Disease Update on Kidney Disease: New Guidelines on Dialysis (301)

Abstract

Objectives 1. Describe the recommendations in the new clinical practice guideline on which patients may not experience a survival benefit with dialysis compared to medical management without dialysis. 2. Explain an evidence-based approach to prognostication in chronic kidney disease and dialysis patients. 3. Discuss an evidence-based approach and preferred medications for the treatment of pain in patients with chronic kidney disease. New dialysis patients increasingly have multiple comorbidities, a high symptom burden, and a significantly shortened life expectancy. Using medical evidence published in the last decade, the Renal Physicians Association has revised its ‘‘Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis’’ for the treatment of this changing population. The presenter who chaired the guideline revision project will review highlights of the new evidence which include (1) newer, more accurate models for estimating prognosis in dialysis patients that employ the ‘‘surprise’’ question, age, serum albumin, and comorbidities; (2) it is now possible to identify elderly stage 4 and 5 chronic kidney disease (CKD) patients who are likely to die prior to initiation of dialysis or for whom dialysis may not provide a survival advantage over medical management without dialysis; (3) pain is undertreated in three-quarters of dialysis patients and clinicians are largely unaware of dialysis patients’ symptoms; and (4) hospice is underutilized in dialysis patients. The ten recommendations in this revised guideline include the following: (1) it is appropriate to forgo (withhold initiation or withdraw ongoing) dialysis for patients with acute kidney injury (AKI), CKD, or end-stage renal disease (ESRD) in certain well-defined situations; (2) palliative care services and interventions should be offered to all AKI, CKD, and ESRD patients who suffer from burdens of their disease in an effort to improve patient-centered outcomes; and (3) the Renal Physicians Association recommends a systematic approach for communication about diagnosis prognosis treatment options and goals of care. The guideline also recommends advance care planning, use of time-limited trials, and a due-process approach for resolving conflicts about whether a patient should be dialyzed. The presenter will reserve time for discussion of participants’ cases and demonstrate application of the guideline to them.