Palliative Care for Patients with Kidney Disease

Abstract

Interest in palliative care has increased in recent times, particularly in its multidisciplinary approach developed to meet the needs of patients with a life-threatening disease and their families. Although the modern concept of palliative simultaneous care postulates the adoption of these qualitative treatments early on during the life-threatening disease (and potentially just after the diagnosis), palliative care is still reserved for patients at the end of their life in most of the clinical realities, and thus is consequently mistaken for hospice care. Patients with acute or chronic kidney disease (CKD) usually experience poor quality of life and decreased survival expectancy and thus may benefit from palliative care. Palliative care requires close collaboration among multiple health care providers, patients, and their families to share the diagnosis, prognosis, realistic treatment goals, and treatment decisions. Several approaches, such as conservative management, extracorporeal, and peritoneal palliative dialysis, can be attempted to globally meet the needs of patients with kidney disease (e.g., physical, social, psychological, or spiritual needs). Particularly for frail patients, pharmacologic management or peritoneal dialysis may be more appropriate than extracorporeal treatment. Extracorporeal dialysis treatment may be disproportionate in these patients and associated with a high burden of symptoms correlated with this invasive procedure. For those patients undergoing extracorporeal dialysis, individualized goal setting and a broader concept of adequacy should be considered as the foundations of extracorporeal palliative dialysis. Interestingly, little evidence is available on palliative and end of life care for acute kidney injury (AKI) patients. In this review, the main variables influencing medical decision-making about palliative care in patients with kidney disease are described, as well as the different approaches that can fulfill the needs of patients with CKD and AKI.

Keywords: acute kidney injury; chronic kidney disease; end of-life care; end-stage kidney disease; kidney replacement therapy; palliative care.

Figure 1

“Adequacy” of extracorporeal treatment and the role of palliative dialysis. Graph of a chronic extracorporeal renal substitution for CKD patient (panel A) and graph of palliative dialysis for “CKD end-of-life” patient (panel B). Each graph considers several variables differently affected by the treatments (0: the variable is minimally influenced; 10: the variable is strongly improved). The area may identify the adequacy of the treatment within the graph: during an ideal therapy, the inner area covers 100% of the graph. For a treatment to be “adequate”, other parameters than solute clearance or fluid balances should be considered for end-of-life patients; in this scenario, an individualized RRT prescription should improve the physical, emotive, and autonomy-related issues.