (50%) whether on chronic dialysis or being treated conservatively
- Typically multifactorial and progressive
- MSK pain is most common (renal bone disease, osteoarthritis, etc.)
5
Q
Causes of pain in ESRD
A
- Primary renal disease
- PCKD
- MM - ESRD related
- Renal bone disease (soft tissue/periarticular calcification)
- Dialysis-related amyloidosis (soft tissue/periarticular calcification - dialysis does not filter out amyloid)
- Peripheral neuropathy
- Calciphylaxis (disruption in phos/Ca+ metabolism, resulting in tissue ischemia and necrosis from calcific uremic arteriolopathy)
- Nephrogenic systemic fibrosis - Dialysis complications
- Ischemic neuropathy from AV fistulas
- Osteomyelitis or discitis (central lines)
- Abdominal wall distention, lower back strain from peritoneal dialysis
- Recurrent cramps, HA, symptomatic hypotension, abdo pain, N/V during dialysis - Comorbidities
- Diabetic neuropathy
- PAD
- OA
6
Q
Analgesics in ESRD
A
Non-opioids
- Acetaminophen generally considered safe
- NSAIDs and ASA may potentiate platelet dysfuction of uremia (increased risk of bleeding) and can accerlate loss of renal function
- Low dose ASA for cardiac protection usually tolerated, avoid NSAIDs otherwise
Opioids
- Active opioid metabolites excreted via kidneys, can accumulate in patients with ESRD and lead to opioid toxicity (esp M3G)
- Avoid morphine, meperidine, codeine)
- Oxycodone can be used with caution (active metabolite - oxymorphone - of uncertain significance in ESRD), use IR only
- Tramadol will accumulate, but may be used with caution
- Hydromorphone, fentanyl, methadone, buprenorphine considered safe
- H6G is renally excreted, but better tolerated than morphine and can be used for dialysis patients with monitoring
7
Q
Safe analgesics in renal failure
A
- Hydromorphone
- H6G renally excreted, but better tolerated than morphine (can use with monitoring)
- Once dosing is stablised, convert to fentanyl patch and limited HM to lower PRN doses - Fentanyl
- Rapidly metabolisted in the liver
- No clinically significant accumulation in ESRD - Methadone
- Excreted in feces and does not appear to accumulate in ESRD - Buprenorphine
- Pharmcokinetics minimally altered in ESRD
- May be effective for chronic pain in ESRD, but limited evidence to support - Acetaminophen
- Max daily dose 3.2g/day (2.6g/day in those with chronic stable liver disease or if malnourished)
8
Q
Medications for neuropathic pain in ESRD
A
- Gabapentin (first line in ESRD)
- 100mg Po qHS, given after dialysis on HD days
- Increase by 100mg q weekly to a max dose of 600mg/HS
- Monitor for CNS effects at doses over 300mg/day (nystagmus, ataxia, tremor, somnolence, reduced LOC) - TCAs (second line, switch to TCA if gabapentin ineffective)
- Note metabolites excreted via kidneys and not effectively removed by dialysis
- No need to dose reduce, but less predictibility in response to doses, and side effects may exacerbate issues already present (dry mouth, orthostasis, somnolence, urinary retention)
- Start desipramine 10mg PO qHS (max dose 50) or nortriptyline 10mg PO qHS
- If ineffective after 4-6 weeks, consider methadone.
9
Q
CNS side effects of gabapentin
A
- Nystagmus
- Ataxia
- Tremor
- Somnolence
- Reduced LOC
*Particularly with doses > 300mg/day
10
Q
Depression in dialysis patients
A
- Common in dialysis patients, prevalence 5-50%
- SSRIs are first line, despite lack of evidence in ESRD
- Hepatically metabolised and metabolites are excreted by the kidneys
- Fluoxetine, norfluoxetine, sertraline, and citalopram appear to be minimally changed in patients with ESRD
- Most evidence for fluoxetine
- Start at 50% usual starting dose and titrate slowly
- Only use TCAs for treatment resistant depression or for those with additional indication (e.g. neuropathyic pain), and SNRIs/NDRIs should be avoided (renally excreted, lack of evidence)
11
Q
Lithium in ESRD
A
- Single dose (usually 600mg) after each dialysis session
- Lithium levels before and after dialysis sessions required to establish therapeutic dose as lithium is readily dialysed
12
Q
Frailty in dialysis patients
A
- Dialysis patients have some of the highest prevalence rates for frailty
- 79% of dialysis patients over 80 years
- Associated with increased morbidity, hospitalization, early mortality
- Dialysis may not be as beneficial and patients may fare better with conservative management
- For most patients age 65 and over, dialysis does not result in a return to pre-dialysis level of functioning
13
Q
Cognitive deficits in CKD
A
- Cognitive deficits tend to appear early in CKD, before transition to ESRD
- By the time patients start dialysis, 73% have either mod or severe cognitive impairment on formal neurocog testing
- Dementia tends to predict mortality
- Dementia can impact EOL decision making and advance care planning
- Consider using the MOCA to screen
14
Q
Importance of facilitated advance care planning in patients with ESRD
A
- Burden of disease
- High mortality rates
- High prevalence of suffering, frailty, cognitive dysfunction
- Patients need to know prognosis and establish GOC early to ensure timely decision making re: initiation/withdrawal of dialysis - Consideration of circumstances under which dialysis should be stopped
- Cognitive impairment
- Process should start early and may require ongoing communication and re-evaluation
- Majority of patients would not want to continue dialysis with significant cognitive impairment
15
Q
When is it appropriate to stop dialysis?
A
- Patients with decision-making capacity, who request dialysis discontinuation. Voluntary decision with full informed consent
- Patients who no longer possess decision-making capacity, but previously indicated refusal of dialysis in an oral or written advance directive
- Patients who no longer possess decision-making capacity and whose SDM refuse dialysis or request that it be discontinued, based on the previous wishes or best interest of the patient
- Patients with profound, irreversible neuro impairment, such that they lack signs of thought, sensation, purposeful behaviour, and awareness of self and environment
- Patients with a medical condition that precludes the technical process of dialysis (note that this does not include age, comorbidity, and functional status per se)
