Written by: Dr. Raymond Cruz
Kidney disease, and its subsequent development of End Stage Renal Disease (ESRD), is the 7th leading cause of death among Filipinos, according to a 2018 study by the National Kidney and Transplant Institute (NKTI). Every hour, one Filipino is said to be diagnosed with the disease. At present, more than 5,000 Filipino patients are presently undergoing dialysis. Worldwide, more than a million people are undergoing renal replacement therapy.
At present, more than 5,000 Filipino patients are presently undergoing dialysis.
Diabetes Mellitus and Hypertension are the most common causes of ESRD, accounting for almost 60% of dialysis patients. With around 7 million Filipinos diagnosed with diabetes and around 12 million having high blood pressure, there is a need to prevent the deterioration of these patients to avoid renal failure in the long run.
With hemodialysis costs at around 3,500 per session, done 3 times a week, the process becomes out of reach for ordinary Filipinos. A shortage of donors also makes it difficult to do kidney transplantation. Thus, prevention is important to avoid financial challenges associated with treatment.
For those with ESRD, Advance Care Planning should take place prior to consideration of stopping dialysis. Median survival after renal dialysis withdrawal is 9 days. Causes of deterioration include elevated blood calcium levels, infection, and opioid toxicity.
All patients with ESRD should have medications for symptom control. Anti-anxiety drugs such as Midazolam and anti-secretory medications such as Hyoscine Butylbromide may also be given subcutaneously to limit fluid overload. Paracetamol is usually given for pain control, and Levomepromazine is administered for vomiting. Opioids should be given cautiously, if at all.
Agitation is common, so one may seek specialist help if this becomes an issue. Suctioning of secretions may also need to be considered as a cause of agitation. A common symptom is anemia, which could be addressed by injected medications for increasing the red blood cell count, or through blood transfusion.
When kidney failure decline is rapid, planning regarding the patient’s wishes and potential care at home is vital. Supportive measures for comfort care must be in place. Because drowsiness and confusion are common, there is a need to counsel family members and caregivers on the approach to these symptoms.
As someone with kidney failure approaches the end of life, decisions should be made with the person.
Managing symptoms for someone with kidney failure can be challenging. Some of the medicines used to treat symptoms can cause further damage to the kidneys. It’s important to for a palliative care team to be readily available to make sure that management is tailor-fit for the patient’s case. As someone with kidney failure approaches the end of life, decisions should be made with the person. Significant others must work closely with professionals when complications ensue.
Palliative care is holistic, providing for the physical, social, psychological and spiritual needs of the person and those important to them. Patient education is associated with better patient outcomes, but there are barriers to its widespread practice. Obstacles include the complex nature of kidney disease information, low awareness, limited health literacy, and lack of readiness to learn. For providers, there is lack of time and clinical confidence to do counselling, particularly when a patient becomes agitated.
The most important aspect of end-of-life management is to maintain quality of life.
Education efficiency may be increased by establishing an interdisciplinary care management team. This includes community health workers providing education in group settings. At The Ruth Foundation, new educational approaches are being undertaken together with quality improvement efforts. Barriers to evaluating public awareness and patient education programs inhibit the identification of successful strategies for broader implementation. However, growing interest in improving patient-centered outcomes may provide new approaches to effective education of people with ESRD.
The most important aspect of end-of-life management is to maintain quality of life. Though life could no longer be prolonged, family members and care givers can work hand in hand to make sure that the last days will be memorable. And when the time comes, what should be remembered are pleasant recollections of a life well-lived.
REFERENCES:
Brown, E., Chambers E.J. and Eggeling, C. 2007. End of Life Care in Nephrology: From Advanced Disease to Bereavement. Oxford: Oxford University Press.
Bunn R. and Ashley C. 2008. The renal drug handbook. 3rd ed. Oxford: Radcliffe Medical Press
Chambers E.J., Germain, M. and Brown, E., Eds., 2004. Supportive care for the renal patient Oxford: Oxford University Press.
Dean, M. 2004. Opioids in renal failure and dialysis patients. Journal of Pain and Symptom Management, 28(5), pp. 497-504.
Douglas, C., Murtagh, F. E. M., Chambers, E. J., Howse, M. and Ellershaw, J. 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. Palliative Medicine, 23(2), pp. 103-110.