Innovation, Improvement, Involvement

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Innovation, Improvement, Involvement

• Scratching the surface
• symptom control in chronic kidney disease
• Emma Murphy, Fliss Murtagh Neil Sheerin

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Aims and limits of this talk

• To present the evidence on management of symptoms
  in CKD
• Highlight the magnitude of symptoms in CKD
• - prevalence, severity, and aetiology
• Case discussion
• Focuses on those patients with GFRnot on dialysis
• Evidence in these populations is extremely
  limited some extrapolated from other populations

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Patient quotes

• Ive waited 20 years for someone to talk to me
  about symptoms
• Of course I understand that I cannot be cured of
  my kidney disease but I am now able to cope with
  my condition
• If clinicians cannot innovate and increase the
  hours on dialysis, the only effective alternative
  is symptom management. Without either, for most
  patients, there is no QOL, and for many, there is
  little reason to live
• I know it was the right decision not to start
  dialysis but I have had all this time with
  improved quality of life

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Staff quotes

• More of a cross over is important palliative
  care not just for the end but for earlier
  symptoms too
• If we could refer more people for symptom
  control it would be a great help
• Better management of pain has really helped
• You may have known patient for 20yrs, like
  familyso distressing when you dont know what to
  do about their symptoms
• Both medical and nursing staff not equipped to
  do so..we are just not good at pain
• Palliative care is like the golden ticket they
  know what to do!!

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What do CKD patients think is important in
end-of-life care?

• Good symptom control
• Avoiding inappropriate prolongation
• Sense of control (information, involvement,
  self-determination)
• Relieving burden
• Strengthening relationships1
• 1Singer 1998 1999

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So how common are symptoms

• ..in conservatively managed
• patients?
• .in patients discontinuing dialysis?

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Systematic review of studies reporting symptom
prevalence

• in conservatively managed patients
• - no evidence
• in dialysis patients
• - 62 studies
• .in patients discontinuing dialysis
• - 1 study

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No of symptoms experienced by each patient
(median, mean, and range)
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Conclusions on symptom prevalence

• More than 1 in 3 conservatively-managed patients
  will have
• poor mobility, fatigue/weakness, pain, pruritus,
  poor appetite, dyspnoea, difficulty sleeping,
  drowsiness, constipation, feeling anxious,
  restless legs
• End of life
• Pain 42, agitation 30, myoclonus 26, dyspnoea
  25, nausea 131
• 1Prospective study of 131
  patients. Cohen 2000)
• 
  

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Symptom control challenging

• Symptoms often from co-morbidity not renal
  disease
• Regular detailed and proactive assessment for
  symptoms important
• CKD stage 4-5 itself constrains use of medication
• avoid
• modified (reduction in dose and/or frequency)
• still dialysing or not

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Pain

• Often believed that patients with ESRD have few
  symptoms and that dying with ESRD is relatively
  symptom free
• Good evidence that symptoms are both
  under-recognised and under-treated1,2
  
• 1Davison
  2003, 2DOPPS 2004

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Causes of pain

• Often from co-morbid conditions
• Ischaemic pain from peripheral vascular disease
• Neuropathic pain from peripheral neuropathy
• Bone pain from eg osteoporosis
• Musculo-skeletal pain
• Angina1
• 1Davison 2003

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Causes of pain

• Less commonly related to renal disease
• Bone pain from renal osteodystrophy
• Cyst pain in polycystic kidney disease
• Rarely calciphylaxis1
• 
  1Davison 2003
• 
  

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Management of pain

• Depends on the stage of CKD
• eGFR
• Identify cause of each pain
• Remove reduce cause where possible

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Pharmacological approach

• WHO analgesic ladder (WHO 1986) devised for
  cancer pain, but provides
• - a systematic and logical approach
• - As with cancer, cause of pain can rarely be
  removed
• The WHO three step analgesic ladder leads to
  effective pain relief in haemodialysis patients1
• 1Barakzoy
  Moss 2006

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Management of pain - opioids

• Opioids undergo hepatic metabolism to inactive
  and active metabolites
• Majority of metabolites excreted by the kidneys
• Are metabolites toxic, do they accumulate and do
  they cross the BBB?

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Morphine or diamorphine should it be used when
eGFR

YES

Readily available

Familiar with use

• NO
• The evidence strongly suggests not
• Significant risk of excess sedation and
  respiratory depression
• Prolonged adverse effects
• Better alternative drugs available

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Fentanyl should it be used when eGFR no dialysis?

• YES
• Safer than morphine
• No toxic metabolites
• Most evidence for safe use

• NO
• 10 drug excreted renally
• Accumulation may occur
• ? Ease of use and availability

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Alfentanil should it be used at end of life
when eGFR

NO

Expensive

May not be available

Break-through pain a problem as short-acting

• YES
• Least likely to cause toxicity
• Good if toxic side-effects develop with other
  opioids

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What to use in mobile out-patients?(end of
life management discussed later)
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Commonly asked questions

• ? Gabapentin
• - Problematic in eGFR
• Eliminated entirely by renal excretion of
  unchanged drug renal clearance directly
  proportional to creatinine clearance
• Risk of neurotoxcity and myoclonus
• What do we use for break through pain?

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Management at end of life

• Agitation and restlessness
• Respiratory tract secretions
• Pain

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Management of terminal restlessness and agitation

• Midazolam
• - Accumulates in renal failure
• - Risk of excess sedation
• Midazolam 1.25 - 2.5mg PRN (can be used up to
  hourly, but rarely needed this often)
• If CSCI required 5-10mg

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Pain at the end of life

• fentanyl sc injection first choice, 25 micrograms
  3-4 hourly
• Volume issues likely to arise with fentanyl BUT
  renal patients dont generally require high doses
• If dose requirements are high ( about fentanyl
  500mcg/24hours), then may need to switch to
  alfentanil
• - fentanyl 200mcg sc alfentanil 1mg sc
• - fentanyl 25 mcg morphine 2 mg
• Note alfentanil 100-200 micrograms is NOT
  optimal for prn doses (only lasts 1-2 hours)

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Management of respiratory tract secretions

• Glycopyrronium
• 0.2 mg PRN
• 0.6-2.4mg in CSCI if symptoms require

• Hyoscine butylbromide
• 20mg PRN
• 40mg-120mg in CSCI if symptoms require

Hyoscine hydrobromide may cause drowsiness
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Mr JK

• 55yrs old
• Chronic kidney disease stage 5 secondary to
  diabetic nephropathy
• IDDM complications - nephropathy, retinopathy
  neuropathy
• Metastatic prostate carcinoma diagnosed late
  2004.
• PSA 900 on diagnosis, then dropped but has been
  rising again despite Zoladex
• Now hormone refractory
• Recent Ix (CT bone scans) confirm bone
  metastases

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Case of Mr JK

• Already aware of poor prognosis
• (advised
• Opted for conservative management
• No planned oncology follow up
• Attending renal palliative clinic
• Keen to discuss symptoms and future
• Serum creatinine now 420, urea 27 (eGFR 14mls/min)

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Case of Mr JK

• C/o severe pain in left lower limb
• aching over his anterolateral thigh lateral leg
• severity 8/10 at worst
• exacerbated by sitting, walking and hip or knee
  extension
• C/o severe pain in right shoulder
• aching in nature and radiates all the way down
  his right arm to his wrist. He grades this pain 7
  out of 10 and it is exacerbated by lying down.
• Rx Co-codamol maximum dose
• little benefit
• well tolerated
• reduces pain by only 20

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• How would you assess and manage his pain?
• What are the possible causes of his pain?

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Case of Mr JK

• He sleeps poorly largely due to his pain
• His sleep is particularly interrupted by a
  stabbing pain in his left forefoot which occurs
  at night but is not helped by sitting out and
  lowering his leg
• He is known to have calcified vessels on recent
  Doppler scans.

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• What might be causing his pain?
• What other treatment would you consider to
  relieve his pain?

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Conclusions

• CKD patients have a high burden of symptoms
  throughout their illness (not just at the EOL)
• Pain in CKD is common, often severe and poorly
  managed
• Effective pain and symptom management is an
  integral component of quality CKD patient care
• For management of pain to be effective,
  psychosocial factors will need to be addressed
  along with the pain
• Must optimise BOTH pharmacological and non
  pharmacological interventions for effective pain
  management

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Conclusions

• Multi professional nephrology teams must focus on
  pain and symptom management (clinical and
  research)
• - training and education
• - culture change
• - dedicated resources
• Management (especially drug use and advance
  planning) can be challenging
• Flexibility and collaboration are key to
  providing good quality care

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Acknowledgements

• The patients for symptom data
• Fliss Murtagh
• Irene Carey Neil Sheerin
• Sarah Watson Kate Shepherd
• Lizzy Bovill
• Renal palliative nurse forum 6/12
• emma.murphy_at_gstt.nhs.uk