- Email: [email protected]
Maximal conservative management
CHRONIC RENAL FAILURE
Maximal conservative management
What’s new? C
Edwina A Brown C
Abstract The aim of renal replacement therapy (RRT) is to prolong the quantity of life without diminishing the quality of remaining years. Unfortunately, in some patients, this is far from reality. Maximal conservative management is the support of patients with end-stage kidney disease (ESKD) without resorting to RRT. This support addresses the patient’s physical, emotional and spiritual needs until the end of life: a multi-disciplinary approach is, therefore, essential. Medical therapy includes the treatment of underlying renal pathology and other manoeuvres to prolong residual renal function, such as antihypertensive medication. As renal function declines, the treatment of renal anaemia with erythropoietin and optimization of fluid balance with diuretics can become more important. Pain control must be achieved but can be problematic in ESKD because of decreased elimination of drugs and their metabolites: various strategies are discussed. There are some data to suggest that selected patients with high co-morbidity live just as long with maximal conservative management as if they had dialysis. However, to withhold RRT from all patients with multiple co-morbidities would be ethically questionable. The decision to opt for non-dialysis medical therapy or conservative care should be made only after shared decision making between the patient, their families and the healthcare team.
More studies confirming that elderly patients with multiple co-morbidities have same survival on conservative care and dialysis Guidelines published by Department of Health discussing teamwork between primary care and specialist renal and palliative care services
attempts to console the family in bereavement: the continued input of the multidisciplinary team is, therefore, essential.2 Having made the decision not to dialyse, the concerns of the patient are similar to those of anyone with a serious medical condition, such as ‘how long have I got?’, ‘how will I feel?’, ‘will it hurt?’, ‘how will I die?’ and ‘where will I die?’: these form the structure of this article.
Survival with or without dialysis Renal survival One of the key medical aims in advanced renal failure is to prolong renal survival, for example, by lowering blood pressure with ACE inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs).3 The treatment of renal anaemia with erythropoiesisstimulating agents is increasingly common in the pre-dialysis population, often dramatically improving performance.4 These strategies continue in those patients who opt for maximal
Keywords conservative management; dialysis; palliative care; quality
Symptom control in maximal conservative management
of life; renal failure; survival
The psychological impact of being on dialysis and the required adjustments to daily living should not be underestimated. This is particularly true of patients with multiple co-morbidities and the frail elderly. Unadjusted mortality of patients on dialysis exceeds that of most cancers, largely due to cardiovascular disease.1 Some patients choose not to dialyse. Occasionally, there may be a strong personal preference expressed as an advance directive. More commonly, the decision is reached during the period of near end-stage kidney disease (ESKD), after the counselling of patients and their families as to the pros and cons of dialysis treatment. The patient and family are supported during this process by specialist renal nurses, social workers and, where available, dedicated renal counsellors. Maximal conservative management addresses the patient’s physical, emotional and spiritual needs until the end of life and
Management
Tired, fatigue, lack of libido Shortness of breath/swollen legs Restless legs Muscle spasm Nerve compression itch
Address anaemia with iron and/or erythropoietin. Dietary advice Diuretics (may need high dose)
Nausea and vomiting: choice depends on cause
Clonazepam, gabapentin, pramipexole Benzodiazepines, clonidine, baclofen Dexamethasone Phosphate binders and dietary advice, antihistamines, gabapentin Suck crushed ice/ice cubes. Good mouth care See Figure 1 Counselling and psychological support usually sufficient. Pharmacological intervention if needed Uraemia e haloperidol; opioids e metoclopramide; chemotherapy e ondansetron
End-of-life symptoms Pain Agitation Excessive secretions
Management See Figure 1 Midazolam, haloperidol Hyoscine butylbromide
Thirst Pain Depression, anxiety
Edwina A Brown DM FRCP is a Consultant Nephrologist in the West London Renal and Transplant Centre at Hammersmith Hospital, London, UK, and a Professor of Renal Medicine at Imperial College London, UK. She is an editor of ‘Supportive care for the renal patient’ published by Oxford University Press (2010) and an author of “End of Life Care in Nephrology” published by Oxford University Press (2007). Competing interests: none declared.
MEDICINE 39:7
Symptom
Table 1
438
Ó 2011 Elsevier Ltd. All rights reserved.
CHRONIC RENAL FAILURE
a consequence of renal failure or renal replacement but is more often due to co-morbidity, such as vascular disease and/or diabetes. Therefore, neuropathic pain is common and can be treated with amitriptyline, gabapentin or pregabalin, with dose adjustment. Pain management needs precision because of the decreased elimination of opioids and their metabolites in renal failure. In addition, non-steroidal anti-inflammatory drugs (NSAIDs) are relatively contraindicated as they can reduce residual renal function and further predispose to a bleeding tendency in an already uraemic patient. Analgesia should follow the WHO analgesic ladder, which is depicted with suggested doses of appropriate drugs in Figure 1.9,10 If opioids are required, it is vital to monitor for signs of accumulation, such as respiratory depression, hallucinations and vomiting. In the end-of-life phase, effective analgesia is paramount and opioids should not be withheld.
The WHO analgesic ladder with some suggested drugs and starting doses for patients with renal impairment (should be tailored for individual patient) Oxycodone • 2.5 mg qds Fentanyl • patch 25 µg/hour • s/c bolus 12.5–25 µg • driver 150–300 µg/24 hours 3. Opioid for moderate-to-severe pain
2. Opioid for mild-to-moderate pain 1 Non-opioid ± adjunct
Buprenorphine • patch 5 µg/hour • sublingual 200 µg Alfentanil • nasal spray 1 mg/ml 2–4 sprays prn • s/c bolus 0.1–0.2 µg • driver 0.6–1.2 mg/24 hours
Quality of life and mode of death
Tramadol 50 mg tds Codeine phosphate 30 mg tds
In a prospective longitudinal study, Murtagh has shown that symptoms and the average functional trajectory are very stable until the last 2e3 months of life when symptoms markedly increase and function declines.11 A recent retrospective study has also shown that conservative care patients spend considerably fewer days in hospital and have a fourfold increased likelihood of dying at home or in a hospice than those on haemodialysis.12 With good symptom management, the usual course is for the patient to become increasingly drowsy, drift into a coma, and die.
Paracetamol 1 g qds Ibuprofen (care) 150 mg bd Gabapentin 100 mg od or pregabalin 25 mg od or amitriptyline 25 mg od or carbamazepine 100 mg bd Symptom management as Table 1
Delivery of maximal conservative management Figure 1
Conservative management is not ‘no treatment’; as well as active management of symptoms and co-morbidities to maximize health, there should be active planning for the end-of-life phase in conjunction with primary care and community palliative care services.13 As patients are usually frail and elderly, care should be as close as possible to home and unnecessary hospital visits should be avoided. Teamwork and good communication between patients, carers, primary care and specialist renal and palliative care services are essential to achieve the goal of a good quality of life and death for a patient, once they have selected conservative management for their end-stage kidney disease. A
conservative therapy unless the adverse effects become intolerable or the patient enters the end-of-life phase of their disease. Patient survival Once a patient has reached ESKD, there are some data to suggest that, for elderly patients with multiple co-morbidities, dialysis does not improve survival. The difficulty in such studies is determining when conservative care should start. Two recent studies, using a starting point of estimated glomerular filtration rate (eGFR) of 15 ml/minute/1.73 m2, have shown that patients more than 75 years old with multiple co-morbidities have the same median survival on conservative care as those on dialysis.5,6 Interestingly, the cohort study from the Lister Hospital also showed a tail of prolonged survival in the conservative care group, but not in the dialysis group.6
REFERENCES 1 Moss AH, Holley JL, Davison SN, et al. Palliative care. Am J Kidney Dis 2004; 43: 172e3. 2 Levy JB, Chambers EJ, Brown EA. Supportive care for the renal patient. Nephrol Dial Transplant 2004; 19: 1357e60. 3 Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril efficacy in nephropathy. Lancet 1998; 352: 1252e6. 4 Collins AJ. Anaemia management prior to dialysis: cardiovascular and cost-benefit observations. Nephrol Dial Transplant 2003; 18(suppl 2): ii2e6. 5 Murtagh FEM, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years
Symptoms and their management Patients with advanced renal failure describe at least as many symptoms as those with cancer.7 The main symptoms and some solutions are shown in Table 1. It is important to adjust the dose of drugs to the eGFR and to titrate up from low initial dosage. Patients also report favourably on non-pharmacological measures, such as regular exercise, psychological support and occupational therapy.
Pain management Pain is particularly common in patients with advanced renal failure, reported in 80% of patients on haemodialysis.8 Pain may be
MEDICINE 39:7
439
Ó 2011 Elsevier Ltd. All rights reserved.
CHRONIC RENAL FAILURE
6
7
8 9 10
11
12
with chronic kidney disease stage 5. Nephrol Dial Transplant 2007; 22: 1955e62. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant 2010; doi:10.1093/ndt/gfq630. Saini T, Murtagh FE, Dupont PJ, McKinnon PM, Hatfield P, Saunders Y. Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliat Med 2006; 20: 631e6. Davison SN. The prevalence and management of chronic pain in endstage renal disease. J Palliat Med 2007; 10: 1277e87. Brown E, Chambers EJ, Eggeling C. End of life care in nephrology. Oxford University Press, 2007. Barakzoy AS, Moss AH. Efficacy of the World Health Organization analgesic ladder to treat pain in end-stage renal disease. J Am Soc Nephrol 2006; 17: 3198e203. Murtagh F, Sheerin N. Conservative management of end-stage renal disease. Supportive care for the renal patient. 2nd edn. Chambers EJ, Brown EA, Germain M, eds. Oxford University Press, 2010. Carson RC, Juszczak M, Davenport A, Burns A. Is maximum conservative management an equivalent treatment option to dialysis for
MEDICINE 39:7
elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 2009; 4: 1611e9. 13 National Health Service End of Life Care in Advanced Kidney Disease. A Framework for implementation. London: NHS, 2009. FURTHER READING Chambers EJ, Brown EA, Germain M. Supportive care for the renal patient. 2nd edn. Oxford: Oxford University Press, 2010. (A complete manual for the holistic care of renal patients).
Practice points C
C
C
C
440
Some patients with end-stage kidney disease do not benefit from dialysis Maximal conservative management includes maximizing renal survival and good symptom management Patients with end-stage kidney disease report as many symptoms as those with cancer Most patients with end-stage kidney disease report pain: this can be controlled
Ó 2011 Elsevier Ltd. All rights reserved.
Maximal conservative management
What’s new? C
Edwina A Brown C
Abstract The aim of renal replacement therapy (RRT) is to prolong the quantity of life without diminishing the quality of remaining years. Unfortunately, in some patients, this is far from reality. Maximal conservative management is the support of patients with end-stage kidney disease (ESKD) without resorting to RRT. This support addresses the patient’s physical, emotional and spiritual needs until the end of life: a multi-disciplinary approach is, therefore, essential. Medical therapy includes the treatment of underlying renal pathology and other manoeuvres to prolong residual renal function, such as antihypertensive medication. As renal function declines, the treatment of renal anaemia with erythropoietin and optimization of fluid balance with diuretics can become more important. Pain control must be achieved but can be problematic in ESKD because of decreased elimination of drugs and their metabolites: various strategies are discussed. There are some data to suggest that selected patients with high co-morbidity live just as long with maximal conservative management as if they had dialysis. However, to withhold RRT from all patients with multiple co-morbidities would be ethically questionable. The decision to opt for non-dialysis medical therapy or conservative care should be made only after shared decision making between the patient, their families and the healthcare team.
More studies confirming that elderly patients with multiple co-morbidities have same survival on conservative care and dialysis Guidelines published by Department of Health discussing teamwork between primary care and specialist renal and palliative care services
attempts to console the family in bereavement: the continued input of the multidisciplinary team is, therefore, essential.2 Having made the decision not to dialyse, the concerns of the patient are similar to those of anyone with a serious medical condition, such as ‘how long have I got?’, ‘how will I feel?’, ‘will it hurt?’, ‘how will I die?’ and ‘where will I die?’: these form the structure of this article.
Survival with or without dialysis Renal survival One of the key medical aims in advanced renal failure is to prolong renal survival, for example, by lowering blood pressure with ACE inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs).3 The treatment of renal anaemia with erythropoiesisstimulating agents is increasingly common in the pre-dialysis population, often dramatically improving performance.4 These strategies continue in those patients who opt for maximal
Keywords conservative management; dialysis; palliative care; quality
Symptom control in maximal conservative management
of life; renal failure; survival
The psychological impact of being on dialysis and the required adjustments to daily living should not be underestimated. This is particularly true of patients with multiple co-morbidities and the frail elderly. Unadjusted mortality of patients on dialysis exceeds that of most cancers, largely due to cardiovascular disease.1 Some patients choose not to dialyse. Occasionally, there may be a strong personal preference expressed as an advance directive. More commonly, the decision is reached during the period of near end-stage kidney disease (ESKD), after the counselling of patients and their families as to the pros and cons of dialysis treatment. The patient and family are supported during this process by specialist renal nurses, social workers and, where available, dedicated renal counsellors. Maximal conservative management addresses the patient’s physical, emotional and spiritual needs until the end of life and
Management
Tired, fatigue, lack of libido Shortness of breath/swollen legs Restless legs Muscle spasm Nerve compression itch
Address anaemia with iron and/or erythropoietin. Dietary advice Diuretics (may need high dose)
Nausea and vomiting: choice depends on cause
Clonazepam, gabapentin, pramipexole Benzodiazepines, clonidine, baclofen Dexamethasone Phosphate binders and dietary advice, antihistamines, gabapentin Suck crushed ice/ice cubes. Good mouth care See Figure 1 Counselling and psychological support usually sufficient. Pharmacological intervention if needed Uraemia e haloperidol; opioids e metoclopramide; chemotherapy e ondansetron
End-of-life symptoms Pain Agitation Excessive secretions
Management See Figure 1 Midazolam, haloperidol Hyoscine butylbromide
Thirst Pain Depression, anxiety
Edwina A Brown DM FRCP is a Consultant Nephrologist in the West London Renal and Transplant Centre at Hammersmith Hospital, London, UK, and a Professor of Renal Medicine at Imperial College London, UK. She is an editor of ‘Supportive care for the renal patient’ published by Oxford University Press (2010) and an author of “End of Life Care in Nephrology” published by Oxford University Press (2007). Competing interests: none declared.
MEDICINE 39:7
Symptom
Table 1
438
Ó 2011 Elsevier Ltd. All rights reserved.
CHRONIC RENAL FAILURE
a consequence of renal failure or renal replacement but is more often due to co-morbidity, such as vascular disease and/or diabetes. Therefore, neuropathic pain is common and can be treated with amitriptyline, gabapentin or pregabalin, with dose adjustment. Pain management needs precision because of the decreased elimination of opioids and their metabolites in renal failure. In addition, non-steroidal anti-inflammatory drugs (NSAIDs) are relatively contraindicated as they can reduce residual renal function and further predispose to a bleeding tendency in an already uraemic patient. Analgesia should follow the WHO analgesic ladder, which is depicted with suggested doses of appropriate drugs in Figure 1.9,10 If opioids are required, it is vital to monitor for signs of accumulation, such as respiratory depression, hallucinations and vomiting. In the end-of-life phase, effective analgesia is paramount and opioids should not be withheld.
The WHO analgesic ladder with some suggested drugs and starting doses for patients with renal impairment (should be tailored for individual patient) Oxycodone • 2.5 mg qds Fentanyl • patch 25 µg/hour • s/c bolus 12.5–25 µg • driver 150–300 µg/24 hours 3. Opioid for moderate-to-severe pain
2. Opioid for mild-to-moderate pain 1 Non-opioid ± adjunct
Buprenorphine • patch 5 µg/hour • sublingual 200 µg Alfentanil • nasal spray 1 mg/ml 2–4 sprays prn • s/c bolus 0.1–0.2 µg • driver 0.6–1.2 mg/24 hours
Quality of life and mode of death
Tramadol 50 mg tds Codeine phosphate 30 mg tds
In a prospective longitudinal study, Murtagh has shown that symptoms and the average functional trajectory are very stable until the last 2e3 months of life when symptoms markedly increase and function declines.11 A recent retrospective study has also shown that conservative care patients spend considerably fewer days in hospital and have a fourfold increased likelihood of dying at home or in a hospice than those on haemodialysis.12 With good symptom management, the usual course is for the patient to become increasingly drowsy, drift into a coma, and die.
Paracetamol 1 g qds Ibuprofen (care) 150 mg bd Gabapentin 100 mg od or pregabalin 25 mg od or amitriptyline 25 mg od or carbamazepine 100 mg bd Symptom management as Table 1
Delivery of maximal conservative management Figure 1
Conservative management is not ‘no treatment’; as well as active management of symptoms and co-morbidities to maximize health, there should be active planning for the end-of-life phase in conjunction with primary care and community palliative care services.13 As patients are usually frail and elderly, care should be as close as possible to home and unnecessary hospital visits should be avoided. Teamwork and good communication between patients, carers, primary care and specialist renal and palliative care services are essential to achieve the goal of a good quality of life and death for a patient, once they have selected conservative management for their end-stage kidney disease. A
conservative therapy unless the adverse effects become intolerable or the patient enters the end-of-life phase of their disease. Patient survival Once a patient has reached ESKD, there are some data to suggest that, for elderly patients with multiple co-morbidities, dialysis does not improve survival. The difficulty in such studies is determining when conservative care should start. Two recent studies, using a starting point of estimated glomerular filtration rate (eGFR) of 15 ml/minute/1.73 m2, have shown that patients more than 75 years old with multiple co-morbidities have the same median survival on conservative care as those on dialysis.5,6 Interestingly, the cohort study from the Lister Hospital also showed a tail of prolonged survival in the conservative care group, but not in the dialysis group.6
REFERENCES 1 Moss AH, Holley JL, Davison SN, et al. Palliative care. Am J Kidney Dis 2004; 43: 172e3. 2 Levy JB, Chambers EJ, Brown EA. Supportive care for the renal patient. Nephrol Dial Transplant 2004; 19: 1357e60. 3 Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril efficacy in nephropathy. Lancet 1998; 352: 1252e6. 4 Collins AJ. Anaemia management prior to dialysis: cardiovascular and cost-benefit observations. Nephrol Dial Transplant 2003; 18(suppl 2): ii2e6. 5 Murtagh FEM, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years
Symptoms and their management Patients with advanced renal failure describe at least as many symptoms as those with cancer.7 The main symptoms and some solutions are shown in Table 1. It is important to adjust the dose of drugs to the eGFR and to titrate up from low initial dosage. Patients also report favourably on non-pharmacological measures, such as regular exercise, psychological support and occupational therapy.
Pain management Pain is particularly common in patients with advanced renal failure, reported in 80% of patients on haemodialysis.8 Pain may be
MEDICINE 39:7
439
Ó 2011 Elsevier Ltd. All rights reserved.
CHRONIC RENAL FAILURE
6
7
8 9 10
11
12
with chronic kidney disease stage 5. Nephrol Dial Transplant 2007; 22: 1955e62. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant 2010; doi:10.1093/ndt/gfq630. Saini T, Murtagh FE, Dupont PJ, McKinnon PM, Hatfield P, Saunders Y. Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliat Med 2006; 20: 631e6. Davison SN. The prevalence and management of chronic pain in endstage renal disease. J Palliat Med 2007; 10: 1277e87. Brown E, Chambers EJ, Eggeling C. End of life care in nephrology. Oxford University Press, 2007. Barakzoy AS, Moss AH. Efficacy of the World Health Organization analgesic ladder to treat pain in end-stage renal disease. J Am Soc Nephrol 2006; 17: 3198e203. Murtagh F, Sheerin N. Conservative management of end-stage renal disease. Supportive care for the renal patient. 2nd edn. Chambers EJ, Brown EA, Germain M, eds. Oxford University Press, 2010. Carson RC, Juszczak M, Davenport A, Burns A. Is maximum conservative management an equivalent treatment option to dialysis for
MEDICINE 39:7
elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 2009; 4: 1611e9. 13 National Health Service End of Life Care in Advanced Kidney Disease. A Framework for implementation. London: NHS, 2009. FURTHER READING Chambers EJ, Brown EA, Germain M. Supportive care for the renal patient. 2nd edn. Oxford: Oxford University Press, 2010. (A complete manual for the holistic care of renal patients).
Practice points C
C
C
C
440
Some patients with end-stage kidney disease do not benefit from dialysis Maximal conservative management includes maximizing renal survival and good symptom management Patients with end-stage kidney disease report as many symptoms as those with cancer Most patients with end-stage kidney disease report pain: this can be controlled
Ó 2011 Elsevier Ltd. All rights reserved.