ESRD Flashcards
1
Q
Dialysis prognosis
A
- 1 year survival 23 %
- 5 year survival 60%
- > 75 years, 50% mortality at 6 months
- increased age
- low albumin
- poor functional status
- comorbidites
2
Q
What is conservative management for ESRD?
A
- active disease management
- anemia, metabolic bone disease, electrolytes
- may remain stable for long periods
- some patients have improved QOL and survival advantage
- dialysis (high mortality rates before and after starting dialysis
3
Q
Pain and ESRD
A
- 50% ESRD patients
- MSk most common
- renal bone disease
- osteoarthritis
4
Q
Causes of pain
A
- Primary renal disease
- PCKD
- MM
- ESRD
- renal bone disease (soft tissue calcifications)
- amlyoidosis (soft tissue calcifications)
- peripheral neuropathy
- calciphylaxis (tissue ischemia/necrosis from calcific uremic ateriopathy)
- systemic fibrosis
- Dialysis complications
- ischemic neuropathy from AV fistula
- osteomyelitis and discitis from central lines
- abdominal pain from peritoneal dialysis
- cramps, HA, hypotension, abdo pain, N/vx during dialysis runs
- Comorbidites
- DM
- PVD
- OA
5
Q
Analgesics in ESRD
A
- Non opioids
- Acetaminophen safe
- NSIDS and ASA –> platelet dysfunction, renal dysfunction. Avoid!
- low dose ASA for cardiac protection ok
- Opioids
- M3G accumulates in RF
- Avoid MORPHINE, MEPERDINE, CODEINE
- Oxycodone with caution (oxymorphone unclear in ESRD)
- Tramadol with caution
- Hydromophone, fentanyl, methadone, buprenorphine safe
- H6G (hydromorphone) renally excreted but safer and better tolerated than M3G
6
Q
Safe / Best analgesics in ESRD
A
-
Hydromorphone
- H6G renally excreted but well tolerated
- can convert to fentanyl patch with limited BTA HM
-
Fentanyl
- liver metabolism
- no active metabolites
- no accumulation in ESRD
-
Methadone
- excreted in feces
- no accumulation in ESRD
-
Buprenorphine
- not altered in ESRD
-
Acetaminophen
- 3.2 g /day max
- 2.6 g / day max if liver disease
7
Q
Neuropathic pain in ESRD
A
- Gabapentin
- first line in ESRd
- 100 mg po qhs after dialysis on dialysis days
- increase by 100 mg q weekly to max 600 mg po qhs
- CNS effects : drowsiness, ataxia, nystagmus, somnolence
- TCA
- second line ESRD
- metabolites excreted by kidneys
- don’t dose reduce
- SE : urinary retention, dry mouth, somnolence, hypotension
- desipramine 10 mg po qhs or nortryptiline 10 mg po qhs
- Methadone
- third line
8
Q
Gabapentin side effects
A
- drowsiness
- nystagmus
- tremor
- ataxia
- decreased LOC
9
Q
Depression in dialysis patients
A
-
SSRI first line
- hepatic metabolism
- excreted by kidneys
- fluoxetine, sertraline, citalopram
- dose reduce to 50%, slow titration
- TCAs second line
-
NO SNRI/NDRI
- renally excreted
10
Q
Frailty in dialysis patients
A
- > 65 years, dialysis does not results in return to pre dialysis levels of function
- common
11
Q
Cognitive impairment in ESRD
A
- appear early
- ESRD - 75% have mod-severe cog impairment
- dementia –> higher mortality
12
Q
List reason why ACP in ESRD is important
A
- High burden of disease
- high mortality rates
- ++ suffering, frailty, cog impairment
- patients need to know prognosis
- Must pre-consider conditions for stopping dialysis
- Cognitive impairment
- large impact
- need SDM
13
Q
When to stop dialysis?
A
- patient requests it with fully informed consent
- no capacity, but previously indicated refusal of dialysis
- no capacity and SDM refuses based on best interest of patient
- significant irreversible cognitive impairment
- medical condition that precludes technical process of dialysis
14
Q
What is the average survival after stopping dialysis?
A
- 8-10 days
- range of 1-48 days
15
Q
What symptoms are typically experiences at EOL after stopping dialysis?
A
- pruritis
- confusion
- nausea
- dyspnea
- agitation
- myoclonus
