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?