Consider Palliative Care Options for Patients With ESRD

Abstract

Kerri Wachter is a senior writer with Elsevier Global Medical News. TAMPA — Patients with end-stage renal disease are good candidates for palliative care and hospice, but many are not referred, according to Dr. Alvin H. Moss. “Nephrologists, by nature, are not inclined toward talking about end-of-life care” and are not trained to deal with it, said Dr. Moss, director of the palliative care service in the nephrology section of West Virginia University, Morgantown. Patients with end-stage renal disease tend to be old with short life expectancies, and they typically have multiple comorbidities and a high symptom burden, Dr. Moss said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association. Most patients on hemodialysis are older than age 65. Of the estimated 85,000 patients on dialysis who die each year, 20%–25% die after choosing to stop dialysis. The 1-year survival rate for dialysis patients is 78%; the 5-year rate is 32%,” he said. Patients on dialysis have an average of nine symptoms, which may include dry skin, fatigue, itching, bone and joint pain, and muscle cramps. Also, half of dialysis patients report pain (J. Am. Soc. Nephrol. 2005;16:2487–94). “The symptom burden is similar for dialysis patients as for cancer patients,” Dr. Moss said. Predictors of poor prognosis for patients with end-stage renal disease include greater age, reduced functional ability, poor nutritional status, and the presence of comorbid illness, Dr. Moss said. “If a patient has severely impaired functional status, it confers a 3.5-fold greater risk of early mortality,” Dr. Moss said. “If the patient is not independent in activities of daily living … we're talking about a significantly increased risk of early death.” Nephrologists are often unsure about which patients to refer for palliative care. “I teach them to ask themselves on rounds, ‘Would I be surprised if this patient died in the next month?’ It takes about 10 seconds,” Dr. Moss said. If the answer is no, the patient is a good candidate for palliative care. “That question turns out to predict those patients who have greater comorbidities, greater pain scores, lower functional status, lower serum albumin levels, and a greatly increased risk of being dead within a year.” In one study, Dr. Moss asked nephrology nurse practitioners to answer this question with regard to their patients. The nurse practitioners indicated that they would not be surprised regarding 22% of patients. One year later, those in the “no” group had a 2.74-fold increased risk of death, compared with those in the “yes” group. “Pain is a very common and severe symptom. … Usually it's the most severe symptom that dialysis patients report,” Dr. Moss said. In one study, pain was undertreated in about three-quarters of dialysis patients (Am. J. Kidney Dis. 2003;42:1239–47). In his own study of 143 dialysis patients, 54% reported pain. Of those who reported pain, 16 were already being treated for pain and 17 refused treatment. Those remaining were treated for pain using the World Health Organization Analgesic ladder (J. Am. Soc. Nephrol. 2006;17:3198–203). Of the 45 patients who completed pre- and posttreatment evaluations, 31% had neuropathic pain, 40% had nociceptive pain, and 29% had both types. Treatment using the analgesic ladder worked equally well for neuropathic and nociceptive pain. Many opioids are renally excreted, so a few precautions are needed when choosing a pain medication for patients with end-stage renal disease, Dr. Moss said. “Because of problems with renal excretion, we have to look at which ones are safe, which ones you might want to use with caution … and which drugs not to use.” Pain medications that are considered safe and effective in this population include fentanyl, methadone, hydromorphone, acetaminophen, gabapentin, and pregabalin. Avoid codeine, meperidine, morphine, and propoxyphene, because the renally excreted active metabolites can accumulate and cause opioid neurotoxicity. “If we're teaching evidence-based medicine, we know there's a higher risk for complications using these pain medications in dialysis patients. … We should use medications that are safer,” he said. Caution should be used in prescribing hydrocodone, oxycodone, tramadol, desipramine, and nortriptyline. These drugs have been reported to be safely used in dialysis patients, but the data on pharmacokinetics are insufficient to conclude that these drugs are safe in this population. AMDA has two resources that could help long-term care medical directors and staff care for residents near death with renal disease: ▸ “Palliative Care in the Long-Term Care Setting” is available at www.amda.com/resources/whatsnew.cfm#palliativecare. ▸ “Clinical Corner: Chronic Kidney Disease” can be found at www.amda.com/tools/clinical/ckd.cfm.