Managing symptoms and complications of chronic kidney disease in palliative care

Brown, 2013Gelfand, 2020Li, 2020Scherer, 2017

Management of chronic kidney disease in patients with palliative care needs depends on potential benefits and burdens of treatment, and the patient’s prognosis, preferences (including preferred care setting) and goals of care—see Principles of symptom management in palliative care. When using a drug in patients with kidney disease, consider whether the dosage needs modification, or whether an alternative drug is required.

Even with dialysis, patients with chronic kidney disease can experience significant symptoms and complications; early engagement with palliative care services can assist with management. Symptoms are similar to those associated with other life-limiting illnesses (eg pain, nausea, insomnia, fatigue, cramps, delirium, seizures, hiccups). Symptoms more specific to chronic kidney disease include uraemic itch and restless legs syndrome. Symptom burden will increase as kidney disease progresses, regardless of dialysis and kidney function. Avoiding high-protein foods may limit the progression of uraemia, but if comfort is the priority, dietary restrictions are no longer appropriate.

Restless legs syndrome occurs in up to a quarter of patients receiving dialysis, and also occurs in other patients with advanced kidney disease. Management involves identifying and addressing causative or exacerbating factors (eg avoiding dopamine antagonists, correcting iron deficiency), and lifestyle interventions (eg aerobic exercise, stretching exercises, good sleep hygiene, aromatherapy massage). Use of a cool dialysate may be considered by the nephrology teamChen, 2022. If drug therapy is required, gabapentin or pregabalin are first-line therapy, and can be used before dialysis if this is when symptoms occur. A non-ergot dopamine agonist (eg ropinirole) may also be usefulLi, 2020Scherer, 2017.