shareen siddiqi consultant nephrologist
TRANSCRIPT
Dialysis Withdrawal
Shareen Siddiqi
Consultant Nephrologist
Overview
CKD/RRT
Life expectancy and mortality on dialysis
Case studies
Symptoms
Advanced care planning
Renal replacement therapy
861 adults pmp on RRT
Median age 58 years old
24.9% RRT patients are over 70
RRT prevalence 80-84 y.o. 1896 pmarp
RRT prevalence >85 y.o. 983 pmarp
Dialysis
1 year age adjusted survival 89.7%
35-39 y.o. – 16x mortality rate of general population
25-29 y.o.– median life remaining is 18.5 years
Relative risk of death for prevalent RRT patients
Dialysis
For >75 y.o. median life remaining
2.4 yrs
For >85 population mortality 2.7x higher than general population
Cause of death for dialysis patients
Cause of death for transplant patients
USRDS 2013
A good death….
and a bad death
Case 1
76 y.o. female
PD – 4 years
Comorbidities
Increasing frailty
PD becoming indequate
Not suitable for HD
Discussions with patient and family about the significance of this
Continue PD
Wanted to see grandson
Symptom relief - CNS
- specialist clinic
Aware of aims and limitations of treatment
Aware could stop if wanted to
Lived 4 months
Saw grandson
Died at home, surrounded by family
Case 2
85 y.o. male
HD 6/12
AKI April 12 – established HD 2/12 admission
CVA
Etoh xs
Short term memory loss
Urosepsis
AF
Readmitted 3x over subsequent 4/12
Frail
Deteriorating
Didn’t want to entertain stopping dialysis
Died 4/7 after 3rd discharge
A good death
A good death is “one that is free from avoidable distress and suffering, for patients, family, and caregivers; in general accord with the patients’ and families’ wishes; and reasonably consistent with clinical, cultural, and ethical standards.”
Dialysis withdrawal
Process variable
Mean 8 days from dialysis discontinuation to death
Symptom relief
Oxycodone/Alfentanil
Midazolam
Haloperidol/Levomepromazine
Hyoscine Butylbromide
Symptom relief
Restless legs -Clonazepam
Pruritis - Gabapentin syrup - Ondansetron (opioid itch)
Dyspnoea (fluid overload) - opioids/fan/diuretics
Advanced Care Planning
Pre empts and prompts conversations
Enables patients to raise dialysis withdrawal
Incorporated into nephrology
- slow process
Questions?