Mary, a 74-year-old widow, was diagnosed with stage 4 chronic kidney disease (CKD) 2 years ago and attends a renal clinic every 12 weeks with her daughter. Today she has been told her kidney function has deteriorated. She has Class III heart failure (New York Heart Association) and osteoarthritis in both knees. She complains of breathlessness, itchiness, overwhelming tiredness, swollen legs and pain in her knees. She has previously told the renal team on a number of occasions that, when the time comes, she would rather be treated without dialysis, although her daughter was opposed to this. She reports that she feels depressed. Routine blood tests reveal an Hb of 6.0 g/dL, an eGFR of 6 mL/min/1.73 m2 and a phosphate of 3.5 mmol/L.
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1. Does this lady need to be admitted to hospital?
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In patients who do not want dialysis or who are clinically unsuitable, supportive management is aimed at symptom control and optimising quality of life as much as is possible. Whilst hospital admissions are to be avoided where possible, in this case it is likely that Mary would benefit from a short stay to assess her needs, initiate and/or adjust her treatment regimes and organise some community support. Admission to a renal ward is usually advisable, as the nurses often work collaboratively with the patient’s GP and community services.
In some cases, a sudden decline in renal function can be attributed to reversible factors such as hypovolaemia (diarrhoea and vomiting or reduced oral intake), sepsis and medications such as non-steroidals, high-dose diuretics and some nephrotoxic antibiotics. It is important to consider and address any contributing factors to a decline in renal function.
It is likely that Mary is already on a fluid restriction. This is to reduce the risk of fluid overload and pulmonary oedema, which is distressing and possibly life threatening. A rule of thumb in determining the level of restriction is the previous days output plus 500 mL. Mary’s swollen legs suggest there has been a reduction in her urine output associated with a decline in her renal function. A complicating factor in this situation is Mary’s heart failure, and optimising cardiac function can lead to a worsening of renal function. High doses of intravenous diuretics may help to remove excess fluid making it easier for Mary to breathe and mobilise. At present, this is usually done under close supervision in hospital. In this situation, it can be normal practice to try to reduce any fluid overload before transfusing the patient.
Lethargy and tiredness is a common symptom in patients with CKD and is usually associated with anaemia. In kidney patients, the decision to transfuse is not based on the haemoglobin level alone but on how symptomatic the patient is. Some patients may be symptomatic with a higher haemoglobin, particularly those who are elderly and/or frail and with a number of other co-existing conditions.
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2. What is her priority for care?
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It is not unusual for people with chronic conditions to feel low in mood, which can affect their ability to make decisions regarding their treatment. Within renal services, conversations about treatment options are ideally introduced in advance of requiring dialysis and revisited over time. Shared decision-making is a process which involves the patient and often the family as both often need reassurance over time that the decision made was the right one for them. In some cases, the GP may prescribe a low dose of anti-depressant and/or refer to a counsellor if patients agree.
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3. If this lady decides not to embark on dialysis does she still need to see her cardiac and orthopaedic physicians?
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There are no hard and fast rules regarding the on-going involvement of other specialities and in some areas specialist renal and heart failure nurses work collaboratively to manage end-of-life symptoms, in conjunction with the community team. Generally speaking, when patients are approaching the terminal phase of their life they are unlikely to benefit from attending routine appointments with additional specialists.
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4. Would it be useful to discuss advance care planning with this lady?
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It is important to encourage all patients with advanced kidney disease to give some thought to their future care, as even when stable their condition can deteriorate very suddenly. Often initial discussions are centred on ‘the place of care’ and how feasible this is, the choice of a key worker to coordinate care and possible scenarios when Mary’s condition deteriorates. Although it can be difficult to predict, it is often helpful for patients and their families to have a rough estimate of how much time they have left. Without being too specific, it can be useful in terms of planning to know they have days instead of weeks or weeks instead of months.
