Renal Supportive Care Research Articles

A Qualitative Study Supporting Optimal Nutrition in Advanced Liver Disease-Unlocking the Potential for Improvement.

Malnutrition rates in Advanced Liver Disease (ALD) are significantly higher than those in well-compensated liver disease. In addition to its physiological impact, malnutrition is detrimental for quality of life and social, emotional, and psychological well-being. Studies within oncology and renal supportive care have identified the influence of non-physiological factors on malnutrition risk. Integrating similar factors into malnutrition screening for ALD could improve identification of at-risk patients to optimize treatment planning. This qualitative study aimed to understand the holistic factors influencing nutritional status in the ALD population. Semi-structured interviews with 21 patients, carers, and clinicians explored the experiences of malnutrition in ALD. Thematic analysis revealed five key themes: (i) appropriateness of healthcare delivery; (ii) health- and food-related factors; (iii) high symptom burden, (iv) social support impacting well-being, and (v) physical and structural supports. Current screening methods do not adequately capture all potential drivers of malnutrition in the ALD population. Adopting a more supportive approach including both physiological and non-physiological factors in ALD malnutrition screening may promote more timely and comprehensive nutritional interventions that address the complex and holistic needs of patients living with ALD.

#1377 Evaluation of state-wide health system implementation of renal supportive care shows substantial net benefits

Abstract Background and Aims In 2016, the New South Wales (NSW) Health system implemented a service to make the principles and practice of palliative medicine comprehensively available to patients receiving chronic kidney disease (CKD) care across NSW. Summative evaluation of the economic value that this multi-disciplinary State-wide RSC service provided following implementation was prospectively planned in the domains of patient experience and economic value. This abstract reports the first cost-benefit analysis of a RSC service. Method De-identified patient-level data was extracted from the NSW Renal Supportive Care Register (a linked dataset comprising admitted patient, non-admitted patient, emergency department episodes and death registrations). Data was compared between 2015/16, prior to implementation of the State-wide RSC service; and 2018/19, following settled operation of the service. A cost-benefit analysis model was constructed to estimate the economic value of the RSC service between 2015/16 and 2018/19; and the projected value to 2029/30 under different scenarios. Multivariate Cox regressions were estimated to measure survival benefits, and a polynomial regression model was employed to estimate the impact of RSC on the share of patients receiving dialysis. Results Considering the actual impact of the NSW RSC service; in 2015/16, 5% (n = 443) of all ESKD patients, (defined as receiving dialysis >3 months, non-dialysis conservative care or in receipt of a functioning transplant) received any RSC service. By 2018/19, 16% (n = 1460) of all ESKD patients had received RSC within NSW. The proportion of patients receiving RSC from a non-dialysis conservative care or dialysis context remained stable between 2015/16 and 2018/19 at 41% and 29% respectively. Patients receiving RSC were estimated to have increased survival by 3-21 weeks, depending on patient characteristics, compared to the scenario of no RSC service. Considering the projected value of ongoing RSC services; scenarios with different assumptions were modelled. Assuming that the proportion of patients receiving different ESKD modalities and the costs of care remained stable, the RSC service would deliver a net financial benefit to the commissioning health system (avoided costs of service minus RSC costs) of ${\$}$109 million Australian Dollars (AUD), with a return on investment of 212%, compared to the scenario of no RSC service. When the economic value for the whole NSW community from increased survival benefit was included, the projected value was ${\$}$275 million AUD, with return on investment of 535%. The projected economic value of RSC was modelled under scenarios of increasing access to the service by ESKD patients (Figure). Increasing RSC access from the achieved 16% to 20% of ESKD patients was projected to deliver maximal economic value, with a 3% fall in ESKD patients receiving dialysis, increasing survival benefit (${\$}$221 million AUD) and economic value ${\$}$94 million AUD. As access to RSC expands further, modelling indicates that additional dialysis substitution becomes less likely but benefits still accrue from survival up to a maximum viable rollout of 50% of the ESKD population receiving RSC, when survival benefits plateau. Conclusion Economic evaluation of this implementation of the Statewide RSC service across NSW Health shows it has been associated with both a net economic benefit and survival benefits four years after implementation. It is projected to provide an economic value of ${\$}$275 million AUD over ten years, which would increase with greater participation of ESKD patients suitable for RSC.

#1563 Family feedback survey on quality of dialysis withdrawal and end-of-life care on hemodialysis patients in an ICU – a single-center study from India

Abstract Background and Aims End-of-life care in hemodialysis is emerging, with limited implementation in developing countries. There is a sparsity of data on dialysis withdrawal and the quality of end-of-life care in these regions. Developing countries differ in their cultural, social, and spiritual practice compared to the Western world and family plays a major role in decision-making. No survey has been done on family's perception of dialysis withdrawal and end-of-life care in our settings. So, we studied feedback from families regarding the quality of dialysis withdrawal and end-of-life care provided to maintenance hemodialysis (MHD) patients admitted to our intensive care unit (ICU). Method This study was conducted at Kasturba Medical College, Manipal, MAHE, Manipal, India between January 2020 to October 2022 involving the data from end-stage kidney disease (ESKD) patients on MHD admitted in the ICU, who had withdrawn from dialysis before death and received end-of-life care as per the hospital policy (Blue Maple) from Renal supportive and Palliative care team. The baseline data was collected for all patients and indications for withdrawal of dialysis and ICU treatment and end-of-life care provided were collected. The next of kin were interviewed by telephone by a single interviewer using a modified Quality of Death and Dying questionnaire. The data was analyzed using SPSS 20 Results Among 98 ESKD patients on maintenance hemodialysis who died in our ICU, 23 were referred to Palliative care, counselled, had withdrawal of dialysis at least 48 hours before death and received end-of-life care. Table 1 outlines baseline characteristics. The mean age was 57 ± 12.09 years, with a male predominance (82.6%). Common comorbidities included hypertension (100%), type 2 diabetes (69.5%), and ischemic heart disease (65.2%). The primary cause for ICU admission was infectious disease (47.8%). The majority of reasons for dialysis withdrawal and end-of-life care were worsening hemodynamic status (82.6%) and illness deterioration (69.5%). After consent and establishment of futility, dialysis withdrawal was done for all patients (100%), No CPR for 100%, withdrawal of inotropes in 50%, and withdrawal of ventilator was done in 80% of the patients. A successful telephonic interview/survey was conducted with 21 out of the 23 subjects, with the majority of next of kin being the spouse (47.6%) followed by children (33.3%) and siblings (14.3%). The questionnaire and response are given in Table 2. All expressed a need for palliative care involvement. 82% accepted the decision of dialysis withdrawal and end-of-life care put forth by the doctor's team without difficulty;74% of families were present with the patient in their final hours and were grateful for the same 20% had their spiritual leader to visit during the end-of-life event. None of the family members (100%) interviewed had a guilty feeling and all had a positive rating on the involvement of the palliative care team and the need to ease patients' distress and suffering during their final hours (100%). Unfortunately, none of the patients had prior discussions of advance care planning (ACP) with their doctors regarding end-of-life care before the specific event Conclusion Our study highlights that families agree with the withdrawal of artificial life support measures, such as MHD, CPR, withdrawal of inotropes, and/withdrawal of ventilator in ICU settings when these interventions are considered futile for end-of-life care in ESKD patients. It also emphasizes the need for ACP, and early integration of palliative care for discussions about dialysis withdrawal, and withholding futile interventions at end-of-life care in ESKD patients, especially in resource-constrained settings like ours, for high-quality end-of-life care. This will also lead to better end-of-life care outcomes and improved patient and family satisfaction with care.

Advances in Human-Centered Care to Address Contemporary Unmet Needs in Chronic Dialysis.

Advances in the treatment of kidney failure with chronic dialysis have stagnated over the past three decades, with over 50% of patients still managed by conventional in-hospital haemodialysis. In parallel, the demands of chronic dialysis medical care have changed and evolved due to a growing population that has higher frailty and multimorbidity. Thus, the gap between the needs of kidney failure patients and the healthcare capability to provide effective overall management has widened. To address this problem, healthcare policy has increasingly aligned towards a human-centred approach. The paradigm shift of human-centred approach places patients at the forefront of decision-making processes, ensuring that specific needs are understood and prioritised. Integration of human-centred approaches with patient care has been shown to improve satisfaction and quality of life. The aim of this narrative is to evaluate the current clinical challenges for managing kidney failure for dialysis providers; summarise current experiences and unmet needs of chronic dialysis patients; and finally emphasise how human-centred care has advanced chronic dialysis care. Specific incremental advances include implementation of renal supportive care; home-assisted dialysis; hybrid dialysis; refinements to dialysis methods; whereas emerging advances include portable and wearable dialysis devices and the potential for the integration of artificial intelligence in clinical practice.

Effect of ethnicity and socioeconomic deprivation on uptake of renal supportive care and dialysis decision-making in older adults.

Renal supportive care has become an increasingly relevant treatment option as the renal patient population ages. Despite the prevalence of kidney disease amongst ethnic minority and socioeconomically deprived patients, evidence focused on supportive care and dialysis decision-making in these groups is limited. This retrospective study selected older patients referred to a low clearance or supportive care service between 1 January 2015 and 31 December 2019. A descriptive analysis of clinical and socioeconomic characteristics according to treatment choice was produced and multivariate logistic regression models used to identify predictive factors for choosing supportive care. Surrogate markers for the success of decision-making processes were evaluated, including time taken to reach a supportive care decision and risk of death without making a treatment decision or within 3 months of starting kidney replacement therapy (KRT). Finally, the association between ethnicity and socioeconomic status and hospital admission rates was compared between treatment groups. Amongst 1768 patients, 515 chose supportive care and 309 chose KRT. Predictive factors for choosing supportive care included age, frailty and a diagnosis of cognitive impairment. However, there was no association with ethnicity or deprivation. Similarly, these factors were not associated with time taken to make a supportive care decision or the mortality outcome. Amongst those on KRT, more socially advantaged patients had decreased rates of hospital admissions compared with those less advantaged (incident rate ratio 0.96, 95% confidence interval 0.92-0.99). Predictive factors for choosing supportive care were clinical, rather than socioeconomic. Lower socioeconomic status was associated with increased rates of hospitalization in the KRT group. This is a possible signal that these groups experienced greater morbidity on KRT versus supportive care, an association not demonstrated amongst higher socioeconomic groups.

End Stage Kidney Disease Patient Experiences of Renal Supportive Care in an Australian Teaching Hospital - A Qualitative Study

ContextRenal Supportive Care Services (RSCS) were introduced in Australia to provide patient-centred care with a focus on better symptom management and improved quality of life in end stage kidney disease (ESKD) patients managed with or without dialysis. While RSCS have demonstrated clinical benefits with reduced length of hospital stay and symptom burden, there is a gap in understanding the experience of patients referred to RSCS. ObjectivesTo identify patient attitudes, beliefs, and perspectives on the RSCS. MethodsQualitative interviews were conducted with 20 participants from both dialysis and conservative treatment pathways. Transcripts were then thematically analysed and primary themes identified, which were reviewed with a stakeholder group that included doctors, nurses and allied health staff to provide triangulation. ResultsPatients perceived the RSCS as a provider of multidisciplinary, holistic and patient-centred care that, in addition, helped to ensure prognostic awareness and timely end-of-life care planning. This contributed to an overall sense of patient empowerment with healthcare decisions. This study identified three major themes: (1) Expectations of care; (2) Experience of care; and (3) Understanding patient needs. ConclusionThe study found that RSCS support patient-centred and family-orientated initiatives in decision making and control over healthcare management. This is empowering for patients. Additional patient values, needs and wants from the RSCS were also identified and these could be addressed to improve the patient experience. Our findings support the ongoing use of RSCS to improve the experience of ESKD patients.

Exploring the Impact of Different Types of Do-Not-Resuscitate Consent on End-of-Life Treatments among Patients with Advanced Kidney Disease: An Observational Study.

Background: Patients with advanced kidney disease have a symptomatic and psychological burden which warrant renal supportive care or palliative care. However, the impact of do-not-resuscitate consent type (signed by patients or surrogates) on end-of-life treatments in these patients remains unclear. Objective: We aim to identify influential factors correlated with different do-not-resuscitate consent types in patients with advanced kidney disease and the impact of do-not-resuscitate consent types on various life-prolonging treatments. Methods: This was a retrospective observational study. We included patients aged 20 years and over, diagnosed with advanced kidney disease and receiving palliative and hospice care consultation services between January 2014 and December 2018 in a tertiary teaching hospital in Taiwan. We reviewed medical records and used logistic regression to identify factors associated with do-not-resuscitate consent types and end-of-life treatments. Results: A total of 275 patients were included, in which 21% signed their do-not-resuscitate consents. A total of 233 patients were followed until death, and 32% of the decedents continued hemodialysis, 75% underwent nasogastric (NG) tube placement, and 70% took antibiotics in their final seven days of life. Do-not-resuscitate consents signed by patients were associated with reduced life-prolonging treatments including feeding tube placement and antibiotic use in the last seven days (odd ratio and 95% confidence interval were 0.16, 0.07–0.34 and 0.33, 0.16–0.69, respectively) compared to do-not-resuscitate consents signed by surrogates. Conclusions: Do-not-resuscitate consent signed by patients and not by surrogates may reflect better patients’ autonomy and reduced life-prolonging treatments in the final seven days of patients with advanced kidney disease.

Identification of factors associated with high-cost use of inpatient care in chronic kidney disease: a registry study

ObjectiveTo explore factors behind inpatient admissions by high-cost users (HCUs) in pre-end-stage chronic kidney disease (CKD).DesignRetrospective analysis of CKD.QLD Registry and hospital admissions of the Queensland Government Department of Health...

MO171BARRIERS TO RENAL SUPPORTIVE CARE IN SINGAPORE: A SURVEY BASED STUDY OF NEPHROLOGISTS, GERIATRICIANS AND PALLIATIVE PHYSICIANS

Abstract Background and Aims Renal supportive care is a patient-centred approach to management of advanced chronic kidney disease, especially in elderly patients. Adoption of renal supportive care in Asian countries has been slow. This study aims to investigate the barriers towards renal supportive care as perceived by physicians in Singapore. Method An online survey was sent out to all practising and training nephrologists, geriatricians and palliative physicians in Singapore public hospitals between October 1st and October 30th 2020. Responses were compiled and analysed. Results Out of 365 surveys sent, 75 nephrologists, 43 geriatricians and 28 palliative care physicians responded, accounting for a 40% response rate. Most of the participants managed 16 to 30 chronic kidney disease patients in a week. Older patients aged >75 years accounted for at least 30% of the chronic kidney disease cohort managed by 72% of respondents. Most agreed that renal supportive care aims to improve quality of life in chronic kidney disease (97.9%) and can be implemented alongside life-prolonging treatments such as dialysis (83.6%). However, only 51.4% recognised a distinction between renal supportive care and palliative care. Fewer nephrologists compared to geriatricians received prior palliative care training (54.7% vs 93.0%) or were certified advanced care planning facilitators (33.3% vs 67.4%). All respondents agreed that nephrologists should be aware of basic principles of palliative care, and 89.7% felt that palliative care should be incorporated into nephrology training. Most were comfortable holding discussions regarding dialysis withholding and withdrawal (93.8% and 87.7% respectively), and managing symptoms of pain (74.7%), breathlessness (87.0%) and anticipated symptoms after dialysis withdrawal (78.8%). Fewer physicians were comfortable with managing symptoms of pruritus (65.1%) and restless legs syndrome (56.2%). Majority (60%) did not feel confident in providing spiritual support as part of end-of-life care. Main barriers to renal supportive care included inadequate time during clinic consults to address the patients’ needs (87%), reliance on family members to make decisions (69.2%), inadequate palliative training during fellowship (67.1%) and inadequate community support services (55.5%). Some cited lack of awareness and acceptability of renal supportive care amongst patients and relatives in Singapore’s Asian cultural context. Most felt that encouraging advanced care planning discussions earlier in the course of chronic kidney disease (80.8%), having dedicated renal supportive care services in hospital (78.1%) and including palliative care rotation as part of training (69.2%) could potentially increase uptake of renal supportive care in Singapore. Conclusion Nephrologists, geriatricians and palliative physicians in Singapore recognise the value of renal supportive care, but are faced with barriers such as patients’ and family’s resistance toward renal supportive care as well as inadequate palliative training. A unique model of renal supportive care with the patient as well as family’s involvement early in the decision-making process is likely to be better perceived in Asian countries. Incorporation of palliative care training in the nephrology fellowship curriculum should be considered.

POS-680 A NATIONWIDE SURVEY OF NEPHROLOGISTS REGARDING PERCEPTION ON RENAL PALLIATIVE CARE SERVICES IN MALAYSIA

There is a huge unmet need for renal supportive care (RSC) among patients with end stage kidney disease (ESKD) in Malaysia. This study aimed to understand perception and knowledge of nephrologists regarding RSC services in Malaysia.

End-stage kidney disease: The last 12 months.

Chronic kidney disease (CKD) is increasingly prevalent in Australia's ageing population. Over the past decade, there has been growing recognition that dialysis does not benefit every patient with end-stage kidney disease (ESKD). Patients with advanced age, significant comorbidities and poor functional status may not gain a survival benefit with dialysis when compared with being managed conservatively. These developments have implications forgeneral practitioners (GPs). A further development has been the emergence ofrenal supportive care, a patient-centred approach that integrates the principles of palliative care into nephrology. The aim of this article is to outline salient aspects in the care of patients with ESKD. Salient aspects throughout the trajectory of ESKD are discussed, including symptoms of CKD, relevant management, prognostication, advance care planning discussions and end-of-life care. The role of the GP is vital, and it is recommended that GPs are involved early in a patient's CKD trajectory.

Liver Transplantation for Acute-on-Chronic Liver Failure Associated With Acute Necrotizing Pancreatitis: A Case Report

Liver transplantation (LT) for acute-on-chronic liver failure (ACLF) accompanied by acute necrotizing pancreatitis is still unclear. We have a reported case of LT for ACLF associated with acute necrotizing pancreatitis. The postoperative multiorgan dysfunction and secondary infection were successfully managed under close supervision. The patient was a 47-year-old man with chronic hepatitis B virus infection presented with ACLF and acute necrotizing pancreatitis. After receiving LT from a deceased donor, the patient's liver functioning rapidly reverted to a normal level, and the acute pancreatitis was simultaneously stabilized. However, the patient later developed multiorgan dysfunction secondary to multidrug resistant bacteria infection, which was treated successfully with repeated percutaneous drainage, sensitive antibiotics, continuous renal replacement therapy, microbial balance, and best supportive care. LT can be considered for ACLF associated with acute necrotic pancreatitis without absolute contraindication. Moreover, we recommend a close observation of possible postoperative severe infection, and cautious multidisciplinary management was needed for the prevention of organ dysfunction.

Renal supportive care programs: An observational study assessing impact on hospitalization and survival outcomes.

Renal supportive care (RSC) programs are used to manage non-dialysis end-stage kidney disease (ESKD) patients. The aim of this study was to analyse the impact of RSC programs on hospitalization and survival outcomes in these patients. A retrospective, single-centre observational cohort study of non-dialysis ESKD patients was undertaken. Hospitalizations and survival from eGFR≤15 ml/min was compared between patients managed in an RSC program (RSC group) and patients receiving standard conservative therapy (non-RSC group). Local databases, physician letters and electronic medical records were used for data collection. Prevalent patients from 2013 to 2017 with eGFR ≤15 ml/min were included. Cox proportion hazard testing and generalized linear modelling was undertaken to adjust for confounders. A total of 172 patients were included (95 RSC; 75 non-RSC). The median age was 82 years [IQR 78-85], 46% were male, the median Charlson-comorbidity Index was 5 [IQR 4-7]. The RSC group had significantly lowered haemoglobin level (102 g/L vs. 111 g/L) and fewer English-speakers (34% vs. 44%). RSC was associated with the decreased number of days in hospital per year (estimated means 46.6 days [95% CI 21-67] vs. 83.2 days [95%CI 60.5-105.8]; p = .01) and decreased number of hospital admissions per year (estimated means 5.4 [95%CI 2.1-8.8] vs. 12.3 [95%CI 8.2-16.4]; p = .01) compared with non-RSC. Median overall survival from eGFR≤15 in the entire cohort was 735 days, with no significant difference between RSC and non-RSC groups (p = .9), both unadjusted and adjusted for confounders. RSC programs can significantly decrease the number and length of hospitalizations in conservatively managed ESKD patients.

Renal supportive care

The Journal of the Ceylon College of Physicians (JCCP) is a peer-reviewed, open access journal published bi-annually by the Ceylon College of Physicians (CCP) in the last week of June and December.The objective of the Journal is to promote good clinical practice and influence policy making across the medical world through publication of original research and peer reviewed articles on current issues and to foster responsible and balanced debate on issues that affect medicine and health care in Sri Lanka. Contributions to the JCCP reflect its national and multidisciplinary readership and include current thinking across a range of medical specialties.

The primary care provider's role in providing supportive and palliative care for patients in chronic renal failure.

Primary care providers are at the core of providing supportive and palliative care to patients with chronic kidney disease in South Africa. Although dialysis is not always needed, and sometimes not appropriate, for all patients with end-stage kidney disease, there is always supportive and palliative care that can be provided to patients and families to improve outcomes. This article explores the referral pathways, renal preservation, supportive and palliative care and, finally, health system interventions that can improve comprehensive care. The integration of renal supportive and palliative care is a relatively new concept in the paradigm of care and will require advocacy and research to ensure all South African patients have access throughout the trajectory of illness.

Renal supportive care, palliative care and end-of-life care: Perceptions of similarities, differences and challenges across Australia and New Zealand.

To understand renal clinicians' views and experiences of RSC, palliative care and end-of-life care. A cross-sectional online survey was undertaken across Australia and New Zealand between February and May 2018. Participants were asked about end-of-life care, RSC, palliative care and an ideal model of RSC. Estimated response rate 13% included 382 clinicians; doctors (32%), nurses (68%); of whom 84% access specialist palliative care and 59% RSC. A lack of agreed treatment goals (86%) and late or rushed treatment decision making (85%) was associated with challenging end-of-life experiences. Variable concepts of RSC were described, with RSC being considered the same as: usual care for all CKD patients (40%), conservative (30%) or palliative care (22%). The term RSC was generally distinct from (77%) and more acceptable than palliative care (80%) with preferential RSC referral for symptoms (86% vs 69%, P < .01) and complex treatment decision making (82% vs 58%, P < .01). Aspirations for RSC included improving symptoms and quality of life (89%), with an ideal model comprising: symptom management (98%), improved nephrology and community service integration (96%) and clinician education (94%). This study revealed challenges for renal clinicians in providing end-of-life care and variation of views and experiences of RSC. It represents opportunities to develop RSC aligned with clinician priorities to improve patient care.

Cognitive Biases in Medicine: The Potential Impact on the Diagnosis of Restless Legs Syndrome in Chronic Kidney Disease

Restless legs syndrome (RLS) is a sensorimotor disorder defined by an uncontrollable “urge to move” the limbs during rest, that is, temporarily relieved by movement and cannot be explained by other medical or behavioral conditions. 1 Allen R.P. Picchietti D.L. Garcia-Borreguero D. et al. Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria--history, rationale, description, and significance. Sleep Med. 2014; 15: 860-873 Crossref PubMed Scopus (738) Google Scholar Individuals with end-stage kidney disease (ESKD) are known to have a high symptom burden, 2 Murtagh F.E. Addington-Hall J. Higginson I.J. The prevalence of symptoms in end-stage renal disease: a systematic review. Adv Chron Kidney Dis. 2007; 14: 82-99 Abstract Full Text Full Text PDF PubMed Scopus (569) Google Scholar , 3 Brown M.A. Collett G.K. Josland E.A. Foote C. Li Q. Brennan F.P. CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life. Clin J Am Soc Neph. 2015; 10: 260-268 Crossref PubMed Scopus (129) Google Scholar , 4 Siriwardana A.N. Hoffman A.T. Brennan F.P. Li K. Brown M.A. Impact of renal supportive care on symptom burden in dialysis patients: a prospective observational cohort study. J Pain Symptom Manage. 2020; 60: 725-736 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar which often goes unrecognized. 5 Weisbord S.D. Fried L.F. Mor M.K. et al. Renal provider recognition of symptoms in patients on maintenance hemodialysis. Clin J Am Soc Nephrol. 2007; 2: 960-967 Crossref PubMed Scopus (181) Google Scholar Uremic RLS is reported to affect almost 30% of patients with ESKD, 6 Giannaki C.D. Hadjigeorgiou G.M. Karatzaferi C. Pantzaris M.C. Stefanidis I. Sakkas G.K. Epidemiology, impact, and treatment options of restless legs syndrome in end-stage renal disease patients: an evidence-based review. Kidney Int. 2014; 85: 1275-1282 Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar ,7 La Manna G. Pizza F. Persici E. et al. Restless legs syndrome enhances cardiovascular risk and mortality in patients with end-stage kidney disease undergoing long-term haemodialysis treatment. Neph Dial Transpl. 2011; 26: 1976-1983 Crossref PubMed Scopus (102) Google Scholar which significantly reduces quality of life and impacts on sleep quality, ability to dialyze, 8 Winkelman J.W. Chertow G.M. Lazarus J.M. Restless legs syndrome in end-stage renal disease. Am J Kidney Dis. 1996; 28: 372-378 Abstract Full Text PDF PubMed Scopus (334) Google Scholar and mortality. 7 La Manna G. Pizza F. Persici E. et al. Restless legs syndrome enhances cardiovascular risk and mortality in patients with end-stage kidney disease undergoing long-term haemodialysis treatment. Neph Dial Transpl. 2011; 26: 1976-1983 Crossref PubMed Scopus (102) Google Scholar ,8 Winkelman J.W. Chertow G.M. Lazarus J.M. Restless legs syndrome in end-stage renal disease. Am J Kidney Dis. 1996; 28: 372-378 Abstract Full Text PDF PubMed Scopus (334) Google Scholar

Abstract 2032: Renal tubule-targeted supportive care nanotherapy for cisplatin-induced acute kidney injury

Abstract Acute kidney injury (AKI) develops in up to 30% of patients who receive cisplatin-based chemotherapy. In this setting, AKI can result in delays in completion of treatment and/or the need to switch to other potentially less effective therapeutic regimens. Despite its high incidence and associated increased morbidity and mortality, there is no effective pharmacologic intervention to treat AKI of any etiology, including AKI resulting from cisplatin or any other nephrotoxic treatments. In the case of cisplatin-induced AKI, it is also imperative that any pharmacologic intervention that could be effective for AKI will not interfere with the systemic chemotherapeutic effects of cisplatin. In prior studies (Nano Letters, 2015), we reported the development of mesoscale nanoparticles (MNPs), composed of poly(lactic-co-glycolic acid) and polyethylene glycol (PLGA-PEG) that localize to the kidneys with a high affinity, primarily to the proximal tubules (the site of injury in AKI), and persist at that location for up to a week. Herein, we encapsulated a small molecule reactive oxygen species scavenger, (edaravone) in the MNPs. Experiments were performed in male C57BL/6 mice with cisplatin-induced AKI (25 mg/kg IP). To assess therapeutic efficacy, tail vein injections of 50 mg/kg edaravone-containing MNPs, 50 mg/kg empty control MNPs, or 30 mg/kg free edaravone were performed 24 hours after cisplatin injection (n=6-8 per group). Mice were euthanized at 72 hours post-cisplatin administration, and kidney and serum were saved for analysis. In a separate group of mice bearing metastatic small cell lung cancer, fluorescent MNPs were injected to determine whether MNPs still localize to the kidneys rather than to the tumor as has been described for other types of nanoparticles. Mice receiving cisplatin had a ~5 fold increase in serum creatinine and severe acute tubular necrosis as compared to controls. In contrast to mice receiving cisplatin alone, mice receiving edaravone-containing MNPs along with cisplatin had normal creatinine and histology similar to controls. Neither treatment with free edaravone nor empty MNPs resulted in a significant improvement in renal function or severity of tubular necrosis in mice with cisplatin-induced AKI. In the presence of AKI, the distribution of MNPs was still highly selective to the renal proximal tubules. In mice with metastatic lung tumors, we determined that MNPs maintain their specific renal distribution and do not localize to tumors as has been described with other smaller nanoparticle systems. These studies demonstrate that edaravone-containing MNPs can be an effective treatment for cisplatin-induced AKI while avoiding the possible therapeutic abatement associated with tumor deposition of reactive oxygen species scavengers. We anticipate that these studies will constitute the basis for the development of novel strategies for the treatment and prevention of cisplatin-induced AKI in humans. Citation Format: Daniel A. Heller, Edgar Jaimes, Ryan Williams, Janki Shah. Renal tubule-targeted supportive care nanotherapy for cisplatin-induced acute kidney injury [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2032.

P0205SYMPTOM BURDEN IN AUSTRALIAN PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE AND END-STAGE KIDNEY DISEASE RECEIVING RENAL SUPPORTIVE CARE: A SINGLE CENTRE COHORT STUDY

Abstract Background and Aims Renal supportive care (RSC) is a novel multidisciplinary patient-centred model of care that focuses on symptom management and quality of life improvement in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD), including conservative care. Despite an increased interest in embedding RSC into routine nephrology practice, there is limited literature on the effects of symptom improvement in patients attending RSC services. We aimed to examine symptom improvement and symptom progression in patients receiving renal supportive care. Method Using Integrated Palliative care Outcome Scale Renal (IPOS-renal) scores collected during routine RSC clinics, we analysed the changes in individual IPOS-renal items and summative scores for symptoms associated with chronic kidney disease, stratified by time from the initial clinic visit (0-6 months, 6-12 months, and &amp;gt;12 months), in all patients attending our RSC service in a tertiary hospital between November 2015 and July 2019. Results Of 245 patients referred to our RSC service, 61 patients completed two or more IPOS-renal surveys. At initial visit, majority of the patients were reviewed at hospital outpatient clinic (n=42, 71%), followed by dialysis (n=8, 13%), home visit (n=6, 10%), and inpatient ward (n=4, 7%). The median (IQR) eGFR was 13 (7-16) ml/min/1.73m2 and median Karnofsky score was 70 (60-80). Weakness (n=59, 97%) and poor mobility (n=52, 85%) were the most common initial complaints. For all reported symptoms, dyspnea improved the most for all three time periods (summative IPOS score changes of 28, 17, and 8 points for 0-6, 6-12, &amp;gt;12 months, respectively). Poor mobility was the only symptom that continued to deteriorate between 0-6 months despite attending renal supportive care (without a physiotherapist). For asymptomatic patients, more than half of the symptoms remained quiescent after attending RSC service for more than 12 months. Among newly developed symptoms, nausea, dyspnea, and drowsiness were most common between 0-6 months. In contrast, pruritus, dry mouth, and constipation were the most common complaints after 12 months. Conclusion RSC interventions provided symptom improvement in patients with advanced CKD and ESKD, but poor mobility remained a concern in this population. Incorporating physiotherapy to RSC may further improve symptom management.

Impact of Renal Supportive Care on Symptom Burden in Dialysis Patients: A Prospective Observational Cohort Study

ContextSymptom burden is a strong predictor of reduced health-related quality of life and survival in patients with end-stage kidney disease. Renal supportive care (RSC) is a comprehensive approach shown to benefit symptoms in nondialysis conservatively managed patients, although its role in dialysis patients has not been reported. ObjectivesThis study aimed to investigate the impacts of RSC intervention on symptoms in dialysis patients. MethodsDialysis patients who were referred to an RSC clinic for symptom control between April 2010 and December 2017 were followed prospectively. Symptoms were scored using the Integrated Palliative care Outcomes Scale-Renal Inventory. Change in symptoms was analyzed at three visits and at final RSC visit within the study period. Correlation and linear regression were used to assess for effect modifiers. ResultsA total of 127 dialysis patients attended the RSC clinic for symptom management. Median age was 74 years, 62% males, median dialysis vintage was 2.2 years, and median-modified Charlson Comorbidity Index was 7. Mean combined physical and emotional symptom score at baseline was 17.5 (SD 9.6), the most overwhelming/severe symptoms being difficulty sleeping (35%), pain (31%), lack of energy (31%), poor mobility (24%), and itch (22%). Eighty patients had follow-up to at least three RSC visits (median 3.1 months). There was significant improvement in combined physical and emotional symptom score during three clinic visits (18.1 vs. 14.2; mean change −3.8; 95% CI −5.7 to −1.9; P < 0.001), with greatest improvement in symptom scores for the five most severe symptoms (each P < 0.001). Follow-up of these 80 patients to final RSC visit (median 13.0 months) showed sustained reduction in mean combined physical and emotional symptom score (18.1 vs. 14.4; mean change −3.7; 95% CI −5.6 to −1.7; P < 0.001). These changes occurred without change in dialysis delivery. ConclusionRSC intervention that focuses on symptom control and patient-centered care is associated with improved total and individual symptom burden in dialysis patients. This supports a role for RSC as a management adjunct in these patients.