Background: It is often believed that patients with advanced chronic kidney disease (CKD) stage 4–5 have few symptoms, and that dying with renal disease is relatively symptom-free. But the symptom burden of patients managed conservatively (without dialysis), with potentially high levels of comorbidity and poor functional status, is unknown. This clinical audit evaluated the prevalence and severity of symptoms in conservatively managed CKD stage 4–5 patients. Methods: Symptom data was collected from all conservatively managed patients from 2 renal units referred to a new renal palliative care service over a 10-month period between April 2005 and January 2006. Data on symptom prevalence and severity was collected as part of their routine clinical care, using a modified version of the Patient Outcome Scale – symptom module (POSs). This patient-completed instrument identifies the presence and severity of 17 symptoms. Demographic data was also collected, including estimated glomerular filtration rate (eGFR) using the MDRD formula, primary renal diagnosis and comorbidity. Results: Symptoms were evaluated in 55 patients, with a mean age of 82 years (SD 5.5, range 66–96). eGFR ranged from 3 to 30 ml/min (median 11, mean 12.75). In patients with CKD stage 4–5, managed without dialysis, the symptom burden is high. The most prevalent symptoms reported were weakness (75%), poor mobility (75%), poor appetite (58%), pain (56%), pruritus (56%) and dyspnoea (49%). The total number of symptoms each individual patient experienced ranged from 1 to 14 (median 7, mean 6.8). Symptoms were frequently reported as moderate, severe, or overwhelming; in 54% of patients with poor mobility, 48% with weakness, 30% with itching, 31% with anorexia and 27% with pain. No significant association was demonstrated between the number of symptoms experienced and either severity of renal disease or comorbidity score. Conclusions: This structured clinical evaluation demonstrates the extent and severity of symptom burden in conservatively managed patients with CKD stage 4–5, and demonstrates the use of an appropriate clinical tool that can be used to assess the efficacy of treatment.

Keywords:
Chronic kidney disease, End-of-life care, Palliative care
1.
Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE: Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007;22:1955–1962.
2.
Munshi SK, Vijayakumar N, Taub NA, Bhullar H, Lo TC, Warwick G: Outcome of renal replacement therapy in the very elderly. Nephrol Dial Transplant 2001;16:128–133.
3.
Smith C, Silva-Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K: Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 2003;95:c40–c46.
4.
Singer PA, Martin DK, Kelner M: Quality end-of-life care: patients’ perspectives. JAMA 1999;281:163–168.
5.
Weisbord SD, Carmody SS, Bruns FJ, Rotondi AJ, Cohen LM, Zeidel ML, et al: Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients. Nephrol Dial Transplant 2003;18:1345–1352.
6.
Cohen LM, Germain M, Poppel DM, Woods A, Kjellstrand CM: Dialysis discontinuation and palliative care. Am J Kidney Dis 2000;36:140–144.
7.
Davison SN: Pain in hemodialysis patients: prevalence, cause, severity, and management. Am J Kidney Dis 2003;42:1239–1247.
8.
Davison SN: Chronic pain in end-stage renal disease. Adv Chronic Kidney Dis 2005;12:326–334.
9.
Bailie GR, Mason NA, Bragg-Gresham JL, Gillespie BW, Young EW: Analgesic prescription patterns among hemodialysis patients in the DOPPS: potential for underprescription. Kidney Int 2004;65:2419–2425.
10.
Murtagh FEM, Addington-Hall J, Higginson IJ: The prevalence of symptoms in end-stage renal disease: a systematic review. Adv Chronic Kidney Dis 2007;14:82–99.
11.
Murtagh F, Addington-Hall J, Edmonds P, Donohoe P, Carey I, Jenkins K, et al: Symptoms in advanced renal disease – a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis. J Palliat Med 2007;10:1266–1276.
12.
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D: A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461–470.
13.
Ansell D, Feest T, Rao R, Williams A, Winearls C: UK Renal Registry Report 2005. Bristol, UK Renal Registry, 2006.
14.
Davies SJ, Phillips L, Naish PF, Russell GI: Quantifying comorbidity in peritoneal dialysis patients and its relationship to other predictors of survival. Nephrol Dial Transplant 2002;17:1085–1092.
15.
Hearn J, Higginson IJ: Development and validation of a core outcome measure for palliative care: the palliative care outcome scale. Palliative Care Core Audit Project Advisory Group. Qual Health Care 1999;8:219–227.
16.
Franks PJ, Salisbury C, Bosanquet N, Wilkinson EK, Lorentzon M, Kite S, et al: The level of need for palliative care: a systematic review of the literature. Palliat Med 2000;14:93–104.
17.
Saini T, Murtagh FE, Dupont PJ, McKinnon PM, Hatfield P, Saunders Y: Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliat Med 2006;20:631–636.
18.
Office for National Statistics. http://www.statistics.gov.uk/neighbourhood-statistics.asp (accessed September 4, 2008).
19.
Chater S, Davison SN, Germain MJ, Cohen LM: Withdrawal from dialysis: a palliative care perspective. Clin Nephrol 2006;66:364–372.
20.
Addington-Hall J, Fakhoury W, McCarthy M: Specialist palliative care in nonmalignant disease. Palliat Med 1998;12:417–427.
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2008
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