Renal Palliative Care Flashcards
What is palliative care?
Approach that intends to improve quality of life of patients with life-threatening illnesses
- Affirms life and regards dying as a normal process
- Addresses the needs of patients and families
What qualities are important in palliative care?
Shared decision making to meet the patient’s goals
- Skilled communication
- Supporting those important to the patient
- Working with partners to provide excellent multidisciplinary care
Describe end stage renal failure.
- Refers to those with Stages 4 and 5 CKD (eGFR <30)
- Common causes include diabetes and ischaemic heart disease
How would you identify those in their last years of life with advanced kidney disease?
- The honest answer to ‘would you be surprised if the patient were to die in the near future’
- Looking for general indicators of decline e.g co-morbidities, advanced disease, decreased response to treatment
- Specific clinical indicators for ESRD - Difficult symptoms despite receiving RRT or choosing not to have dialysis
Describe the factors surrounding a patient’s decision not to start dialysis.
- Evidence that in the elderly patients who have multiple co-morbidities - may not provide significantly improved length or quality of life
Describe the groups of people with renal impairment who are in palliative care.
- Patients with renal failure as a primary life-limiting illness who opt for conservative care
- Patients with renal failure as a primary illness on dialysis but who develop complications or deterioration despite dialysis or another life-limiting serious illness (eg cancer)
- Patients who develop renal failure as part of another illness (e.g cancer) due to treatment or complications (eg hydronephrosis).
- Patients who have renal impairment as a co-morbidity. Old age, hypertension, atherosclerosis and diabetes are risk factors.
What are the common reported symptoms with ESRF?
Lack of Energy
Pruritus
Drowsiness
Dyspnoea
Worrying and difficulty concentrating
Describe the process of prescribing in renal impairment i.e what sort of things would you need to consider. PART 1
- Renal impairment can cause accumulation of renally excreted drugs (or
active metabolites) and prolonged half-life
e.g. analgesics such as Gabapentin, Pregabalin, Morphine.
- Renal impairment can cause accumulation of renally excreted drugs (or
- Low albumin can cause changes in amounts of free/active drugs which are normally protein-bound in the bloodstream e.g. Phenytoin
- Reduced effect of drugs which act on the kidney e.g. diuretics
Describe the process of prescribing in renal impairment i.e what sort of things would you need to consider. PART 2
- Increased sensitivity to some drug effects e.g. uraemia thought to increase amount of psychoactive drugs able to cross the blood-brain barrier e.g. chlorpromazine
- Increased renal toxicity/damage from certain drugs e.g. NSAIDs
How should opioids be used during pain management in CKD? PART 1
- Codeine, morphine and oxycodone all have active metabolites excreted by the kidneys. Tramadol also has active metabolites.
- Oxycodone has a similar analgesic effect to morphine, but some evidence that hallucinations may occur less commonly.
- Use all with caution in Stage 2 and 3 CKD, and ideally avoid especially regular administration, in Stages 4 and 5 CKD
How should opioids be used during pain management in CKD? PART 2
- Opioids with no active metabolites excreted by the kidney are suitable for use in renal failure e.g. fentanyl, alfentanil and (specialist use only) methadone.
- Buprenorphine does have active metabolites but do not cross blood brain barrier. Suitable for renal failure.
How should opioids be used during pain management in CKD? PART 3
- Most suitable opioids (Fentanyl, buprenorphine) are transdermal patches with long duration of action…useful in stable pain but not suitable for initial or rapid titration of analgesia
- Can use Alfentanil or Fentanyl injection instead as a continuous subcutaneous infusion
How should opioids be used during pain management in CKD? PART 4
- Alfentanil is ten times as potent as diamorphine (e.g. 10mg diamorphine is equivalent to 1mg alfentanil)
- Clinical experience/limited data suggest that oral Oxycodone can be used with caution by starting with low doses, reduced frequency and cautious titration and can then be switched to buprenorphine or fentanyl patch.
Describe opioid use during breakaway pain.
- May need to use oral opioids (eg oxycodone) for breakthrough pain – but at reduced dose and frequency with careful monitoring and warning for side effects of drowsiness and confusion
- Instant release fentanyl preparations can have a role as well.
Describe neuropathic pain management in those with renal disease.
- Adjuvant analgesics may require dose adjustment in renal impairment: e.g. Gabapentin, Pregabalin
- Amitriptyline, Carbemazepine – normal dose in renal failure but use cautiously
