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Collins A, Hui D, Davison SN, Ducharlet K, Murtagh F, Chang YK, Philip J. Referral Criteria to Specialist Palliative Care for People with Advanced Chronic Kidney Disease: A Systematic Review. J Pain Symptom Manage 2023; 66:541-550.e1. [PMID: 37507095 DOI: 10.1016/j.jpainsymman.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023]
Abstract
CONTEXT People with advanced chronic kidney disease (CKD) have significant morbidity, yet for many, access to palliative care occurs late, if at all. OBJECTIVES This study sought to examine criteria for referral to specialist palliative care for adults with advanced CKD with a view to improving use of these essential services. METHODS Systematic review of studies detailing referral criteria to palliative care in advanced CKD conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline and registered (PROSPERO: CRD42021230751). DATA SOURCES Electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed) were used to identify potential studies, which were subjected to double review, data extraction, thematic coding, and descriptive analyses. RESULTS Searches yielded 650 unique titles ultimately resulting in 56 studies addressing referral criteria to specialist palliative care in advanced CKD. Of 10 categories of referral criteria, most commonly discussed were: Critical times of treatment decision making (n = 23, 41%); physical or emotional symptoms (n = 22, 39%); limited prognosis (n = 18, 32%); patient age and comorbidities (n = 18, 32%); category of CKD/ biochemical criteria (n = 13, 23%); functional decline (n = 13, 23); psychosocial needs (n = 9, 16%); future care planning (n = 9, 16%); anticipated decline in illness course (n = 8, 14%); and hospital use (n = 8, 14%). CONCLUSION Clinicians consider referral to specialist palliative care for a wide range of reasons, with many related to care needs. As palliative care continues to integrate with nephrology, our findings represent a key step towards developing consensus criteria to standardize referral for patients with chronic kidney diseases.
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Affiliation(s)
- Anna Collins
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia
| | - David Hui
- Department of Palliative Care (D.H., Y.K.C.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sara N Davison
- Division of Nephrology & Immunology (S.N.D.), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kathryn Ducharlet
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia; Department of Nephrology (K.D.), St Vincent's Hospital, Melbourne, Australia; Eastern Health Clinical School (K.D.), Monash University, Melbourne, Australia; Eastern Health Integrated Renal Services (K.D.), Melbourne, Australia
| | - Fliss Murtagh
- Wolfson Palliative Care Research Centre (F.M.), Hull York Medical School, University of Hull, UK
| | - Yuchieh Kathryn Chang
- Department of Palliative Care (D.H., Y.K.C.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer Philip
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia; Palliative Care Service (J.P.), Royal Melbourne Hospital, Parkville, Australia; Palliative Care Service (J.P.), Peter MacCallum Cancer Centre, Melbourne, Australia.
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Yi C, Ye H, Lin J, Chang Y, Zhang X, Zhou T, Yang R, Yang X. The incidence of pain and its association with quality of life in patients with peritoneal dialysis. Ren Fail 2022; 44:724-730. [PMID: 35491880 PMCID: PMC9068003 DOI: 10.1080/0886022x.2022.2068444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/13/2022] [Accepted: 04/13/2022] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The aims of this study were to investigate the incidence of pain in peritoneal dialysis (PD) patients and to analyze the correlation between pain and quality of life. METHODS PD patients who followed up in our PD center from March 2016 to December 2017 were included. The Short-Form McGill Pain Questionnaire was used to assess pain status. Depression status, sleep quality, quality of life and clinical data were also collected. RESULTS A total of 463 PD patients were included, of whom 153 patients (33.1%) with pain. The main cause of pain was calcium and phosphorus metabolism disorder (51.6%). About 101 patients (66.0%) had multiple sites of pain, and 28 patients (18.3%) with pain were treated with analgesic drugs. Binary Logistic regression analysis showed that older age (OR = 1.026; p = 0.032) and higher intact parathyroid hormone level (OR = 1.043; p = 0.040) were independent risk factors for pain in PD patients. Multivariate analysis showed that score of pain rating index was an independent risk factor for depressive symptoms (OR = 1.100; p = 0.015), the score of Pittsburgh sleep quality index (B = 0.005; p = 0.044) and the score of physical component scale (B= -0.727; p = 0.016) in PD patients. CONCLUSIONS The incidence of pain in PD patients was 33.1%. Older age and higher intact parathyroid hormone level were independent risk factors for pain. Pain was independently associated with depressive symptoms, sleep quality and quality of life in PD patients.
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Affiliation(s)
- Chunyan Yi
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Hongjian Ye
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Jianxiong Lin
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Yao Chang
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Xiaodan Zhang
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Ting Zhou
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Rui Yang
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
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de Rooij ENM, Meuleman Y, de Fijter JW, Jager KJ, Chesnaye NC, Evans M, Caskey FJ, Torino C, Porto G, Szymczak M, Drechsler C, Wanner C, Dekker FW, Hoogeveen EK. Symptom Burden before and after Dialysis Initiation in Older Patients. Clin J Am Soc Nephrol 2022; 17:1719-1729. [PMID: 36357126 PMCID: PMC9718015 DOI: 10.2215/cjn.09190822] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/14/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES For older patients with kidney failure, lowering symptom burden may be more important than prolonging life. Dialysis initiation may affect individual kidney failure-related symptoms differently, but the change in symptoms before and after start of dialysis has not been studied. Therefore, we investigated the course of total and individual symptom number and burden before and after starting dialysis in older patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The European Quality (EQUAL) study is an ongoing, prospective, multicenter study in patients ≥65 years with an incident eGFR ≤20 ml/min per 1.73 m2. Using the dialysis symptom index (DSI), 30 symptoms were assessed every 3-6 months between 2012 and 2021. Scores for symptom number range from zero to 30 and, for burden, from zero to 150, with higher scores indicating more severity. Using mixed effects models, we studied symptoms during the year preceding and the year after dialysis initiation. RESULTS We included 456 incident patients on dialysis who filled out at least one DSI during the year before or after dialysis. At dialysis initiation, mean (SD) participant age was 76 (6) years, 75% were men, mean (SD) eGFR was 8 (3) ml/min per 1.73 m2, 44% had diabetes, and 46% had cardiovascular disease. In the year before dialysis initiation, symptom number increased +3.6 (95% confidence interval [95% CI], +2.5 to +4.6) and symptom burden increased +13.3 (95% CI, +9.5 to +17.0). In the year after, symptom number changed -0.9 (95% CI, -3.4 to +1.5) and burden decreased -5.9 (95% CI, -14.9 to -3.0). At dialysis initiation, "fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" had the highest prevalence of 81%, 69%, and 68%, respectively, with a burden of 2.7, 2.4, and 2.3, respectively. "Fatigue" somewhat improved after dialysis initiation, whereas the prevalence and burden of sexual symptoms further increased. CONCLUSIONS Symptom burden worsened considerably before and stabilized after dialysis initiation. "Fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" were considered most burdensome, of which only "fatigue" somewhat improved after dialysis initiation.
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Affiliation(s)
- Esther N M de Rooij
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yvette Meuleman
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kitty J Jager
- European Renal Association Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas C Chesnaye
- European Renal Association Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Marie Evans
- Renal Unit, Department of Clinical Intervention and Technology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Claudia Torino
- National Research Council - Institute of Clinical Physiology, Reggio Calabria, Italy
| | - Gaetana Porto
- Grande Ospedale Metropolitano Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | | | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Hornig C, Apel C, Ficociello LH, Kendzia D, Anger M, Bowry SK. Switching from high-flux dialysis to hemodiafiltration: Cost-consequences for patients, providers, and payers. Semin Dial 2022; 35:405-412. [PMID: 35301753 DOI: 10.1111/sdi.13075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022]
Abstract
Hemodiafiltration (HDF) achieves a more efficient reduction of the uremic toxic load compared to standard high-flux hemodialysis (HF-HD) by virtue of the combined diffusive and convective clearances of a broad spectrum of uremic retention solutes. Clinical trials and registry data suggest that HDF improves patient outcomes. Despite the acknowledged need to improve survival rates of dialysis patients and the survival benefit HDF offers, there is little to no utilization in some countries (such as the US) in prescribing HDF to their patients. In this analysis, we present the healthcare value-based case for HDF (relative to HF-HD) from the patient, provider, and payor perspectives. The improved survival and reduced morbidity observed in studies conducted outside the US, as well as the reduced hospitalization, are attractive for each stakeholder. We also consider the potential barriers to greater utilization of HDF therapies, including unfounded concerns regarding additional costs of HDF, e.g., for the preparation and microbial testing of quality of substitution fluids. Ultrapure fluids are easily attainable and prepared from dialysis fluids using established "online" (OL) technologies. OL-HDF has matured to a level whereby little additional effort is required to safely implement it as all modern machine systems are today equipped with the OL-HDF functionality. Countries already convinced of the advantages of HF-HD are thus well positioned to make the transition to OL-HDF to achieve further clinical and associated economic benefits. Healthcare systems struggling to cope with the increasing demand for HD therapies would therefore, like patients, be beneficiaries in the long term with increased usage of OL-HDF for end stage kidney disease patients.
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Affiliation(s)
- Carsten Hornig
- Department of Health Economics and Market Access, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Christian Apel
- Department of Health Economics and Market Access, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Linda H Ficociello
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts, USA
| | - Dana Kendzia
- Department of Health Economics and Market Access, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Michael Anger
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts, USA
| | - Sudhir K Bowry
- Dialysis-at-Crossroads (D@X) Advisory, Bad Nauheim, Germany
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Roy PJ, Weltman M, Dember LM, Liebschutz J, Jhamb M. Pain management in patients with chronic kidney disease and end-stage kidney disease. Curr Opin Nephrol Hypertens 2020; 29:671-680. [PMID: 32941189 PMCID: PMC7753951 DOI: 10.1097/mnh.0000000000000646] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW This review evaluates current recommendations for pain management in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) with a specific focus on evidence for opioid analgesia, including the partial agonist, buprenorphine. RECENT FINDINGS Recent evidence supports the use of physical activity and other nonpharmacologic therapies, either alone or with pharmacological therapies, for pain management. Nonopioid analgesics, including acetaminophen, topical analgesics, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and TCA may be considered based on pain cause and type, with careful dose considerations in kidney disease. NSAIDs may be used in CKD and ESKD for short durations with careful monitoring. Opioid use should be minimized and reserved for patients who have failed other therapies. Opioids have been associated with increased adverse events in this population, and thus should be used cautiously after risk/benefit discussion with the patient. Opioids that are safer to use in kidney disease include oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine. Buprenorphine appears to be a promising and safer option due to its partial agonism at the mu opioid receptor. SUMMARY Pain is poorly managed in patients with kidney disease. Nonpharmacological and nonopioid analgesics should be first-line approaches for pain management. Opioid use should be minimized with careful monitoring and dose adjustment.
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Affiliation(s)
- Payel Jhoom Roy
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine
| | - Melanie Weltman
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy
| | - Laura M. Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, and Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Jane Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine
| | - Manisha Jhamb
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh
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