Supportive Care for the Person with Chronic Kidney Disease. Dr. J. Kappel May 2014

Transcription

1 Supportive Care for the Person with Chronic Kidney Disease Dr. J. Kappel May 2014

2 Objectives 1 To develop an understanding of renal replacement therapy (RRT) and comprehensive conservative management and why they are chosen 2

3 Objectives 2 To provide a framework for appropriate care for those people with chronic kidney disease (CKD) who chose not to initiate RRT or for those who chose to terminate RRT. 3

4 Objectives 1 To develop an understanding of renal replacement therapy (RRT) and comprehensive conservative management and why they are chosen 4

5 Chronic Kidney Disease - Stages Stage 1 Description Kidney Damage with Normal or GFR GFR (ml/min/1.73 m 2 ) >90 2 Mild GFR Moderate GFR Severe GFR Kidney Failure <15 or Dialysis 5 Adapted from Am J Kidney Dis 2002; 39 (2, Suppl. 1): S46-S75

6 When do you initiate RRT? Uremic symptoms Pruritus, restless legs, altered appetite Weight loss Uncontrolled hyperkalemia, acidosis, pulmonary edema Signs - pericardial friction rub, neuropathy, encephalopathy Numbers - CrCl 6 mls/min in absence of anything else CMAJ February

7 Incident ESRD Patients by Age 800 R P M P Source: CORR Annual Report

8 Primary Diagnosis of Incident ESRD Patients 60 R P M P Diabetes RVD GN PCKD Source: CORR Annual Report

9 Dialysis Treatment for ESRD Peritoneal Dialysis Hemodialysis In Hospital In Satellite unit At home Transplantation Comprehensive Conservative Management 9

10 Peritoneal Dialysis 10

11 Hemodialysis 11

12 Hemodialysis 12

13 Transplantation 13

14 Comprehensive Conservative Management Interdisciplinary care model Provide excellent symptom control Strengthen psychosocial and spiritual support Focus on quality of life for patient and family Allow for a smooth transition to palliative and hospice care 14

15 Process for Choosing Treatment CCM vs RRT 1 Transplant Dialysis 2 Home Hospital/Clinic 3 HD PD 4 Conventional Nocturnal CAPD 5 5 Short Daily CPD Adapted from: Golper et al Seminars in Dialysis Vol 26, No 2l 15

16 Factors to consider Patient Factors Values and preferences Prognosis Physical factors: abdominal surgeries, peripheral vascular disease, other comorbid conditions Support system System Factors Capacity Knowledge Financial Potential to harm Collaborative decision between patient, family and healthcare team 16

17 Potential Medical, Emotional and Social Harms Related to Dialysis Medical Complications of vascular/peritoneal access Infections/sepsis Acceleration of renal failure Dialysis trial Worsening of pre-existing vascular disease including dementia Functional decline in frail and vulnerable people Pain with needles Prolonged immobilization Dialysis related muscle cramps, fatigue, headache, chronic low back pain Generally feeling unwell Adapted from: Should an Elderly Patient with Stage V CKD and Dementia be started on Dialysis? Irene Ying, Zoe Levitt, Sarbjit Vanita Jassal 17

18 Potential Medical, Emotional and Social Harms Related to Dialysis Emotional and Social Time and cost commuting to dialysis center Limited to no employment opportunities Social and cultural isolation Movement from place of residence Inability or reduced ability to travel for leisure Medicalization of death Adapted from: Should an Elderly Patient with Stage V CKD and Dementia be started on Dialysis? Irene Ying, Zoe Levitt, Sarbjit Vanita Jassal 18

19 Prognosis in ESRD Most patients and physicians tend to overestimate survival Many patients and health care providers are reluctant to discuss prognosis Lack of confidence in predicting prognosis Fear of abolishing hope Discomfort with such discussions Estimating prognosis is vital to decision making about starting and stopping dialysis Needs to be part of the discussion when deciding about options 19

20 Prognosis in ESRD Trajectory of illness Mortality risk factors 20

21 Trajectory of Illness Models exist for chronic lung disease, heart failure, stroke and diabetes Acute declines are common among dialysis patients hospitalized for: Acute MI Limb amputation Sepsis from hemodialysis lines Hip fractures Functional status declines, risk of death increases Burden of therapy outweighs benefits in many cases 21

22 Trajectory of Illness Advance Care Planning in CKD/ESRD: An Evolving Process Jean L. Holley 22

23 Low serum albumin Mortality Risk Factors Consistent and strong predictor of death Poor functional status Highly predictive of early death Comorbid conditions ischemic heart disease, cancer, peripheral vascular disease, dementia and diabetes Modified Charlson Comorbidity Index Composite score of age and multiple comorbid conditions The risk of a 40-year old on dialysis dying from a myocardial infarction is about 100 times greater than the risk for a person the same age with normal renal function 23

24 Patient age Mortality Risk Factors O Hare et al 24

25 Mortality Risk Factors Tamara KI

26 Mortality Risk Factors Answering NO to the surprise question Would you be surprised if this patient died within the next 12 months? 26

27 Online calculators Prognosis in ESRD Exact prognosis for an individual may be unclear These prognostic tools can aid in advance care planning Do the patients want this information Canadian study in CKD clinic: 97% wanted this information, but mostly Caucasian US study: 51% wanted this information, more ethnically diverse 27

28 Prognosis 28

29 Should an Elderly Patient with Stage V CKD and Dementia be started on Dialysis? Irene Ying, Zoe Levitt, Sarbjit Vanita Jassal 29

30 Objectives 1 To develop an understanding of renal replacement therapy (RRT) and comprehensive conservative management and why they are chosen 30

31 Objectives 2 To provide a framework for appropriate care for those people with chronic kidney disease (CKD) who chose not to initiate RRT or for those who chose to terminate RRT. 31

32 Those who choose not to initiate RRT Can live for months and even years after making this decision Interdisciplinary care includes: Diet Anemia management Blood pressure control Symptom control Psychological/spiritual support Death from renal failure is NOT PAINFUL 32

33 Those who choose to stop RRT The option of withdrawing from dialysis is an appropriate topic to be discussed by nephrologists/health care providers whenever a patient or family member mentions it and when patients suffer irreversible, profound neurologic impairment. About 20 25% of patients per year choose to stop dialysis The burden of therapy now outweighs any expectation of benefit and we are simply prolonging death 33

34 Framework for Appropriate Care Interdisciplinary team care Identifying patients with poor prognosis either before RRT or during the course of RRT and thus in need of supportive care Advance care planning Symptom assessment and management Care of the dying patient Bereavement processes for families and staff 34

35 Clinical Practice Guideline Renal Physicians Association Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis Kidney End-of-Life Coalition 35

36 Once dialysis is stopped Death can occur fairly quickly or the patient may live for several weeks depending on the amount of residual renal function. Average life span is about 7 days. Range 1 49 days. Certain subsets of the population seem to have especially short survival: Patients who are admitted to hospital or inpatient hospice unit. Patients who are bed bound with altered level of consciousness. Patients with edema have shorter survival, suggesting that volume status affects prognosis. 36

37 Symptom Burden Extensive Severe Significantly impacts quality of life Patients often underreport their symptoms 37

38 Symptom Burden Modified Edmonton Symptom Assessment System 10 visual analogue scales with a superimposed 0 10 scale for pain, activity, nausea, pruritus, depression, anxiety, drowsiness, appetite, wellbeing and shortness of breath 38

39 39

40 Symptom assessment 40

41 Symptom Control - Pain Most common problem in all May be due to their primary disease PCKD Or to concurrent comorbidity diabetes, PVD Or to disease from their renal failure calciphylaxis, renal bone disease 41

42 Symptom Control - Pain Use of analgesics By mouth if possible By the clock given regularly By the ladder (next slide) For the individual No standard doses Attention to detail 42

43 WHO Analgesic Ladder Modified for safety in CKD patients Step 3: Severe Pain (7-10) Hydromorphone, Methadone, Fentanyl, Oxycodone + Nonopioid analgesics + Adjuvants Step 2: Moderate Pain (5-6) Hydromorphone, Oxycodone, Tramadol + Nonopioid analgesics + Adjuvants Step 1: Mild Pain (1-4) Acetaminophen + Adjuvants 43

44 WHO Analgesic Ladder Modified for safety in CKD patients Step 3: Severe Pain (7-10) Hydromorphone, Methadone, Fentanyl, Oxycodone + Nonopioid analgesics + Adjuvants Step 2: Moderate Pain (5-6) Hydromorphone, Oxycodone, Tramadol + Nonopioid analgesics + Adjuvants Step 1: Mild Pain (1-4) Acetaminophen + Adjuvants NSAIDs: Higher risk of bleeding but can be used 44

45 WHO Analgesic Ladder Modified for safety in CKD patients Step 3: Severe Pain (7-10) Hydromorphone, Methadone, Fentanyl, Oxycodone + Nonopioid analgesics + Adjuvants Step 1: Mild Pain (1-4) Acetaminophen + Adjuvants Step 2: Moderate Pain (5-6) Hydromorphone, Oxycodone, Tramadol + Nonopioid analgesics + Adjuvants Codeine: metabolites accumulate, constipation Tramadol: mg bid Morphine not well tolerated, constipation, myoclonic jerks Demerol causes seizures Hydromorphone needs dose titration Oxycodone well tolerated by some, possible abuse by others 45

46 WHO Analgesic Ladder Modified for safety in CKD patients Step 3: Severe Pain (7-10) Hydromorphone, Methadone, Fentanyl, Oxycodone + Nonopioid analgesics + Adjuvants Step 2: Moderate Pain (5-6) Hydromorphone, Oxycodone, Tramadol + Nonopioid analgesics + Adjuvants Methadone not removed by dialysis, use as in other patients, well tolerated Fentanyl very helpful Step 1: Mild Pain (1-4) Acetaminophen + Adjuvants 46

47 Adjuvant Drugs: Neuropathic Pain TCAs Amitriptyline, Nortriptyline Sedation, dry mouth, constipation, urinary retention, fatigue, postural hypotension Can alter seizure threshold mg qhs Anticonvulsants Carbamazepine Interaction with warfarin Well tolerated 200 mg od increasing to maximum dose of 1600 mg Valproic acid GI irritation, weight gain 200 mg increasing to a maximum dose of 1000 mg 47

48 Adjuvant Drugs: Neuropathic Pain Anticonvulsants Gabapentin Drowsiness, ataxia Titrate slowly, up to 600 mg/day generally tolerated Clonazepam Sedation mg qhs 48

49 Adjuvant Drugs- MSK Pain Corticosteroids Benzodiazepines for muscle spasms Baclofen for muscle spasm not recommended as CNS side effects common Quinine sulphate for muscle cramps 49

50 Symptom Control - Pruritus Multiple etiologies: Hyperphosphatemia, increased calciumphosphate deposition in skin, dry skin, inadequate dialysis, anemia, iron deficiency Management: Review of diet with particular attention to phosphate. If a patient has decided to stop dialysis, there are no diet restrictions control pruritus with drugs (next slide). Use emollients such as oatmeal moisturizer, mineral oil or Uremol cream 50

51 Symptom Control - Pruritus Management: Phosphate binders such as Amphogel or Basaljel. Oral anti-histamines of your choice Capsaicin cream bid-qid Photo therapy with UVB ultraviolet light three times weekly Narcan can be useful Cholestyramine 1 pkg bid but can interfere with the absorption of other drugs Thalidomide 100 mg at hs 51

52 Symptom Control Restless Legs Unclear as to whether this is related to uremic neuropathy or to other associated comorbid conditions. Anemia, iron deficiency may be implicated Management: TCAs, lithium, neuroleptics and caffeine aggravates RLS Treat anemia and iron deficiency Trial of benzodiazepines: Clonazepam mg qhs Dopaminergic agents: Sinemet 25/100 mg od tid Gabapentin mg od Tachyphylaxis occurs and therefore after 3-4 months the drugs may need to be rotated. 52

53 Symptom Control- Shortness of Breath Etiology Salt and water excess Further decline in renal function Advancing cardiac disease Management: Salt and water restriction Diuretics Lasix 120 mg po/iv q4-6h Nitro patch Oxygen Scopolamine patch Opioids Benzodiazepines 53

54 Symptom Control - Anorexia Multiple etiologies: Advancing renal failure, inadequate dialysis, anemia, depression, dry mouth, constipation, diabetic gastro paresis Management: Oral moisturizers Anemia treatment Anti-emetic Anti-depressants with appetite stimulating properties Trial of zinc 50 mg bid po Trial of appetite stimulants: Megace, Nabilone, Prednisone 54

55 Symptom Control Nausea/Vomiting Etiology Uremia Fluid-electrolyte abnormalities Hypotension Comorbid conditions Medication side effects Management: Treat hypotension If due to gastroparesis, use Maxeran 5-10 mg ½ hour prior to meals Use standard anti-emetics Gravol, Stemetil Haloperidol mg po/sc tid Ondansetron in usual doses 55

56 Symptom Control - Constipation Etiology is usually the renal diet which restricts fruits, vegetables and high fibre foods (ie bran) together with the fluid restriction, physical inactivity and medications such as Amphogel Management: Stool softeners Lactulose, Mag citrate, Lax-a-Day 56

57 Etiology Symptom Control - Insomnia Anemia Sleep apnea RLS Management Treat anemia Diagnose and treat sleep apnea/rls Avoid caffeine, smoking, alcohol and napping in the daytime Sleep aides Zoplicone usual dose Any benzodiazepine 57

58 Symptom Control - Tiredness Etiology Anemia Iron deficiency Depression Insomnia Poor nutrition Medications Management: Treat anemia and iron deficiency Treat insomnia Encourage exercise Trial of anti-depressants 58

59 Framework for Appropriate Care Interdisciplinary team care Identifying patients with poor prognosis either before RRT or during the course of RRT and thus in need of supportive care Advance care planning Symptom assessment and management Care of the dying patient Bereavement processes for families and staff 59

60 Objectives 2 To provide a framework for appropriate care for those people with chronic kidney disease (CKD) who chose not to initiate RRT or for those who chose to terminate RRT. 60

61 Questions? 61

62 Resources