A Brief Synopsis of AFP's "End-Stage Renal Disease: Symptom Management and Advance Care Planning"

A brief synopsis of:
End-Stage Renal Disease: Symptom Management and Advance Care Planning
NINA R. O’CONNOR, MD, Arkansas Hospice, Little Rock, Arkansas, AMY M. CORCORAN, MD, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
Am Fam Physician. 2012 Apr 1;85(7):705-710.
http://www.aafp.org/afp/2012/0401/p705.pdf

     End stage renal disease has three components; initiation of dialysis, symptom management, and advance directives. According to this article, dialysis has not shown survival benefit over conservative management.   Conservative management consists of proper fluid balance, diet, blood pressure control,  anemia treatment, and electrolyte management (potassium, calcium, phosphorus, and those causing acidosis). There does not appear to be a benefit in early adoption in dialysis so delayed onset of treatment is valid. Patients who discontinue dialysis will have a life expectancy of 1-2 weeks on average.
     Pain is a common symptom in patients on dialysis, especially if they have comorbid conditions (which is more commonplace with the increased availability of treatment centers). Calciphylaxis is an illness exclusively in dialysis patients. Altered metabolism of calcium and phosphorus causes skin ischemia and vessel calcification. Symptoms include a painful rash and overt necrosis (I had a patient with calciphylaxis on my first day as a medical student in the hospital. The poor woman was in so much pain when the hair on her leg got stuck to the adhesive on the wound-vac).  For mild pain, acetaminophen can be used safely. NSAIDs should be avoid because it may cause GI bleeding in a patient with platelet dysfunction from the uremia.  Tramadol can be used for moderate to severe pain, but is must be dose and interval adjusted. Fentanyl or methadone can be used for those needing opioids. Codeine, hydrocodone, morphine and meperidine are not recommended. Hydromorphone and oxycodone should be used with caution. Gabapentin is widely used for neuropathic pain, although the evidence of effectiveness is controversial. TCAs should be avoided. 
    Other symptoms seen in renal failure patients include fatigue, pruritus,  drowsiness, dyspnea, dry mouth, myalgia, RLS, anorexia, constipation and edema.  Pruritus can be managed with phosphate binders, emollients, antihistamines, ondansetron and naltrexone. Fatigued patients should be assessed for edema and depression. Nausea can be managed with ondansetron, metoclopramide and haloperidol. Encouraging physical therapy can help the dyspnea and fatigue. 
     Patients with end stage renal disease have a limited life expectancy. Patients who fill out an advance directive are more likely to talk with their family about end-of-life intervention. As far as hospice is concerned, end stage renal disease is not covered by medicare. Patients with a comorbid terminal condition can get hospice care with dialysis benefits under medicare.