Symptom Management in ESKD
Patients with advanced CKD experience multiple symptoms that contribute to their disease burden [16] . These guidelines are compiled to assist healthcare providers in managing patients with symptoms associated with advanced CKD. Validated scoring tools The routine screening of physical and emotional symptoms is recommended at each consultation using a validated tool. Recommended tools include: In
Patients with advanced CKD experience multiple symptoms that contribute to their disease burden [16]. These guidelines are compiled to assist healthcare providers in managing patients with symptoms associated with advanced CKD.
Validated scoring tools
The routine screening of physical and emotional symptoms is recommended at each consultation using a validated tool. Recommended tools include:
- Integrated Palliative Care Renal Outcome Scale–Renal (IPOS–Renal) [17-19] (see Addendum 3).
- ESAS-r (Edmonton Symptom Assessment Systemrevised: Renal) [20] (see Addendum 4).
- Brief Pain Inventory [21] (see addendum 4).
The causes of a patient’s symptoms other than the kidney disease should always be considered.
Table 1 describes the management of common symptoms using a stepwise approach, utilizing medicines that are predominantly on the Essential Medicines List (EML). Adjusting the dose for renal function is important. The golden rule is start low and go slow, with frequent reassessment.
Table 1. Management of common symptoms of advanced CKD [16,22].
| Symptom & Prevalence | Likely causes | Non-pharmacological Management | Pharmacological (stepwise approach) Management |
| Nausea, vomiting, bitter taste and anorexia [16] 46% (9–90%) |
Metabolic acidosis Drugs (e.g. opiates) Constipation Delayed gastric emptying Uraemic toxins |
Exclude offending drug Small, frequent meals Avoid alcohol, greasy, spicy, sweet and bitter-tasting food and drinks Postprandial upright position Complementary therapies (ginger, relaxation, acupuncture, etc.) |
- Metoclopramide (low dose) 5–10 mg tds (oral, SC or IM) half-an-hour before meals. Start with 5 mg tds and titrate to maximal dose of 10 mg tds [23] - Haloperidol 0.5–1.5 mg/24 h CSCI/PO/ SC initiation dose. Max dose 5 mg/24 h. For occasional use dose unchanged, for regular use half the dose [23] Recommended but not on the EDL - * Ondansetron 4–8 mg tds (oral or SC/ IV) (caution: very constipating) |
| Constipation 8–65% |
Phosphate binders (calcium carbonate) |
Mild exercise Bulking agents like fibre are not recommended for patients using constipating medication or with decreased fluid/food intake or decreased activity |
- Lactulose syrup 15 mL po (daily, can increase to bd) - Liquid paraffin - Senokot 2 tab po nocte - Dulcolax (bisacodyl) 5–20 mg po nocte - Fleet enema PR (if constipation severe) |
| Depression and anxiety [16,24-29] 25–40% |
It is normal to feel sad when diagnosed with a life-threatening illness. However, when low mood is constant, depression needs to be excluded. |
Manage distressing symptoms: psychosocial and spiritual factors that can contribute to anxiety and low mood. Support groups or encourage support from family, peer groups, religious leaders and friends. Exercise improves mood and anxiety in CKD patients. |
- Citalopram 5–10 mg daily - Fluoxetine 10–20 mg daily - Sertraline 25 mg mane - Amitriptyline 10 mg nocte may also assist with sleep disturbance (titrate according to response up to 25 mg) - Lorazepam 0.5–1.0 mg sublingual or orally may be used for short-term relief of anxiety |
| Uraemic pruritis [16, 24-29] 41% (24% severe) |
Exacerbating factors Non-dermatological Anaemia Iron deficiency Dermatological Xerosis Drug related Contact dermatitis Infestation |
Appropriate skin care Bath in lukewarm water and use fragrance-free soap Pat dry Moisturize with aqueous emollients |
- Antihistamines have a very limited role. - * Pregabalin 25–75 mg (initiate at 25 mg nocte and titrate up slowly. ESKD on a conservative pathway, 25 mg on alternate nights) - UV-B light therapy may be beneficial in patients with refractory symptoms (may only be offered in tertiary centres) - Patients on dialysis: dialysis adequacy and calcium and phosphate balance should be addressed Recommended but not on the EDL - Capsaicin cream 0.025% - * Gabapentin 100–200 mg nocte (initiate 100 mg nocte alternate days and titrate up slowly. If the patient is on dialysis this should be given after dialysis) |
| Pain [18,30-32] No studies on long-term use of any analgesics in CKD 58% |
Determine cause: Exclude rheumatological: gout, rheumatoid arthritis, osteoarthritis Steal syndrome |
- Exercise, physiotherapy, massage, acupuncture or heat therapy - Behavioural therapy: cognitive behavioural therapy, relaxation therapy |
- If there is an identified pain syndrome (e.g. OA, diabetic peripheral neuropathy, cancer, gout) treat according to guidelines for that syndrome for the general population, adjusting medication according to eGFR Recommended but not on the EDL |
| Neuropathic pain | Same as pain above | - * Pregabalin 25–75 mg (initiate at 25 mg nocte and titrate up slowly. ESKD on a conservative pathway, 25 mg on alternate nights) - Amitriptyline 10 mg nocte may also be effective, assisting with both neuropathic pain and sleep disturbance (may titrate according to response up to 25 mg) - Add opioids (as in section above): stepwise process if moderate to severe pain in titrated doses. Recommended but not on the EDL - * Gabapentin 100–200 mg nocte (initiate 100 mg nocte alternate days and titrate up slowly. If the patient is on dialysis, this should be given after dialysis) |
|
| Sleep disturbances [16] 60.1% (54.9– 83.1%) |
Anaemia: see Table 2 Vitamin D deficiency Metabolic acidosis Hypo/ hyperthyroidism Adrenal insufficiency Anxiety Depression Medications: benzodiazepines antidepressants opioids |
- Exercise - Psychosocial and spiritual support - Cognitive and psychological therapies, e.g. relaxation therapy, meditation - Optimize sleep hygiene (no stimulants, reserve bedroom for sleep) - Complementary activities (acupuncture, massage) |
- Take a detailed sleep history and treat if able - Manage restless leg syndrome, pruritus, pain and obstructive sleep apnoea - If pain present treat as above - Amitriptyline 10 mg nocte may also be effective, assisting with both neuropathic pain and sleep disturbance (may titrate according to response up to 25 mg) Drugs recommended but not on EDL - * EPO if available (see KDIGO guidelines) [34] - * Melatonin (if available) 2 mg po 1-2 h prior to sleep |
| Fatigue | Anaemia (Table 2) Deconditioning Depression Insomnia |
- Psychosocial and spiritual care - Encourage regular physical activity (involve occupational therapy) - Cognitive and psychological therapies, e.g. relaxation therapy, meditation |
- Treat anaemia as per Table 2 and below [34] - Treat depression as above |
| Restless legs [16,35] 10–20% |
Anaemia and iron deficiency (Table 2) Hyperphosphataemia (may contribute) Medications such as dopamine antagonists, antidepressants |
- Ensure sufficient iron stores (ferritin > 200 ng/mL and transferrin saturation > 20%) - Correct hyperphosphataemia - Avoid caffeine-containing drinks, particularly after midday - Optimise sleep hygiene (no stimulants, reserve bedroom for sleep) - Complementary activities (acupuncture, massage) |
- * Pregabalin: 25–50 mg may also be used in divided or single night-time dose. Higher doses may result in side effects in patients with stage 5 CKD. Start at 25 mg and titrate to effect Recommended but not on EDL - * Gabapentin 50–300 mg in the evening. Start on alternate days, 1–2 hours before sleep |
| Shortness of breath | Anaemia Infection Pulmonary oedema Anxiety |
- Sit upright - Position by a window or use a fan to blow air gently across the face - Maintain a humid environment - Pursed lip breathing - Supplemental oxygen if hypoxic - Complementary therapies (e.g. relaxation techniques and music) - Consider role of diet: fluids and sodium intake |
Fluid overload |
Abbreviations: mg, milligram; tds, three times daily; SC, subcutaneous; IM, intramuscular; PR, per rectum; h, hour; CBT, cognitive behavioural therapy; CSCI, continuous subcutaneous infusion; EDL, Essential Drugs List; eGFR, estimated glomerular filtration rate; po, per os; od, once daily; qid, six-hourly; IV, intravenous; mL, millilitres; UV-B, ultraviolet; EPO, erythropoietin; prn, as required.
* Drugs not available on the EDL or requiring initiation at a tertiary hospital.
Wearne, N., Krause, R., Davidson, B., and Brennan, F., 2020. Renal palliative and supportive care in South Africa – A consensus statement. African Journal of Nephrology, 23(1), pp.86-107.