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Innovation, Improvement, Involvement

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Emma Murphy, Fliss Murtagh & Neil Sheerin. 2. Aims and limits of this talk ... Sarah Watson & Kate Shepherd. Lizzy Bovill. Renal palliative nurse forum 6/12 ... – PowerPoint PPT presentation

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Title: Innovation, Improvement, Involvement


1
Innovation, Improvement, Involvement
  • Scratching the surface
  • symptom control in chronic kidney disease
  • Emma Murphy, Fliss Murtagh Neil Sheerin

2
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

3
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

4
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!!

5
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

6
So how common are symptoms
  • ..in conservatively managed
  • patients?
  • .in patients discontinuing dialysis?

7
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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9
No of symptoms experienced by each patient
(median, mean, and range)
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11
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)


12
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

13
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

14
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

15
Causes of pain
  • Less commonly related to renal disease
  • Bone pain from renal osteodystrophy
  • Cyst pain in polycystic kidney disease
  • Rarely calciphylaxis1

  • 1Davison 2003


16
Management of pain
  • Depends on the stage of CKD
  • eGFR
  • Identify cause of each pain
  • Remove reduce cause where possible

17
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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19
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?

20
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

    21
    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

    22
    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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    27
    What to use in mobile out-patients?(end of
    life management discussed later)
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    30
    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?

    31
    Management at end of life
    • Agitation and restlessness
    • Respiratory tract secretions
    • Pain

    32
    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

    33
    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)

    34
    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
    35
    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

    36
    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)

    37
    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

    38
    • How would you assess and manage his pain?
    • What are the possible causes of his pain?

    39
    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.

    40
    • What might be causing his pain?
    • What other treatment would you consider to
      relieve his pain?

    41
    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

    42
    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

    43
    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
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