Symptom management for the adult patient dying with advanced chronic kidney disease: A review of the literature and development of evidence-based guidelines by a United Kingdom Expert Consensus Group
Restricted accessResearch articleFirst published online March, 2009
Symptom management for the adult patient dying with advanced chronic kidney disease: A review of the literature and development of evidence-based guidelines by a United Kingdom Expert Consensus Group
Improvement in end-of-life-care is required for patients dying with chronic kidney disease (CKD). The UK government now recommends that tools such as the Liverpool Care Pathway for the Dying Patient (LCP) be used to enhance the care of those patients dying with CKD. The LCP was originally developed for patients dying with terminal cancer, however has been shown to be transferable to patients dying with heart failure or stroke. On this background, in 2005 a UK National Renal LCP Steering Group was formed. The aim was to determine whether or not the generic LCP was transferable to patients dying with CKD. An Expert Consensus sub-group was established to produce evidence-based prescribing guidelines to allow safe and effective symptom control for patients dying with renal failure. These guidelines were finalised by the Expert Consensus group in August 2007 and endorsed by the Department of Health in March 2008. A literature search on symptom control and end-of-life care in renal failure was performed. A summary of the evidence was presented at a National Steering Group meeting. Opinions were given and provisional guidelines discussed. A first draft was produced and individually reviewed by all members of the Expert Group. Following review, amendments were made and a second draft written. This was presented to the entire National Steering Group and again individual comments were taken into consideration. A third and fourth draft were written and individually reviewed, before the guidelines were finalised by the Expert Consensus group. Patients dying with advanced CKD suffer symptoms similar to patients dying of cancer. The Renal LCP prescribing guidelines aim to control the same symptoms as the generic LCP: pain, dyspnoea, terminal restlessness and agitation, nausea and respiratory tract secretions. The evidence for the production of the guidelines is discussed and how a consensus was reached. A summary of the guidelines is given and the complete guidelines document is available via the Marie Curie Palliative Care Institute, Liverpool website.
1 Ansell D Feest T Rao R Williams A Winearls C . UK Renal Registry Report 2005.Bristol, UK: UK Renal Registry; 2006.
2.
2 Roderick P Davies R Jones C Feest T Smith S Farrington K . Simulation model of renal replacement therapy: Predicting future demand in England. Nephrol Dial Transplant2004; 19: 692–701.
3.
3 Smith C Silva-Gane M Chandna S Warwicker P Greenwood R Farrington K . [see comment] Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract2003; 95: c40–c46.
4.
4 Munshi SK Vijayakumar N Taub NA Bhullar H Lo TC Warwick G . Outcome of renal replacement therapy in the very elderly. Nephrol Dial Transplant2001; 16: 128–133.
5.
5 Murtagh FE Marsh JE Donohoe P Ekbal NJ Sheerin NS Harris FE . Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant2007; 22: 1955–1962.
6.
6 Devins GM Armstrong SJ Mandin H Paul LC Hons RB Burgess ED . Recurrent pain, illness intrusiveness, and quality of life in end-stage renal disease. Pain1990; 42: 279–285.
7.
7 Cohen LM McCue JD Germain M Kjellstrand CM . Dialysis discontinuation. A 'good' death. Arch Intern Med1995; 155: 42–49.
8.
8 Cohen LM Germain M Poppel DM Woods A Kjellstrand CM . Dialysis discontinuation and palliative care. Am J Kidney Dis2000; 36: 140–144.
9.
9 Sprangers MA de Regt EB Andries F van Agt HM Bijl RV de Boer JB . Which chronic conditions are associated with better or poorer quality of life. J Clin Epidemiol2000; 53: 895–907.
10.
10 Department of Health. National Service Framework for Renal Services - Part 2; 2005.
11.
11 J Ellershaw S Wilkinson , (). Care of the dying: A pathway to excellence.Oxford: Oxford University Press; 2003.
12.
12 Ellershaw J Ward C . Care of the dying patient: the last hours or days of life. BMJ2003; 326: 30–34.
13.
13 Jack C Jones L Jack BA Gambles M Murphy D Ellershaw JE . Towards a good death: the impact of the care of the dying pathway in an acute stroke unit. Age Ageing2004; 33: 625–626.
14.
14 Doyle D Hanks G Cherny N Calman K . Oxford textbook of palliative medicine.3rd ed.Oxford: Oxford University Press; 2004.
15.
15 Chambers EJ Germain M Brown E . Supportive Care for the Renal Patient.1st ed.Oxford: Oxford University Press; 2004.
16.
16 Ashley C Currie A . The renal drug handbook.2nd ed.Abingdon, UK: Radcliffe Medical Press Ltd; 2004.
17.
17 Murtagh F Chai MO Donohoe P Edmonds P Higginson I . The use of opioid analgesia in end-stage renal disease patients managed without dialysis: recommendations for practice. J Pain Palliat Care Pharmacother2007; 21: 5–17.
18.
19.
19 Cockcroft DW Gault MH . Prediction of creatinine clearance from serum creatinine. Nephron1976; 16: 31–41.
20.
20 Levey AS Bosch JP Lewis JB Greene T Rogers N Roth D . A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med1999; 130: 461–470.
21.
21 Murtagh F Addington-Hall J Higginson IJ . The prevalence of symptoms in end-stage renal disease: a systematic review. Adv Chronic Kidney Dis2007; 14: 82–99.
22.
22 Murtagh F Addington-Hall J Edmonds P Donohoe P Carey I Jenkins K . Symptoms in advanced renal disease - a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis. J Palliat Med2007; 10: 1266–1276.
23.
23 Cohen LM Germain MJ Poppel DM Woods AL Pekow PS Kjellstrand CM . Dying well after discontinuing the life-support treatment of dialysis. Arch Intern Med2000; 160: 2513–2518.
25 Mannix K . Palliation of nausea and vomiting. In: G Hanks N Cherny K Calman D Doyle , (eds). Oxford textbook of palliative medicine.3rd ed.Oxford: Oxford University Press; 2005. p. 459–467.
26.
26 Sirota RA Kimmel PL Trichtinger MD Diamond BF Stein HD Yudis M . Metoclopramide-induced parkinsonism in hemodialysis patients. Report of two cases. Arch Intern Med1986; 146: 2070–2071.
27.
27 May G Kumar R . Best evidence topic report. Use of intravenous cyclizine in cardiac chest pain. Emerg Med J2006; 23: 61–62.
28.
28 Kirvela M . Ali-Melkkila, t, Iisalo, E, Lindgren, L. Pharmacokinetics of Glycoyrronium in uraemic patients. Br J Anaesth1993; 71: 437–439.
29.
29 Ali-Melkkila T Kanto J Iisalo E . Pharmacokinetics and related pharmacodynamics of anticholinergic drugs. Acta Anaesthesiol Scand1993; 37: 633–642.
30.
30 Bauer TM Ritz R Haberthur C Ha HR Hunkeler W Sleight AJ . Prolonged sedation due to accumulation of conjugated metabolites of midazolam. Lancet1995; 346: 145–147.
31.
31 Hanks GW Conno F Cherny N Hanna M Kalso E McQuay HJ . Morphine and alternative opioids in cancer pain: the EAPC recommendations. Br J Cancer2001; 84: 587–593.
32.
32 Aitkenhead AR Vater M Achola K Cooper CM Smith G . Pharmacokinetics of single-dose i.v. morphine in normal volunteers and patients with end-stage renal failure. Br J Anaesth1984; 56: 813–819.
33.
33 Wolff J Bigler D Christensen CB Rasmussen SN Andersen HB Tonnesen KH . Influence of renal function on the elimination of morphine and morphine glucuronides. Eur J Clin Pharmacol1988; 34: 353–357.
34.
34 Sawe J Odar-Cederlof I . Kinetics of morphine in patients with renal failure. Eur J Clin Pharmacol1987; 32: 377–382.
35.
35 Angst MS Buhrer M Lotsch J . Insidious intoxication after morphine treatment in renal failure: delayed onset of morphine-6-glucuronide action. Anesthesiology2000; 92: 1473–1476.
36.
36 Bodd E Jacobsen D Lund E Ripel A Morland J Wiik-Larsen E . Morphine-6-glucuronide might mediate the prolonged opioid effect of morphine in acute renal failure. Hum Exp Toxicol1990; 9: 317–321.
37.
37 Conway BR Fogarty DG Nelson WE Doherty CC . Opiate toxicity in patients with renal failure. BMJ2006; 332: 345–346.
38.
38 D'Honneur G Gilton A Sandouk P Scherrmann JM Duvaldestin P . Plasma and cerebrospinal fluid concentrations of morphine and morphine glucuronides after oral morphine. The influence of renal failure. Anesthesiology1994; 81: 87–93.
39.
39 Dean M . Opioids in renal failure and dialysis patients. J Pain Symptom Manage2004; 28: 497–504.
40.
40 Mercadante S Arcuri E . Opioids and renal function. J Pain2004; 5: 2–19.
41.
41 Heiskanen T Kalso E . Controlled-release oxycodone and morphine in cancer related pain. Pain1997; 73: 37–45.
42.
42 Mucci-LoRusso P Berman BS Silberstein PT Citron ML Bressler L Weinstein SM . Controlled-release oxycodone compared with controlled-release morphine in the treatment of cancer pain: a randomized, double-blind, parallel-group study. Eur J Pain1998; 2: 239–249.
43.
43 Foral PA Ineck JR Nystrom KK . Oxycodone Accumulation in a Hemodialysis Patient. South Med J2007; 100: 212–214.
45 Broadbent A Khor K Heaney A . Palliation and chronic renal failure: opioid and other palliative medications - Dosage guidelines. Progress in Palliative Care.2003; 11: 183–190.
46.
46 Durnin C Hind ID Wickens MM Yates DB Molz KH . Pharmacokinetics of oral immediate-release hydromorphone (Dilaudid IR) in subjects with renal impairment. Proc West Pharmacol Soc2001; 44: 81–82.
47.
47 Babul N Darke AC Hagen N . Hydromorphone metabolite accumulation in renal failure. J Pain Symptom Manage1995; 10: 184–186.
48.
48 Lee MA Leng ME Tiernan EJ . Retrospective study of the use of hydromorphone in palliative care patients with normal and abnormal urea and creatinine. Palliat Med2001; 15: 26–34.
49.
49 Paix A Coleman A Lees J Grigson J Brooksbank M Thorne D . Subcutaneous fentanyl and sufentanil infusion substitution for morphine intolerance in cancer pain management. Pain1995; 63: 263–269.
50.
50 Davies G Kingswood C Street M . Pharmacokinetics of opioids in renal dysfunction. Clin Pharmacokinet1996; 31: 410–422.
51.
51 Coral IM Moore AR Strunin L . Plasma concentrations of fentanyl in normal surgical patients with severe renal failure. Br J Anaesth1980; 52: 101P.
52.
52 Labroo RB Paine MF Thummel KE Kharasch ED . Fentanyl metabolism by human hepatic and intestinal cytochrome P450 3A4: implications for interindividual variability in disposition, efficacy, and drug interactions. Drug Metab Dispos1997; 25: 1072–1080.
53.
53 Koehntop DE Rodman JH . Fentanyl pharmacokinetics in patients undergoing renal transplantation. Pharmacotherapy1997; 17: 746–752.
54.
54 Alazia M Levron JC . [Pharmacokinetic study of prolonged infusion of fentanyl in intensive care] Ann Fr Anesth Reanim1987; 6: 465–466.
55.
55 Bower S Hull CJ . Comparative pharmacokinetics of fentanyl and alfentanil. Br J Anaesth1982; 54: 871–877.
56.
56 Meuldermans W Van Peer A Hendrickx J Woestenborghs R Lauwers W Heykants J . Alfentanil pharmacokinetics and metabolism in humans. Anesthesiology1988; 69: 527–534.
57.
57 Bower S Sear JW . Disposition of alfentanil in patients receiving a renal transplant. J Pharm Pharmacol1989; 41: 654–657.
58.
58 Chauvin M Lebrault C Levron JC Duvaldestin P . Pharmacokinetics of alfentanil in chronic renal failure. Anesth Analg1987; 66: 53–56.
59.
60.
60 Ansell D Roderick P Hodsman A Steenkamp R Tomson C . Survival of incident and prevalent patients. In: D Ansell J Feehally TG Feest C Tomson AJ Williams G Warwick , (eds), UK Renal Registry Report 2007.Bristol, UK: UK Renal Registry. 2007. p. 93–119. [chapter 6]
