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W3011261667 abstract "Kidney supportive care is the application of palliative medicine principles and practices to patients with kidney disease. The goal is alleviation of suffering through treatment of symptoms, empathic communication, and support for psychosocial distress. Kidney supportive care includes primary palliative care provided by nephrology teams, as well as referral of patients with complex distress for comanagement by an interprofessional specialty palliative care team, when available. The team may include physicians, nurses, social workers, chaplains, and dieticians. Comanagement with nephrologists offers an additional layer of support to patients and families as prognostic awareness, patient preferences, and care decisions are explored. Kidney supportive care can be offered to patients experiencing acute kidney injury or chronic kidney disease, including those with kidney failure treated by kidney replacement therapy (dialysis and transplantation). Kidney supportive care includes but is not limited to end-of-life care. This installment of the Core Curriculum in Nephrology outlines several practical applications of kidney supportive care, with a focus on the nephrologist’s approach to symptom management, active medical management of kidney failure without dialysis (also known as comprehensive conservative care), acute kidney injury in seriously ill patients, and withdrawal from dialysis. Kidney supportive care is the application of palliative medicine principles and practices to patients with kidney disease. The goal is alleviation of suffering through treatment of symptoms, empathic communication, and support for psychosocial distress. Kidney supportive care includes primary palliative care provided by nephrology teams, as well as referral of patients with complex distress for comanagement by an interprofessional specialty palliative care team, when available. The team may include physicians, nurses, social workers, chaplains, and dieticians. Comanagement with nephrologists offers an additional layer of support to patients and families as prognostic awareness, patient preferences, and care decisions are explored. Kidney supportive care can be offered to patients experiencing acute kidney injury or chronic kidney disease, including those with kidney failure treated by kidney replacement therapy (dialysis and transplantation). Kidney supportive care includes but is not limited to end-of-life care. This installment of the Core Curriculum in Nephrology outlines several practical applications of kidney supportive care, with a focus on the nephrologist’s approach to symptom management, active medical management of kidney failure without dialysis (also known as comprehensive conservative care), acute kidney injury in seriously ill patients, and withdrawal from dialysis. FEATURE EDITOR:Asghar RastegarADVISORY BOARD:Ursula C. BrewsterMichael ChoiAnn O’HareManoocher SoleimaniThe Core Curriculum aims to give trainees in nephrology a strong knowledge base in core topics in the specialty by providing an overview of the topic and citing key references, including the foundational literature that led to current clinical approaches. FEATURE EDITOR: Asghar Rastegar ADVISORY BOARD: Ursula C. Brewster Michael Choi Ann O’Hare Manoocher Soleimani The Core Curriculum aims to give trainees in nephrology a strong knowledge base in core topics in the specialty by providing an overview of the topic and citing key references, including the foundational literature that led to current clinical approaches. Kidney supportive care is palliative care for patients with kidney disease. It is a growing subspecialty of the field of nephrology, like transplantation nephrology or onconephrology, but unlike those, it can be applied to all patients living with advanced kidney disease from any cause and on any dialysis modality. Similar to palliative care in oncology, the goal is reduction of suffering throughout the trajectory of illness, including (but not limited to) the end of life. Kidney supportive care is ideally provided through collaboration of nephrologists (who use “primary palliative care” skills) and palliative care specialists, whose approach usually includes an interprofessional team with nurses, social workers, dieticians, and chaplains (Table 1).Table 1Primary and Specialty Palliative Care in NephrologyDomain of CarePrimary Palliative Care by Nephrology TeamSpecialty Palliative Care ConsultationSymptom managementRoutine symptom assessment and treatmentRefractory symptom treatment, including pain, neuropathy, itch, nausea, and anxiety/depressionDecision makingCommunication about patient priorities, prognosis, dialysis modality optionsAssistance with navigation of complex clinical situations or interpersonal dynamicsInterdisciplinary team supportScreening for social, spiritual, or nutritional distressAccess to dieticians, chaplains, and social workers trained in palliationConservative careMedical CKD management with focus on quality of lifeAssistance with advance care planning and end of life careAbbreviation: CKD, chronic kidney disease.Based on information presented in Quill and Abernethy, 2013 (N Engl J Med. https://doi.org/10.1056/NEJMp1215620). Open table in a new tab Abbreviation: CKD, chronic kidney disease. Based on information presented in Quill and Abernethy, 2013 (N Engl J Med. https://doi.org/10.1056/NEJMp1215620). Randomized prospective trials in the fields of oncology, heart failure, and others have shown substantial improvements in quality of life, functional status, depression, and anxiety for people treated with palliative care as compared with standard specialty care alone. Though many imagine that palliation in nephrology amounts to stopping dialysis and hospice care, kidney supportive care is much broader, with numerous areas of focus that are applicable to patients across the illness spectrum (Fig 1). This includes intensive physical symptom management, heightened attention to nonphysical dimensions of suffering, iterative and patient-centered explorations of prognostic awareness, elicitation of patient preferences, and in some cases, the option of managing advancing disease without dialysis, which has been called “maximal” or “active” or “nondialytic” medical management, “conservative kidney management,” “comprehensive conservative care,” or simply “conservative care.” These terms are interchangeable, and in this discussion we use “active medical management” and “comprehensive conservative care” for their emphasis on holistic ongoing care. To understand the relevance of kidney supportive care, it is essential to understand the evolving epidemiology of kidney disease, which is particularly remarkable in the realm of dialysis. Since maintenance dialysis for kidney failure became available in the 1960s (and universally covered in the United States by the Social Security Amendments of 1972), the patient population treated by nephrologists has become older and more ill. In 1978, 25% of incident dialysis patients were 65 years or older and only 10% had diabetes. By 2016, 50% of incident dialysis patients in the United States were older than 65 years, 23% were older than 75 years, and 47% had kidney failure attributed to diabetes. Some also have debilitating and life-limiting illnesses at the time of dialysis initiation, such as cancer, cardiovascular disease, and dementia. Though early legislation may have intended to increase access to dialysis as a bridge to transplantation or renal recovery, today dialysis in the United States is often a “destination” therapy by which life is prolonged but health and function are not always restored. In the past 2 decades, recognition has increased that patients with advanced age or comorbid illnesses experience high mortality rates and high symptom burdens on dialysis. Their survival is worse than for many cancers. Patients who start dialysis at age 75 years have on average 1- and 3-year adjusted survivals of 63% and 33%, respectively. Furthermore, among patients older than 80 years, some observational studies have shown no survival benefit with starting dialysis as compared with active medical management. For this reason, the election of a nondialytic approach for patients with advanced age or frailty is gaining acceptance. However, comprehensive conservative care is not yet a well-established component of nephrology fellowship education or routine practice. To raise awareness and fuel a global effort to develop kidney supportive care, in 2013, international leaders in palliative care and nephrology convened at a KDIGO (Kidney Disease: Improving Global Outcomes) controversies conference on supportive care, where they defined fundamental principles and competence domains. These included: (1) identification of patients most likely to benefit from supportive care, (2) symptom assessment and management, (3) communication of prognosis, (4) shared decision making to advance goal-concordant care, and (5) effective use of local palliative medicine and hospice resources. It is important to emphasize that these domains are applicable to patients across the continuum of illness severity and chronicity, including patients with acute kidney injury (AKI) and chronic kidney disease (CKD) who are not receiving dialysis and patients with kidney transplants. Kidney supportive care programs are most robust in Canada, the United Kingdom, Australia, New Zealand, and Hong Kong. Limitations to widespread implementation in the United States include misperceptions of palliative medicine, inadequate training and modeling of these skills, limited access to and number of palliative care experts, and financial systems that do not incentivize palliative metrics. However, the serious nature of advanced kidney disease coupled with high mortality and high symptom burden necessitates the inclusion of supportive care as a standard component of all nephrology practice. ►Combs SA, Culp S, Matlock DD, et al. Update on end-of-life care training during nephrology fellowship: a cross-sectional national survey of fellows. Am J Kidney Dis. 2015;65(2):233-239. ★ ESSENTIAL READING►Davison SN, Levin A, Moss AH, et al. Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care. Kidney Int. 2015;88(3):447-459.►Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175. ★ ESSENTIAL READING►Tamura MK, Meier DE. Five policies to promote palliative care for patients with ESRD. Clin J Am Soc Nephrol. 2013;8(10):1783-1790. “I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism” – Modernized Hippocratic Oath, revised by Louis Lasagna Patients with advanced kidney disease experience a high frequency of physical and psychological symptoms, comparable to patients with cancer (Table 2). There is evidence that nephrologists underrecognize and undertreat these symptoms. A cornerstone of kidney supportive care is symptom management, which can be accomplished across a multitude of care settings, including clinics, hospitals, and dialysis units.Table 2Symptoms in Patients With End-Stage Kidney Disease on Dialysis and Active Medical ManagementSymptomPrevalence in Patients on HD in the United StatesPrevalence in Patients on Comprehensive Conservative Care in the United KingdomFatigue/weakness68%75%Dry skin72%35%Pruritus54%56%Pain (bone or joint)50%56%Dry mouth45%20%Insomnia44%36%Muscle cramps43%NRDiarrhea17%11%Worrying/anxiety28%42%Shortness of breath19%49%Decreased appetite29%58%Feeling sad or depressed24%33%Restless legs29%24%Nausea26%36%Constipation21%42%Vomiting11%25%Abbreviations: HD, hemodialysis; NR, not reported.Prevalence data for HD patients based on Weisbord et al, 2005 (J Am Soc Nephrol. https://doi.org/10.1681/ASN.2005020157); for comprehensive conservative care patients, on Murphy et al, 2009 (Nephron Clin Pract. https://doi.org/10.1159/000183177). Open table in a new tab Abbreviations: HD, hemodialysis; NR, not reported. Prevalence data for HD patients based on Weisbord et al, 2005 (J Am Soc Nephrol. https://doi.org/10.1681/ASN.2005020157); for comprehensive conservative care patients, on Murphy et al, 2009 (Nephron Clin Pract. https://doi.org/10.1159/000183177). Patients underreport symptoms unless asked explicitly about them, and there are robust data that regular assessments with validated tools can reduce symptom burden over time. Options for assessment tools are listed in Box 1. In programs in Australia, the United Kingdom, and Canada, nurses and advanced practice providers conduct periodic symptom assessments with patients and families. In the United States, a few academic centers have devised similar programs, mostly led by nephrologists who are dual trained in nephrology and palliative medicine.Box 1Symptom and Function Assessment Tools•Edmonton Symptom Assessment Revised: Renal (ESAS-Renal) (http://palliative.org/NewPC/_pdfs/tools/ESASr%20Renal.pdf)•Integrated Palliative Care Outcome Scale Renal (IPOS-Renal) (https://pos-pal.org/maix/ipos-renal-in-english.php)•Dialysis Symptom Index (DSI) (www.jpsmjournal.com/article/S0885-3924(03)00517-7/fulltext)•Karnofsky Performance Status (KPS) score (http://www.npcrc.org/files/news/karnofsky_performance_scale.pdf)•Eastern Cooperative Oncology Group (ECOG) (https://ecog-acrin.org/resources/ecog-performance-status) •Edmonton Symptom Assessment Revised: Renal (ESAS-Renal) (http://palliative.org/NewPC/_pdfs/tools/ESASr%20Renal.pdf)•Integrated Palliative Care Outcome Scale Renal (IPOS-Renal) (https://pos-pal.org/maix/ipos-renal-in-english.php)•Dialysis Symptom Index (DSI) (www.jpsmjournal.com/article/S0885-3924(03)00517-7/fulltext)•Karnofsky Performance Status (KPS) score (http://www.npcrc.org/files/news/karnofsky_performance_scale.pdf)•Eastern Cooperative Oncology Group (ECOG) (https://ecog-acrin.org/resources/ecog-performance-status) In general, the approach to symptom management should involve evaluation for cause, reversible factors, level of distress or dysfunction caused by symptoms, nonpharmacologic and pharmacologic intervention options, expectation management, and acknowledgement of limitations of therapy. Of note, at this time there are no financial incentives related directly to symptom control among patients receiving dialysis. Although large dialysis organizations require annual symptom assessments such as the Kidney Disease Quality of Life instrument, therapeutic intervention is variable. ►Davison SN, Jassal SV. Supportive care: integration of patient-centered kidney care to manage symptoms and geriatric syndromes. Clin J Am Soc Nephrol. 2016;11(10):1882-1891. ★ ESSENTIAL READING►Murphy EL, Murtagh FEM, Carey I, Sheerin NS. Understanding symptoms in patients with advanced CKD managed without dialysis: use of a short patient-completed assessment tool. Nephron Clin Pract. 2009;111(1):c74-c80.►Weisbord SD, Fried LF, Mor MK, et al. Renal provider recognition of symptoms in patients on maintenance hemodialysis. Clin J Am Soc Nephrol. 2007;2(5):960-967. ★ ESSENTIAL READING Case 1: A 48-year-old man with autosomal dominant polycystic kidney disease who received a deceased donor kidney transplant develops posttransplantation lymphoproliferative disorder. He is treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), which eventually leads to remission of the posttransplantation lymphoproliferative disorder. However, toward the end of his treatment he develops severe pain in his feet and hands. The pain is bilateral, worse at night, and feels like “electric shocks.” It prevents him from sleeping. Vincristine-related neuropathy is diagnosed.Question 1: Which of the following is NOT a therapeutic tool for the treatment of neuropathy?a)Gabapentinb)Subcutaneous lidocainec)Methadoned)Duloxetinee)KetorolacFor the answer to the question, see the following text. Case 1: A 48-year-old man with autosomal dominant polycystic kidney disease who received a deceased donor kidney transplant develops posttransplantation lymphoproliferative disorder. He is treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), which eventually leads to remission of the posttransplantation lymphoproliferative disorder. However, toward the end of his treatment he develops severe pain in his feet and hands. The pain is bilateral, worse at night, and feels like “electric shocks.” It prevents him from sleeping. Vincristine-related neuropathy is diagnosed. Question 1: Which of the following is NOT a therapeutic tool for the treatment of neuropathy?a)Gabapentinb)Subcutaneous lidocainec)Methadoned)Duloxetinee)Ketorolac For the answer to the question, see the following text. Neuropathy is common in patients with kidney disease. Distinct from nociceptive pain, which is triggered by tissue damage and resolves when the tissue has healed, neuropathic pain results from damage to or pathology within the nervous system. Although the most common cause of neuropathic pain in patients with kidney disease is diabetes mellitus, there are a variety of other causes, including degenerative joint diseases, stroke, chemotherapy, and paraneoplastic conditions. The first step in treating neuropathy is determining the cause. If caused by a nerve root compression, such as lumbar radiculopathy (“sciatica”) or median nerve compression (carpal tunnel syndrome), pharmacologic management is usually ineffective and therapeutic options include surgery, steroid injections or neurolytic blocks, and supportive measures (bracing, ice, etc). Neuropathy that affects diffuse distal nerve fibers, including the symmetric distal peripheral neuropathy of diabetes and medication toxicity, is more amenable to pharmacotherapy. Borrowing from the stepwise treatment approach that has been recommended for neuropathy in the general population and taking into consideration metabolism differences and adverse effects in patients with kidney disease, the first-line pharmacologic treatment for neuropathy is a calcium channel alpha-2-delta ligand (gabapentin or pregabalin). While pregabalin is approved by the US Food and Drug Administration for diabetic neuropathy and data from randomized controlled trials (RCTs) confirm its efficacy, it is not available as a generic and therefore can be prohibitively expensive. Gabapentin, for which there is a generic version, is used off label. Alternatives include selective serotonin-norepinephrine reuptake inhibitors such as duloxetine and tricyclic antidepressants such as amitriptyline. Potential adverse effects and recommended starting doses are outlined in Table 3. In patients with CKD, it is essential to start with low doses and uptitrate slowly because adverse effects can be dangerous. Furthermore, toxicity from inappropriate dosing can cause aversion and mistrust in both the patient and provider toward these effective medications.Table 3Treatments for Neuropathy in Patients With Kidney DiseaseClassAgentsStarting DosesMost Common Adverse EffectsCalcium channel alpha-2-delta ligandsaCaution and close monitoring are recommended with any off-label use of calcium channel alpha-2-delta ligands.GabapentinPregabalinGabapentin: 100 mg daily at night (if on dialysis, reduce to 100 mg 3×/wk after dialysis)Pregabalin: 25 mg daily at night (if on dialysis, reduce to 25 mg 3×/wk after dialysis)Dizziness, drowsiness, edema, ataxiaSerotonin-norepinephrine reuptake inhibitorsDuloxetineVenlafaxine (extended release)TramadolDuloxetine: 30 mg daily (if on dialysis, avoid)Venlafaxine: 37.5 mg dailyTramadol: 50 mg every 8-12 hHeadache, drowsiness, dry mouth, nausea, insomnia, withdrawal syndromesTricyclic antidepressantsAmitriptyline10 mg daily at nightDry mouth, urinary retention, blurred vision, change in libido, dizziness, weight gain, insomniaVoltage-gated sodium channel blockersLidocainebReferral recommended to pain management specialist.MexiletenebReferral recommended to pain management specialist.Lidocaine: weight-basedMexiletene: 150 mg 1-2×/dDizziness, ataxia, nervousness, tremor, arrhythmiaOpioidsMethadonebReferral recommended to pain management specialist.2.5 mg every 8-12 hConstipation, weight gain, delirium, sexual dysfunction, prolonged QTcTopical agentsLidocaine patchCapsaicinLidocaine: 1 patch every 12 h; can wear up to 3 patches at a single timeCapsaicin: 0.025% ointment, compounded with menthol when availableNumbness (lidocaine), burning (capsaicin)a Caution and close monitoring are recommended with any off-label use of calcium channel alpha-2-delta ligands.b Referral recommended to pain management specialist. Open table in a new tab For severe or refractory neuropathic pain, referral to a palliative care or pain management specialist may be helpful for access to advanced therapies, including trials of opioids, lidocaine, and ketamine. Of the opioids, hydromorphone, fentanyl, and methadone are safest in the setting of decreased glomerular filtration rate (GFR), and methadone has the most efficacy for neuropathic pain due to its antagonism of the NMDA (N-methyl-d-aspartate) receptor. Of note, heightened awareness of the harms of opioids has led to recommendations by medical societies to avoid or deprescribe opioids in chronic noncancer pain conditions. Among all patients with serious illness, including those with advanced kidney disease, the potential risks and benefits of therapy need to be considered in the individual context of each patient. Close monitoring for adverse effects, functional goal setting, and careful dose titration are all standard parts of specialty palliative care. Nonsteroidal anti-inflammatory drugs such as ketorolac have no established role in the treatment of neuropathy, but many pain syndromes are a mix of nociceptive and neuropathic pain. Recently, in the context of heightened awareness of the potential harms of opioids, there has been increasing enthusiasm for trialing nonsteroidal anti-inflammatory drugs in select situations. However, they would not be an effective choice for the patient in this case. The correct answer to question 1 is therefore (e). With specific regard to chemotherapy-related neuropathy, knowing the natural history of the pain syndrome can facilitate shared decision making among nephrologists, oncologists, and patients regarding the need for intervention versus watchful waiting. With vincristine-related neuropathy, symptoms are dose dependent and usually reversible, with improvement seen gradually over months after discontinuation of the drug. ►Davison SN. Clinical pharmacology considerations in pain management in patients with advanced kidney failure. Clin J Am Soc Nephrol. 2019;14(6):917-931. ★ ESSENTIAL READING►Davison SN, Koncicki H, Brennan FP. Pain in chronic kidney disease: a scoping review. Semin Dial. 2014;27(2):188-204.►Finnerup NP, Attai N, Haroutounian, S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162-173. Case 2: A 63-year-old woman with advanced CKD from hypertensive nephrosclerosis presents for follow-up in the clinic. She is active on a waiting list for a kidney transplant. Her energy level is good and she is still working. She is eating well and her weight has been stable, with no hiccups, nausea, vomiting, or dysgeusia. Her main concern is itch, which affects her upper arms, thighs, chest, and back. It is worse at night and after showers. On physical examination, there is no rash. The skin is dry and there are scattered excoriations. Laboratory study results include the following values: serum creatinine, 4.1 mg/dL (corresponding to an estimated GFR of 11 mL/min/1.73 m2 as calculated using the CKD-EPI equation); potassium, 4.2 mg/dL; bicarbonate, 22 mEq/L; serum urea nitrogen, 39 mg/dL; hemoglobin, 11.1 g/dL on treatment with a monthly erythropoiesis-stimulating agent; serum albumin, 3.9 mg/dL; phosphorus, 5.3 mg/dL; and parathyroid hormone, 95 pg/mL.Question 2: What is the best next step?a)Initiate dialysisb)Refer to dermatologyc)Treat with topical emollients and low-dose gabapentinoidsd)Treat with evening primrose oile)Start UV light treatmentFor the answer to the question, see the following text. Case 2: A 63-year-old woman with advanced CKD from hypertensive nephrosclerosis presents for follow-up in the clinic. She is active on a waiting list for a kidney transplant. Her energy level is good and she is still working. She is eating well and her weight has been stable, with no hiccups, nausea, vomiting, or dysgeusia. Her main concern is itch, which affects her upper arms, thighs, chest, and back. It is worse at night and after showers. On physical examination, there is no rash. The skin is dry and there are scattered excoriations. Laboratory study results include the following values: serum creatinine, 4.1 mg/dL (corresponding to an estimated GFR of 11 mL/min/1.73 m2 as calculated using the CKD-EPI equation); potassium, 4.2 mg/dL; bicarbonate, 22 mEq/L; serum urea nitrogen, 39 mg/dL; hemoglobin, 11.1 g/dL on treatment with a monthly erythropoiesis-stimulating agent; serum albumin, 3.9 mg/dL; phosphorus, 5.3 mg/dL; and parathyroid hormone, 95 pg/mL. Question 2: What is the best next step?a)Initiate dialysisb)Refer to dermatologyc)Treat with topical emollients and low-dose gabapentinoidsd)Treat with evening primrose oile)Start UV light treatment For the answer to the question, see the following text. Not only is itch common among people living with kidney disease, it is often severe enough to influence mood, sleep quality, interpersonal relationships, and overall health-related quality of life. Among patients receiving dialysis, moderate to severe pruritus has been associated with a 17% higher mortality rate. Although pruritus may not be easy to cure, several small RCTs have shown that it can improve with treatment. Most importantly, decreasing the intensity of itch has shown to correlate with a significant improvement in health-related quality of life. The pathogenesis of uremic pruritus has been elucidated by recent advances in cutaneous neurophysiology. The sensation of itch is transmitted by myelinated A-delta afferent nerves and unmyelinated C-fibers, of which a minority (10%) are histaminergic and a majority (90%) are histamine-independent. The neurotransmission of itch through these C-fibers is complex and likely related to the uremic alterations in the immunochemical milieu of the epidermal and dermal skin layers. The therapeutic implications of this complex pathogenesis are important. Antihistamines such as diphenhydramine are commonly prescribed but they do not target the underlying pathophysiology. Although some patients depend on them to “get through” a dialysis treatment, this may stem primarily from their sedative properties rather than actual alleviation of itch. In a recent analysis of DOPPS (Dialysis Outcomes and Practice Patterns Study) data, more than two-thirds of surveyed medical directors in 17 different countries underestimated the prevalence of pruritus among patients in their facilities, and 57% used oral antihistamines as first-line long-term therapy. A clinical approach to pruritus is outlined in Figure 2. The first step is to confirm the diagnosis by history and physical examination. The distribution of uremic itch is almost always in large discontinuous bilateral skin areas involving the arms, legs, and torso. On physical examination, the most common skin finding in uremic pruritus is normal epidermis, with possible dryness or superficial excoriations. Presence of a rash suggests a primary dermatologic condition and warrants referral to dermatology. When uremic pruritus is confirmed, treatment options must be tailored to the individual patient. All patients with pruritus, even those without evident xerosis, should be advised to apply a daily over-the-counter emollient and reapply after bathing. Bathing in tepid (rather than hot) water may also reduce itch. In addition to moisturizers, data suggest that lotions with pramocaine (a topical anesthetic, also known as pramoxine) alleviate pruritus better than other moisturizing emollients. If itch persists, the next step is to try low-dose gabapentin or pregabalin. Although both have been shown to reduce pruritus significantly in small RCTs, it is important to note that neither is approved by the US Food and Drug Administration for this indication. Low doses are appropriate for people with kidney disease. The dosage or frequency can be increased as needed and tolerated, with careful adjustment for GFR. It is essential to monitor for signs of toxicity, including dizziness, changes in mental status, myoclonus, and swelling. There is no superiority of one agent over the other, and their adverse effects are comparable. Patient preference and financial cost should therefore guide initial agent selection. The correct answer to question 2 is (c). A key component of treating uremic pruritus is setting expectations. It is highly likely that therapy will need to be adjusted after initiation, as in hypertension. ►Brennan FP, Josland E, Kelly JJ. Chronic pruritus: histamine is not always the answer! J Pain Symptom Manage. 2015;50(4):566-570. ★ ESSENTIAL READING►Combs SA, Teixeira JP, Germain MJ. Pruritus in kidney disease. Semin Nephrol. 2015;35(4):383-391.►Lau T, Leung S, Lau W. Gabapentin for uremic pruritus in hemodialysis patients: a qualitative systematic review. Can J Kidney Health Dis. 2016;3:1-14.►Pisoni RL, Wikstrom B, Elder SJ, et al. Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Ne" @default.
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