End-stage renal disease: symptom management and advance care planning

The prevalence of end-stage renal disease continues to increase, and dialysis is offered to older and more medically complex patients. Pain is problematic in up to one-half of patients receiving dialysis and may result from renal and nonrenal etiologies. Opioids can be prescribed safely, but the patient's renal function must be considered when selecting a drug and when determining the dosage. Fentanyl and methadone are considered the safest opioids for use in patients with end-stage renal disease. Nonpain symptoms are common and affect quality of life. Phosphate binders, ondansetron, and naltrexone can be helpful for pruritus. Fatigue can be managed with treatment of anemia and optimization of dialysis, but persistent fatigue should prompt screening for depression. Ondansetron, metoclopramide, and haloperidol are effective for uremia-associated nausea. Nondialytic management may be preferable to dialysis initiation in older patients and in those with additional life-limiting illnesses, and may not significantly decrease life expectancy. Delaying dialysis initiation is also an option. Patients with end-stage renal disease should have advance directives, including documentation of situations in which they would no longer want dialysis.     

How do we optimize the management of chronic renal failure?]

Optimization of the management of chronic renal failure (CRF) is aimed at decreasing morbidity and mortality risks of CRF patients, due to the progression of CRF toward end-stage renal disease (ESRD), and to CRF-related complications with functional or life-threatening consequences. The so-called spontaneous progression of CRF toward ESRD depends on factors related to the primary renal disease, and on non-specific factors mainly related to hypertension and renal functional adaptations to nephron loss. Secondary prevention of CRF needs: early identification of primary renal disease, in order to start specific therapies; the treatment of hypertension; dietary advice on protein intake; prevention of events and drug toxicity potentially harmful to renal function. Clinical events appear late in the course of CRF, following several disorders often present for a long time: hypertension, dyslipidemia, phosphocalcic disorders, anaemia, malnutrition). These disorders should be screened for, and treated, as a part of tertiary prevention measures. When dialysis becomes unavoidable, early information and medical preparation of the patient are mandatory, giving the best chances of success to the applied dialysis method. Unfortunately, most CRF patients are referred at a late stage of the disease, when the effects of therapeutic interventions are limited; this results in increased length of hospital stays, increased risk of early dialysis complications, and decreased capacity to be treated at home.     

PHARMACOKINETICS OF FLECAINIDE IN A PATIENT UNDERGOING CONTINUOUS AMBULATORY PERITONEAL DIALYSIS

The disposition of flecainide was studied in a 60-year-old, 92 kg man, who was being administered flecainide to control ventricular arrhythmias. The patient was also being treated with continuous ambulatory peritoneal dialysis (CAPD) for end-stage renal disease. The patient was given two single doses of 100 mg and 200 mg of flecainide 1 week apart. Serum, dialysate and urine samples were collected at appropriate times. Areas under the serum concentration-time curves were used to calculate total body clearance, renal clearance and CAPD clearance. The values obtained were 56.6 ml/min, 6.2 ml/min and 2.2 ml/min, respectively. The percentage of a given dose of flecainide removed in 24 h by residual renal function and by CAPD was 4.7% and 1.1% respectively. It is suggested that the dosage reduction required for patients taking flecainide during CAPD should be similar to that for patients with end-stage renal disease but not on dialysis. No dosage change is required during CAPD.     

Pregnancy in end-stage renal disease patients and treatment with peritoneal dialysis: report of two cases.

Pregnancy in end-stage renal disease patients is infrequent and is associated with fetal loss, premature delivery, intrauterine growth restriction, and lack of control of or exacerbation of or onset of hypertension. Even after replacement of renal function, the prognosis for the patient and the fetus is poor. A point of controversy is the renal replacement therapy method. This report is based on two clinical cases of pregnancy in peritoneal dialysis patients that resulted in full-term delivery. Adequate metabolic and blood pressure control was achieved during pregnancy, the only mutual complication being the presence of polyhydramnios. However, both infants were healthy for their gestational age and without neonatal complications. We may conclude that peritoneal dialysis is an acceptable therapeutic option for pregnant patients and their fetuses.     

Prognosis curves for patients with polycystic kidney disease

In patients with polycystic kidney disease and in many patients with other chronic renal diseases kidney function decreases from year to year. When the increase in serum creatinine concentration is followed graphically, the time for dialysis/transplantation can be predicted long beforehand. Based on the course of azotaemia in 34 patients with polycystic disease prognosis curves have been prepared. By comparing the course of a patient with the average course of similar patients, additional information can be gained. A statistical method for making a prognosis curve for kidney function in end-stage polycystic renal disease is described.     

Recurrent Torsades de Pointes After Sotalol Therapy for Symptomatic Paroxysmal Atrial Fibrillation in a Patient with End-Stage Renal Disease

BACKGROUND: In recent years there has been ain increase in the use of class III antiarrhythmic drugs such as sotalol, amiodarone, and the so-called pure class III compound for the control of cardiac arrhythmias. It appears there has been a corresponding increase in the frequency of torsades de pointes (TdP). METHODS AND RESULTS: The case reported here, a patient on daily renal dialysis for end-stage renal disease, has important implications for class III agents, which are excreted largely by the kidneys. A relatively low dose of sotalol administered for the prevention of recurrences of atrial fabrillation, with a fast ventricular response producing angina, led to modest increases in the QT interval and moderate bradycardia. This culminated in the development of TdP, which deteriorated into ventricular fibrillation, from which the patient could be resuscitated with considerable difficulty. Dialysis after the occurrence of TdP led to further and striking prolongation of the QT interval associated with numerous episodes of TdP for several days before control was achieved. The atrial fibrillation and recurrences of TdP were eventually controlled with oral amiodarone. CONCLUSIONS: This case emphasizes that in the absence of significant renal function, use of sotalol may not be safe because drug accumulation may not be controlled adequately with renal dialysis. In view of this, in patients with end-stage renal disease, the use of sotalol for arrhythmia control appears contraindicated and alternative agents, the excretion of which does not occur by the renal route, should be used.     

Chronic dialysis in patients with multiple myeloma and renal failure: a worthwhile treatment

Severe renal failure is a life-threatening complication of multiple myeloma. Aggressive treatment can reverse acute renal failure in many cases but the prognosis for those who require chronic renal replacement therapy is not clear. We have reviewed the treatment of these patients in the Brighton, Dulwich and Guy's Hospitals renal units. Twenty-three patients were treated for a total of 385 months. Over half presented with end-stage renal failure and required dialysis immediately. Fifteen patients died during the study period and actuarial survival was 45 per cent at one year; six have survived for longer than two years. No prognostic features at presentation were identified but those who responded to chemotherapy survived significantly longer than those who did not. Haemodialysis and continuous ambulatory peritoneal dialysis (CAPD) appeared to be equally effective treatments. Complications from dialysis were more common than in patients with renal failure from other causes. Infection in those treated by CAPD was a serious problem and may be exacerbated by aggressive chemotherapy. Maintenance dialysis offers some patients with multiple myeloma long-term survival and should be offered to all patients who are considered to warrant continuing treatment for their underlying disease.     

Aluminum, iron, lead, cadmium, copper, zinc, chromium, magnesium, strontium, and calcium content in bone of end-stage renal failure patients.

BACKGROUND: Little is known about trace metal alterations in the bones of dialysis patients or whether particular types of renal osteodystrophy are associated with either increased or decreased skeletal concentrations of trace elements. Because these patients are at risk for alterations of trace elements as well as for morbidity from skeletal disorders, we measured trace elements in bone of patients with end-stage renal disease. METHODS: We analyzed bone biopsies of 100 end-stage renal failure patients enrolled in a hemodialysis program. The trace metal contents of bone biopsies with histological features of either osteomalacia, adynamic bone disease, mixed lesion, normal histology, or hyperparathyroidism were compared with each other and with the trace metal contents of bone of subjects with normal renal function. Trace metals were measured by atomic absorption spectrometry. RESULTS: The concentrations of aluminum, chromium, and cadmium were increased in bone of end-stage renal failure patients. Comparing the trace metal/calcium ratio, significantly higher values were found for the bone chromium/calcium, aluminum/calcium, zinc/calcium, magnesium/calcium, and strontium/calcium ratios. Among types of renal osteodystrophy, increased bone aluminum, lead, and strontium concentrations and strontium/calcium and aluminum/calcium ratios were found in dialysis patients with osteomalacia vs the other types of renal osteodystrophy considered as one group. Moreover, the concentrations of several trace elements in bone were significantly correlated with each other. Bone aluminum was correlated with the time on dialysis, whereas bone iron, aluminum, magnesium, and strontium tended to be associated with patient age. Bone trace metal concentrations did not depend on vitamin D intake nor on the patients' gender. CONCLUSIONS: The concentration of several trace elements in bone of end-stage renal failure patients is disturbed, and some of the trace metals under study might share pathways of absorption, distribution, and accumulation. The clinical significance of the increased/decreased concentrations of several trace elements other than aluminum in bone of dialysis patients deserves further investigation.     

Outcomes of atherosclerotic renal artery stenosis managed without revascularization

OBJECTIVE: To determine how often patients with renal artery stenosis (RAS) managed without revascularization progress to accelerated hypertension and/or renal failure. PATIENTS AND METHODS: We examined the outcomes of 68 patients (mean +/- SEM age, 71.8 +/- 0.9 years) with high-grade (>70%) RAS identified between 1989 and 1993 who were treated without renal revascularization for at least 6 months after angiography. The time to last follow-up averaged 38.9 +/- 2.8 months. Other vascular beds were affected in 66 of the 68 patients. End points were revascularization, nephrectomy, dialysis, or death. RESULTS: The mean +/- SEM serum creatinine level rose from 1.4 +/- 0.1 to 2.0 +/- 0.2 mg/dL (P<.001). Mean +/- SEM blood pressure did not change (157 +/- 3/83+/-2 vs 155 +/- 3/79 +/- 2 mm Hg), but the need (mean +/- SEM) for medication increased from 1.6+/-0.1 to 1.9+/-0.1 drugs (P=.02). Four patients (5.8%) eventually underwent renal revascularization for refractory hypertension (1 patient), for progressive stenosis (1 patient), and during aortic reconstruction (2 patients). One additional patient underwent nephrectomy to improve blood pressure control. Five others (7.4%) developed end-stage renal disease (ESRD) for reasons other than progressive vascular disease, namely, diabetes (3 patients), atheroemboli (1 patient), and contrast toxicity without RAS progression (1 patient). In 1 further case, the reason for ESRD was unknown, and it may have been caused by vascular occlusion. During follow-up, 19 patients died of unrelated causes, including myocardial infarction and stroke. CONCLUSIONS: These data indicate that antihypertensive medication requirements increased and renal function deteriorated modestly in a subset of patients with atherosclerotic RAS managed initially without vascular intervention. Many achieved stable blood pressure for many years. Deterioration of renal function and mortality risk were greatest in patients with bilateral stenosis or stenosis to a solitary functioning kidney. These results reinforce the need for meticulous follow-up for disease progression but underscore the role of competing risks and high mortality from other cardiovascular diseases, which primarily determine the outcomes in patients with RAS and widespread atherosclerotic disease.     

日间小剂量递增腹膜透析在终末期肾病患者的应用研究

目的：研究并探讨终末期肾病患者非卧床腹膜透析不同透析模式的临床疗效。方法通过对终末期肾病腹膜透析患者残肾功能较好的患者采取不同的透析模式,将患者随机分为两组：日间小剂量递增组（26例）,透析液总量每日4.5～8 L,夜间不留腹;持续标准透析剂量组（24例）,每日透析液量8 L,夜间留腹,比较两组研究开始与终点的营养指标、血生化指标、透析充分性、残肾功能、胱抑素 C。结果两组患者至观察终点血浆白蛋白、24 h尿量、残肾功能、胱抑素C比较差异有统计学意义（P＜0.05）。两组血K＋、血P3＋、二氧化碳结合力（CO2CP）、24 h超滤量、透析充分性指标每周总尿素氮清除率（Kt/V）、每周总肌苷清除率（Ccr）,比较差异无统计学意义（P＞0.05）,两组置管后1个月内导管堵管、渗漏发生率比较差异无统计学意义（P＞0.05）。两组的每日透析液总量和透析时间均有统计学差异（P＜0.05）。结论（1）残肾功能较好的终末期肾病患者,置管后早期采用日间小剂量递增式腹膜透析可使患者尽早得到治疗,并且不增加早期导管堵管与渗漏;（2）初期应用小剂量递增式腹膜透析可减少残肾功能的丢失,并维持相对较好的营养状况。（3）与持续标准剂量组比较,小剂量递增式腹膜透析可减少腹膜透析初期透析液的用量。     

Chronic peritoneal dialysis in the elderly: a review.

During the past few decades, the pattern of end-stage renal disease has changed significantly with the emerging predominance of elderly patients. Because this heterogeneous population is characterized by a physiological decline in function of all organs, the nephrologist must contemplate the special needs of individual patients when they develop end-stage renal disease. Before the initiation of dialysis, these patients must be given detailed information to help them select the particular mode that will maximize their quality of life. According to available data, peritoneal dialysis offers some advantages for elderly patients, such as hemodynamic stability, steady-state metabolic control, good control of hypertension, independence from hospital, and avoidance of repeated vascular access. Early referral promotes the establishment of peritoneal access and minimizes the consequences of uremia, subsequent morbidity, and frequent hospitalization. Elderly patients are compliant and highly motivated to cooperate with their treatment. They have no higher modality-related complications than younger patients and their quality of life is satisfactory. Although most have comorbid conditions that interfere with self-performance of dialysis, such as impaired vision and reduced physical and mental activity, they can perform peritoneal dialysis successfully if they have a high level of family support. Patients who do not have family support may have successful peritoneal dialysis if they have access to a network of medical and social support, that is, private home nurses, rehabilitation and chronic care dialysis units, or nursing homes.     

Rehabilitation, aging and chronic renal disease.

Restorative management of the disabled elderly requires knowledge about realistic functional expectations, in addition to knowledge about a patient's particular disease. Health outlook, especially sense of control, should also be assessed because rehabilitation depends on the patient's active participation. A comparison of 349 older end-stage renal disease (ESRD) patients on chronic dialysis and 354 similar-age persons selected as a control group showed that significantly compromised physical function and health outlook were reported by the dialysis patients compared with the control group. Increasing exercise capacity and participation in dialysis self-care activity are recommended ways to improve physical functioning and health outlook among ESRD patients. Individuals who cannot perform strenuous activity can improve in level of fitness; improvements in anemia and muscle strength are key variables. Clinical application of therapeutic and rehabilitative strategies to improve physical function and health outlook in the geriatric renal patient is greatly needed.     

血液透析联合腹膜透析治疗终末期肾病的临床体会

目的 比较血液透析联合腹膜透析与单纯血液透析治疗终末期肾病的疗效。方法 对采用血液透析联合腹膜透析方式与单纯血液透析治疗终末期肾病的患者各9例者进行对照分析，观察两组患者透析前后血液生化指标及透析后主要并发症。结果 采用联合透析后血液中白蛋白、甲状旁腺激素（iPTH）含量较单纯血液（HD组）透析后明显降低（P<0.05），而血红蛋白含量较HD组高（P<0.05）;所观察的各项并发症的出现机会在联合透析组也明显低于单纯血液透析。结论 具备血透和腹透两种通路的终末期肾病患者采用联合方式透析比单纯血液透析治疗更具优越性。     

Survivors of acute renal failure who do not recover renal function

Overall survival in 1095 with severe acute renal failure (ARF) between 1984 and 1995 was 59.5%. Of these, 107 (16.2%) remained dependent on long-term dialysis. The frequency of end-stage renal failure (ESRF) in survivors of ARF varied between 3% and 41% according to the cause of ARF, being highest in those with acute renal parenchymal disease (in whom survival was also among the highest at 84%) and lowest in ARF due to obstetrics and trauma. Patients failing to regain adequate renal function did not appear to differ on clinical grounds from survivors who became dialysis-independent. Survival in those requiring long-term dialysis was less good than for other patients with ESRF, partly due to excess mortality in those for whom vascular disease or surgery was the precipitating cause of ARF. Six patients recovered sufficient renal function to become independent of dialysis after 3-18 months on regular dialysis therapy (6-21 months after onset of ARF). ESRF resulting from ARF is more frequent than previously reported. This increase may be due to a changing case-mix, increasing age of patients (and hence reduced capacity for renal recovery), and an increase in aggressive surgery for patients with advanced vascular disease. This presents a significant and increasing problem, with implications for both clinical management and the provision of dialysis services.      

Pharmacokinetics of linezolid in subjects with renal dysfunction

Linezolid is a member of a new, unique class of synthetic antibacterial agents called oxazolidinones that are effective against gram-positive bacteria, including vancomycin-resistant organisms. We tested the hypothesis that the linezolid clearance would not be altered in subjects with renal dysfunction. Twenty-four subjects with renal function that ranged from normal to severe chronic impairment were enrolled, including patients with end-stage renal disease who were maintained on hemodialysis. Hemodialysis subjects were studied while they were both on and off dialysis. Linezolid was administered as a single oral 600-mg dose, and plasma and urine samples were assayed for linezolid and metabolites for 48 h for all subjects and for up to 96 h for those subjects with impaired renal function not on dialysis. The total apparent oral clearance of linezolid did not change with renal function and ranged from 92.5 to 109.6 ml/min for subjects not requiring dialysis. For subjects on dialysis, the total apparent oral clearance increased from 76.6 ml/min on their off-dialysis day to 130.0 ml/min on their on-dialysis day. Approximately one-third of the dose was removed by dialysis. However, those subjects with severe renal insufficiency (creatinine clearance, <40 ml/min) and those with end-stage renal disease maintained on hemodialysis had higher concentrations of both metabolites. We conclude that no adjustment of the linezolid dosage is needed in subjects with renal dysfunction or subjects on hemodialysis.     

Predialysis patient education: effects on functioning and well-being in uraemic patients

This study evaluated the effects of a predialysis patient education programme on functioning and well-being in 28 uraemic patients. The programme consisted of four group sessions with the following themes: renal disease and dietary restriction, active renal replacement therapy, physical exercise, and the impact of chronic renal failure on economy, family and social life. Three to 9 months after having started dialysis the patients were evaluated regarding symptoms, perceived health (Health Index), functional (SIP) and emotional (STAI) status. Twenty-eight patients already on dialysis treatment informed according to conventional routines constituted the comparison group. There were no significant differences between the groups regarding age, sex, educational or social background, duration of kidney disease, choice of dialysis treatment, cause of renal disease and laboratory tests except for s-urea. The patients who participated in the education programme scored significantly better mood, less mobility problems (HI), less functional disabilities (SIP) and lower levels of anxiety (STAI) compared to the comparison group. There were no significant differences between the two groups regarding symptoms and overall health. The differences between the groups prevailed during the first 6 months on dialysis treatment, after which the differences disappeared. In the comparison group age correlated significantly to anxiety and overall SIP, which was not the case in the experimental group. In conclusion, the experimental group that participated in a predialysis patient education programme, showed better functional and emotional well-being than the non-educated comparison group. The positive effects of participating in an education programme prevailed during the first 6 months of dialysis treatment. Moreover, the younger patients seemed especially to benefit from participation in a predialysis patient education programme. It is suggested that patient education should be ongoing for patients with end-stage renal failure initiated during the predialysis stage and continued after maintenance dialysis has been established.     

Percutaneous transluminal angioplasty improves blood pressure and renal function in renovascular hypertension

Thirty-three patients with renal angiographic evidence of significant renal artery stenosis were referred for percutaneous transluminal angioplasty. The indications were poorly controlled hypertension (n = 13) or hypertension associated with deteriorating renal function (n = 20). Their mean age was 56 (23-73) years (12 males, 21 females). Causes of the renal artery stenosis were fibromuscular dysplasia (n = 8) and atheromatous changes (n = 25). Four patients were excluded, three due to technical failure. Forty-five angioplasties were performed in 29 patients with a mean observation period after angioplasty of 18 (one to 60) months. During this period eight patients (28 per cent) had a diastolic blood pressure of less than 90 mmHg without antihypertensive drugs, a further 15 patients (52 per cent) had improved blood pressure control with a significant reduction in the number and amount of antihypertensive drugs, but six patients (20 per cent) showed no improvement in blood pressure. Hypertension associated with the stenosis of fibromuscular dysplasia responded better to angioplasty than hypertension associated with atheromatous renal artery stenosis. Improvement in renal function was noted in eight patients with no change in 16 patients. Two patients with end-stage renal failure and atheromatous intrarenal vascular disease became dialysis dependent within four weeks of the procedure. One major and four minor complications occurred but there were no deaths related to angioplasty. Together with results from other centres this study indicates that percutaneous transluminal angioplasty should be considered the initial treatment choice for all patients with renovascular hypertension due to fibromuscular dysplasia and atheromatous renal artery stenosis.     

Supportive and palliative care for the patient with end-stage renal disease

As the numbers of patients presenting with end-stage renal disease (ESRD) increases, more are opting to withdraw from dialysis, often due to increased suffering and poor prognosis related to other comorbidities. Concurrently, other renal patients are deciding to forgo dialysis, recognizing that the burden of frequent dialysis may outweigh likely survival and quality-of-life benefits. Renal nursing is concerned with the health needs of individuals and their carers who are experiencing a progressive decline in renal function or who have lost renal function completely, and there is a focus on the provision of renal replacement therapy such as haemodialysis. As more patients decide to withdraw from, or not to embark on, dialysis, an enhanced approach to assessment and control of symptoms, as well as supportive management is required, including effective and high-quality palliative care. There is a necessity for renal nurses to change from disease management through interventions of a physiological nature to that of providing support and symptom management. This article discusses the supportive and palliative nursing care needs of a population largely unheard in the literature - patients with ESRD - and highlights the need for further patient and carer-centred research in this area.     

Chronic Dialysis in Patients with Multiple Myeloma and Renal Failure: A Worthwhile Treatment

Severe renal failure is a life-threatening complication of multiplemyeloma. Aggressive treatment can reverse acute renal failurein many cases but the prognosis for those who require chronicrenal replacement therapy is not clear. We have reviewed thetreatment of these patients in the Brighton, Dulwich and Guy'sHospitals renal units. Twenty-three patients were treated for a total of 385 months.Over half presented with end-stage renal failure and requireddialysis immediately. Fifteen patients died during the studyperiod and actuarial survival was 45 per cent at one year; sixhave survived for longer than two years. No prognostic featuresat presentation were identified but those who responded to chemotherapysurvived significantly longer than those who did not. Haemodialysisand continuous ambulatory peritoneal dialysis (CAPD) appearedto be equally effective treatments. Complications from dialysis were more common than in patientswith renal failure from other causes. Infection in those treatedby CAPD was a serious problem and may be exacerbated by aggressivechemotherapy. Maintenance dialysis offers some patients with multiple myelomalong-term survival and should be offered to all patients whoare considered to warrant continuing treatment for their underlyingdisease.     

Kidney transplantation: state of the art

Despite ever-improving health care and new advances in medical technology, the number of Americans who develop end-stage renal disease continues to increase. Diabetes remains the leading cause of new cases, followed by hypertension and glomerulonephritis. More than 200,000 patients require dialysis and more than 40,000 are awaiting kidneys for transplantation. Kidney transplantation has been extremely successful with 1-year patient and graft survival rates at 95% and 90%, respectively. The advantages of kidney transplantation are reversal of many of the pathophysiologic changes associated with renal failure as normal kidney function is restored, elimination of dependence on dialysis and the associated dietary restrictions, the opportunity to return to normal life activities, and lower medical costs than dialysis after the first year. The shortage of donor kidneys is the major limiting factor. Because of the supply and demand discrepancy, maximum use of donors from all sources, appropriate recipient selection, and equitable allocation are critical.