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https://ninkatec.com/palliative-care-guide-kidney-failure/
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Nefrologia (Engl Ed). 2018 Sep-Oct;38(5):560-562. English, Spanish. doi: 10.1016/j.nefro.2017.11.021. PMID: 30316480.
. PLoS Med 19(4): e1003954. https://doi.org/10.1371/journal. pmed.1003954
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• Symptoms are in any treatment modality • Symptoms are in any stage of CKD • Symptoms are prevalent • Symptoms are multiple • Symptoms are burdensome and effect QOL • Dialysis is not the answer of symptoms management • Symptoms are treatable
• Symptoms are there • Clinicians need to address • And manage symptoms
I-POS –S (Renal) ESAS r- Renal Dialysis Symptom Index(DSI)
ESAS r – RENAL = ESAS + itch, insomnia, restless legs
Am J Kidney Dis. 75(5):793-806.
EEMMA : • Evaluation: คน้ หา วนิ ิจฉยั หาสาเหตอุ าการ • Explanation: อธิบาย กาหนดเปา้ หมาย • Management: drug & non drug • Monitoring: ผลการรกั ษาอาการ อาการใหม่ • Attention to detail: ใสใ่ จทกุ อาการท่ีเกิดขนึ้ Twycross R, Wilcock A, Toller CR. 2009.
Complex and multifactorial Anaemia - Hb best kept at 11-12 Electrolyte imbalance : Hyper K Hypo K Hyper Ca Hypo Ca Hypo Mg Hypo Na Hypo PO4
• Nutritional deficiency • Depression • Insomnia > Daytime somnolence • Pain > deconditioning
Fatigue will have an effect on multiple other aspects for the patient : • QOL • ADLs • Need for transport assistance • Frustration
• Optimise Dialysis • Correct reversible causes • Physiotherapy – gentle exercise • Sleep Hygiene • Social Supports
• Assess for possible non renal causes of muscle cramps – Structural foot/leg disorders – Peripheral vascular disease – Poor glycemic control – Hypothyroidism, iron deficiency, hypomagnesemia – Review medication; IV iron sucrose (up to 23%), oral contraceptive (3.5-14%), nifedipine (2-8%), pyrazinamide (1-10%), statins (4-5%), long-acting ß- agonists (2-3%), diuretics (especially potassium- sparing and thiazid), ß-blocker, benzodiazepines. BC Renal
• Preventing muscle cramps: – Daily stretching (hold stretch for 10-20 seconds and repeat 3-5 times). – Get up and walk around if sitting for long periods. – If leg cramps at night, stretch and light exercise (e.g. stationary bike) before bed – Keep the bed covers loose – Drink plenty of fluids, if not on fluid restrictions. – Avoid exercising in extreme heat. – Limit alcohol and caffeine. – Wear comfortable shoes with proper support and avoid walking on concrete floors BC Renal
• Easing the pain of muscle cramps: – Massage and stretch the cramped muscle. – Apply hot or cold to the tight muscle (e.g., warm towel or pad, hot shower, massage with ice) • Avoiding/easing muscle cramps pain during dialysis – Low intensity exercise during dialysis. – Minimize intra-dialytic weight gain and related hypotension. – Consider higher dialysate sodium concentration (sodium ramping) BC Renal
• Vitamin E, 400 units po daily • Gabapentin 100mg po HS, titrate by 100mg Q7days. Maximum dose should be adjusted based on renal function. May consider 50mg po HS as a starting dose in frail elderly BC Renal
• Assess and correct possible contributing factors: – Iron deficiency – Sleep deprivation – Neuropathic pain – Medication(s) that can cause/exacerbate restless legs. e.g. antipsychotics (such as haloperidol, olanzapine, risperidone), metoclopramide, antidepressants (such as SSRIs, mirtazapine, TCAs), carbamazepine, lithium BC Renal
• Preventing restless legs: – Avoid or limit caffeine, alcohol and nicotine. – Plan for breaks of time to walk around and stretch. – Stay daytime physical activity. help with sleep at night. – For RLS at night, promote sleep hygiene – For RLS during the day, encourage activities that enhance mental alertness (e.g., crossword, puzzles, video games). – Acupuncture/Acupressure may help to decrease the symptoms BC Renal
• For hemodialysis patient: – Encourage intradialytic exercise training, e.g. cycling for 45 minutes at 50 rpm during dialysis – Consider changing dialysis schedule from late to morning sessions – Consider longer more frequent dialysis • In PD patients – consider change dialysis exchange times to accommodate exercise, by reducing intra abdominal pressure and increasing patient comfort. • Easing the discomfort of restless legs: – Stretch &/or massage the affected area. – Take a warm or cool bath and apply hot or cold packs – Perform relaxation techniques or do a mentally distraction BC Renal
• For intermittent RLS, ―levodopa/carbidopa 100/25 mg tablet – ½ tablet PO PRN prior to anticipated RLS event, titrate Q3-7 days to effect up to 200/50 mg PO daily. If breakthrough cramps during the night, try changing controlled release formulation. • For daily RLS, ―consider dopamine agonists • Compared to levodopa, decreased risk of augmentation but increased incidence of hypotension and nausea. Caution re: sleep attack (driving is not recommended) ―Ropinirole 0.25 mg PO 2 hours prior to HS; increase by 0.25 mg PO Q7-14 days (most require ≤ 2mg/day; accumulation is unlikely but dosing has not been studied in eGFR < 30mL/min). BC Renal
• if RLS with concomitant painful neuropathy, leg cramp or pruritus or ineffective with dopaminergic agent switch to: • Gabapentin 100mg po HS, titrate by 100mg Q7days. Maximum dose should be adjusted based on renal function and Consider 50mg po HS in frail elderly OR • Pregabalin 25 mg PO HS; titrate by 25 mg Q7days. BC Renal Iron infusions – temporary benefit
Epidemiology of pain in CKD Dialysis patients – 58 % Mean weighted prevalence over 36 studies Davison S, Koncicki H, Brennan F. Pain in Chronic Kidney Disease : A Scoping Review. Seminars in Dialysis 2014; 27(2): 188-204. 49 % reported the pain as moderate to severe Data on conservatively managed patients is more limited but shows similar prevalence and severity figures. Murtagh FEM et al. A Cross-sectional Survey of Symptom Prevalence in Stage 5 CKD managed without Dialysis. J Pall Med (2007) 10;6:1266-1276. Brennan FP. Et al. Symptoms in patients with CKD managed without dialysis. Progress in Palliative Care 2015 (in Press)
Impact on function and QOL Davison (2002) 69 dialysis patients 62% stated that pain interfered with their ability to participate and enjoy recreational activities. 51 % stated that pain caused them “extreme suffering” 41 % stated that pain caused them to consider ceasing Dialysis Positive correlation with depression Davison S, Jhangri GS. J Pain Symptom Management 2005; 30(5): 465-473
Causes Calciphylaxis • Infections: osteomyelitis, N Engl J Med 378;18 nejm.org May 3, 2018 cellulitis • Procedures: needling of arterial venous fistulas • Peripheral neuropathy: diabetic neuropathy, uremic neuropathy • Peripheral vascular disease: diabetes, hypertension • Musculoskeletal: renal osteodystrophy, osteoarthritis, osteoporosis Sara Davison and David Hui. Kidney Palliative Care. Oxford American Handbook of Hospice and Palliative Medicine and Supportive Care, 2016
Pain Management in ESKD WHO 1. Mild pain Ladder • Paracetamol 500-1000 mg qid (Max 3 g/day): Safe and effective • NSAIDs: Should be avoid 2. Moderate pain • Tramadol o For dialysis patients 50 – 100 mg bd (max) o For conservative patients 50 mg bd (max) • Codeine: serious side effects use in ESRD 3. Severe pain • Strong opioid ANZSN Renal Supportive Care Guidelines 2013
Opioid Dose Adjustment Shyam Gelot et al. US Pharm. 2014;39(8):34-38.
Of the C Fibres that are itch-sensitive : 10 % are Histamine-dependent 90 % are Histamine-independent Davidson S. J Neuroscience 2007;27: 10007-14 Nainer B. J Neurophysiology 2008;100: 2062-9.
CKD-aP
Non pharm Topical • Dressing • Moisturisers • Temp • Emollients • Avoid warm shower • Capsicins
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