Supportive care for renal patients

Supportive Care for Renal Patients
With Established Renal Failure
Information for GPs & District Nurses Richard Bright Renal Unit Version 3
Southmead Hospital May 2008
Westbury-on-Trym Supportive Care Group
BS10 5NB

Part II of the Renal National Service Framework (2005) recognises that some patients will
decide not to undergo dialysis treatment and will instead receive non-dialytic or supportive
therapy. In this leaflet we aim to provide information on established renal failure and the
management of symptoms associated with it. The final section provides guidance on end of
life care.
What is Established Renal Failure (ERF)?
Chronic kidney disease means that both kidneys have been damaged irreversibly. The chemical
waste products and toxins that are normally removed by the kidneys build up in the blood
causing the symptoms of kidney failure. At very low levels of kidney function (usually less
than 10% of normal) dialysis or kidney transplantation is required to relieve symptoms and to
preserve life. This level of kidney function is known as established renal failure (ERF)
For people with ERF, dialysis treatment is usually life saving, improving symptoms and quality
of life. However, the treatment is demanding and time-consuming and it is often necessary for
the patient to make lasting lifestyle changes. These changes include modification to diet and
fluid intake. Patients who choose to have haemodialysis usually begin by attending the main
unit at Southmead Hospital before transferring to a satellite unit nearer to their home for
haemodialysis treatment three times per week. Understandably, these changes and demands can
prove a physical and psychological burden to the patient and their family/carers.
Dialysis treatment only replaces some functions of the kidney. It cannot reverse the effects of
the patient’s other co-morbid conditions and in some cases may not improve the patient’s
quality of life. In such situations it is important for all concerned to have a clear view of the
likely advantages and disadvantages of undertaking dialysis treatment. This should take
account of the patient’s particular problems, circumstances and concerns. Reaching this point
usually involves a good deal of discussion over a period of time between the patient, their
relatives and carers and the renal team at Southmead.
If dialysis is not started, established renal failure will eventually lead to death.
Supportive care for renal patients recognises that:
• Patients with multiple co-morbidities may not benefit from dialysis
• Patients may choose not to have dialysis
• Some patients may choose to stop dialysis and wish to die at home
• These patients should be on the GP practice’s supportive care register
As stated in the Renal NSF a ‘no-dialysis’ option is not a ‘no treatment’ option.
The patient and their family will receive continued support from the renal multidisciplinary
team working in conjunction with yourselves and social workers as appropriate and where
needed specialist palliative care. The patient will receive symptom management including
treatment of anaemia with erythropoietin and optimisation of the management of co-morbid
conditions to improve quality of life.

Recognising the Pre terminal phase and end of life care

The symptoms associated with ERF vary. Symptoms such as nausea and vomiting, anorexia,
insomnia, anxiety, depression and lethargy with decreasing performance status may be present
for months. Severe symptoms usually only arise within the last two weeks of life.
Introducing palliative care at an early stage for those patients who have chosen not to have
dialysis can result in better symptom control and can help the passage into end of life care.
Discussion early in the course of disease about a person’s wishes for end of life care should aid
in decision making and should be recorded to help all those involved in the patient’s care know
what the wishes are for an individual.
Symptoms patients may experience
There are a variety of symptoms that patients with ERF may experience. Attached is some
information regarding these symptoms and suggested treatment options both in the pre-terminal
phase and later in the days leading up to the patient’s death.
If you find symptom control difficult please get further advice from your local Palliative Care
Ongoing support from the renal team

Patients whose end-stage renal disease is being managed without dialysis or transplantation will
usually remain under the care of a renal physician and attend outpatient clinics. The renal
education and renal community team will support them and will plan to visit them at home and
liaise with the patient’s general practitioner and district nurse team. Joint home visits maybe
undertaken where appropriate.

Useful Telephone Numbers

Renal Outpatients


Supportive Care for the Renal Patient (2004) Edited by Chambers, Germain and Brown
OUP ISBN 0198516169
Renal National Service Framework Part II. (2005) D.O.H.
Possible Causes
If usual anti emetics ineffective try levomepromazine 6mg once daily increasing to tds (higher doses may cause drowsiness). If vomiting 5mg sc stat. Decreased production by the kidneys of the Weekly/fortnightly injections of EPO (sc) (‘Aranesp’ or Darbepoetin alfa) usually hormone erythropoietin (EPO) which stimulates the bone marrow to produce red blood cells. Iron supplementation may also be necessary (usually iv). Aim for haemoglobin 10.5-12.5 g/dl High dose diuretic i.e. frusemide 80-500mg per day, higher doses divided morning Correct acidosis with sodium bicarbonate 1.2g tds po Antihistamine e.g. Chlorphenamine, Hydroxyzine (at night) Small, regular meals of whatever patients likes. Advice from renal dietitians. Reassurance to family re patients decreased appetite. Specific cause unknown, common in renal failure. Clonazepam 500 micrograms p.o. nocte Levodopa 62.5mg (Madopar) p.o. nocte Tonic Water Quinine Sulphate 200-300mg p.o. nocte Problem/Symptom
Possible Causes
Uraemia, medication, exclude oral thrush Stimulate saliva Chewing gum, boiled sweets Artificial saliva (Pig origin) – Saliva Orthana Review medication Manage insomnia / sleep hygiene Night sedation e.g. Zopiclone 3.75mg 1-2 nocte (Advise intermittent use) Treat depression. Where appropriate provide spiritual support. Psychological interventions & or anti depressant medication. Reduced dietary and fluid intake / Immobility / Senna 2-4 tablets bd Sodium docusate 100mg bd up to 500mg/24hrs Movicol 1-2 sachets daily, depending on result/frequency of bowel action. Psycho sexual counselling / Review need for medication Pain is not usually a symptom in ERF but often Refer to WHO analgesic ladder modified for ERF patients All steps: Adjuvants as indicated by type of pain see over Problem/Symptom
Possible Causes
Barriers to good pain control
Multiple co-morbidities and multiple drug regimes Hydromorphone 1.3 mg p.o. 1 hourly prn care with >4 doses/24hrs Hydromorphone 1.3 mg p.o. 4-6 hourly and 1.3mg p.o. 1 hourly prn for break through pain. Possible repeated doses over several days may lead to toxicity (drowsiness, myoclonic jerks) warn patient; therefore if on a regular strong opioid i.e >4 X 1.3mg hydromorphone doses daily, consider off loading background dose to a 12mcg/hr Fentanyl patch and continue with prn. Continue to titrate using hydromorphone 1.3mg 1 hourly. If > TD fentanyl dose > 50 micrograms/hr. may need to increase the prn dose of hydromorphone as background dose increases. Subcutaneous Route – Intermittent Pain Fentanyl 12.5mcg-25mcg s/c as needed up to 1 hourly After 24 hours, review medication, if two or more PRN doses or patient still in pain set up syringe driver to run over 24 hours as below. Subcutaneous Route – Continuous Pain Start continuous subcutaneous infusion in syringe driver with fentanyl Starting dose depends on size, age and severity of pain 150-300mcg/24hrs fentanyl is a possible starting dose with PRN medication S/C Fentanyl 1/10 to 1.6 of 24hr dose Adjuvant Drugs Clonazepam useful adjuvant for neuropathic pain in ERF 500mcg PO or S/C 12 hourly, maximum dose 1mg in 24hrs. Amitripyline: start low and titrate slowly or gabapentin (dose modified according to eGFR) NSAID: Consider selective CoxII inhibitors, as there is increased risk of GI toxicity in patients with ERF. NSAID should not be used in patients who are not being dialysed as may actively worsen renal function except where this only means of symptom control and discussed with pt, family or renal team.


Case 1:12-cv-00595-UNA Document 1 Filed 05/14/12 Page 1 of 15 PageID #: 1__________________________________________ __________________________________________) COMPLAINT Plaintiff Novartis Pharmaceuticals Corporation (“Novartis”), by its undersigned attorneys, brings this action against Defendants Lupin Ltd. and Lupin Pharmaceuticals, Inc. (“Lupin Inc.”; collectively “Lupin”).

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Adam Scott Levine, M.D., J.D. Personal Data: Education: Stetson University Col ege of Law, J.D. conferred cum laude December 2009 Johns Hopkins University School of Medicine, Department of Obstetrics and Gynecology Division of Reproductive Endocrinology and Infertility, Fel owship in Reproductive Endocrinology 1996 - 1998 Medical University of South Carolina, Residency in Obs

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