Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Palliative Renal Medicine

CRGH Physicians Education Program presentation
by

Angus Ritchie

on 6 August 2013

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Palliative Renal Medicine

Palliative
Renal
Medicine

65F eGFR 5
Diabetic nephropathy
HT, chol, IHD, PVD
Starts PD
Survival 65-74y (95% CI)
1y 85 (84-86)
2y 61 (60-63)
5y 39 (37-41)
ANZDATA 2010
T2 Diabetes 50%
IHD 100%
Cause of death
"Social" 37%
Cardiac 34%
Infection 12%
Vascular & Misc 18%
5YS comparison
Colorectal cancer
Stage IIIC 44%
Grace et al Nephrology 2012
Transplant?
772 Tx in Australia in 2009
59 Tx in >65y
Typical appointment
20min/month
Events, dialysis, diabetes
Blood pressure, weight, fluid assessment
Blood results (find results)
Medication review and scripts
Education
Dictate letter
Long
term
dialysis
How do you feel?
"Ok, tired..."
What about...
Pain
Itch
Restless legs
Insomnia
Anorexia
Dysguesia
Constipation
What if >75y
Palliative Medicine Principles
Applied to Renal Patients
Focus on QOL
Symptom management
Psychosocial support
Care of the dying patient
Non-dialysis pathway

Uraemic pruritis
Prevalent & troublesome
Update on mechanisms
Complex aetiology & interactions
Who doesn't benefit from dialysis?
Comparative Survival Data
Cost of dialysis
Separating itch from pain
multiple mu-opioid receptors (MORs)
MOR1D KO rats

Anti-histamine sensitive v insensitive itch
Unmyelinated C-fibres eg mosquito bites
Myelinated A-fibres eg Cowage
Chen et al. Cell 2011
Ringkamp et al. J Neuroscience 2011
Uraemic toxins
Biochemical abnormalities
Cutaneous xerosis
Mood, depression
Insomnia
Inflammation
Medical comorbidities
ITCH National Registry Investigators
Itch daily or nearly daily in >80%
Moderate or extreme UP in 42%
Ongoing for >1y in 60%
Correlation with HR-QOL measures
mood
social relations
sleep
Mathur VS, et al. A longitudinal study of uremic pruritis in hemodialysis patients. CJASN 2010
Treatment Options
Effective
Ineffective
Emollients
menthol
capsaicin
Gabapentin
pregabalin
Antidepressants
doxepin
mirtazepine
Topical CNI
tacrolimus
pimecrolimus
Broadband UV B
Thalidomide
Aromatherapy
Antihistamines
Acupuncture
Ondansetron
Opiate antagonists
Beware alternative diagnosis!
Dialysis reactions
Drug reactions
Scabies
Predicting survival ...
Predictive tools?
HD mortality predictor
Case 1
81M
Dementia (multi-infarct)
Coronary artery disease
Moderate LV dys
Declining function
Albumin 30
Case 2
75F
Morbid obesity
OSA+cor pulmonale
Home 02
T2 diabetes
Poor compliance
Essentially immobile
Albumin 40
Dialysis via vascath
Diabetes
GN

Vascular
Other
New starters (all comers)
The raw numbers
Estimated 5YS >80%

with IHD
without IHD
Murtagh NDT 2007
Carson CJASN 2009
Finished
Annual Symposium
St George Renal Supportive Care Clinic
The best model?
Not!
Full transcript