Symptom management for people on haemodialysis: Insights from KDIGO

Historically, the focus of optimal care for kidney patients has been on hard outcomes, such as cardiovascular events, hospital admissions and mortality. More recently, however, the focus has shifted to include outcomes relating to patients’ quality of life, preferences and life participation. A recently published systematic review, including 449 studies, found that people on dialysis reported a large number of symptoms, with varying severity (Fletcher et al, 2022). The effect of symptom impact on functioning could be more important to patients than symptom frequency or even severity. 

Recognising this, Kidney Disease: Improving Global Outcomes (KDIGO) initiated a controversies conference in 2022, with nephrology professionals and patients, to look at symptom burden and its management in people on dialysis. The consensus recommendations from this work are now published (Mehrotra et al, 2023). There are some key recommendations from this that will be relevant to the way we manage people on dialysis. The first suggests that, “Regular global symptom screening should be incorporated into routine clinical practice.” This recommendation is supported by the recently published Renal Services Transformation Programme for enhanced supportive care, which recommends the same (NHS Futures, 2023). One symptom-screening tool currently used by some renal centres is the IPOS renal score. This score asks patients to prioritise their main concerns/symptoms over the last week. 

The second key recommendation is that, “Nephrology multidisciplinary teams should take the lead in symptom management, with holistic care as the goal”, and notes that many symptoms will require the expertise of other healthcare providers, as is seen in some renal centres where palliative care specialists are involved in renal supportive care clinics. 

Although there may be an awareness of symptoms by the renal clinical team, it can be difficult to manage certain symptoms owing to lack of available therapeutic options. One particular example is fatigue, which is multifactorial and has been shown to be particularly prevalent and burdensome for people on dialysis. However, there is also an increasing desire to improve symptom management and, this month, a group from Pittsburgh looked at a Technology Assisted Collaborative Care intervention in haemodialysis patients with significant levels of fatigue, depression and pain. Compared to a control of monthly health education, the stepped intervention of monthly cognitive behaviour therapy and/or pharmacotherapy reduced fatigue and pain over 6 months (Jhamb et al, 2023). This is promising for patients, although consideration should be given to the resource required to provide the service on a large scale.

There have also been new developments within the treatment of chronic kidney disease-associated pruritus (CKD-aP). Difelikefalin, a novel treatment for CKD-aP for people on haemodialysis, was recommended by a recent NICE technology appraisal for moderate-to-severe pruritus (based on the Worst Itch Numeric Rating Scale [WI-NRS]; NICE, 2023), with good quality randomised controlled trial data supporting the outcomes of improvement in pruritus and sleep scores (Topf et al, 2022). This is great news in the management CKD-aP, with the added benefit of not adding to pill burden. A further randomised controlled study just published, examined the use of sertraline 50 mg twice daily in haemodialysis patients with pruritus versus placebo (Elsayed et al, 2023). The study found significant reduction in itch scores at 8 weeks with sertraline. 

As the KDIGO paper highlights, we still have many unanswered questions. Further research is needed to understand the pathophysiology of symptoms (which may help develop new treatments), and how well symptom assessment meets patient priorities and what is an acceptable frequency of ongoing assessment. However, the recommendations from this KDIGO controversies conference are the first step in highlighting symptoms as a priority for care.

A digest of the report can be read here.

References

Elsayed MM, Elgohary IE, Abdelhamid HHS et al (2023) The effectiveness of sertraline in alleviating uremic pruritus in hemodialysis patients: a randomized clinical trial. BMC Nephrol 24: 155

Fletcher BR, Damery S, Aiyegbusi OL et al (2022) Symptom burden and health-related quality of life in chronic kidney disease: A global systematic review and meta-analysis. PLoS Med 19: e1003954

Jhamb M, Steel JL, Yabes JG et al (2023) Effects of technology assisted stepped collaborative care intervention to improve symptoms in patients undergoing hemodialysis: The TĀCcare randomized clinical trial. JAMA Intern Med 20 Jun; e232215 [Epub ahead of print]

Mehrotra R, Davison SN, Farrington K et al; for Conference Participants (2023) Managing the symptom burden associated with maintenance dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 7 Jun [Epub ahead of print]

NHS Futures (2023) Renal Service Transformation Programme. Available at:  https://future.nhs.uk/RSTP (accessed 21.07.23)

NICE (2023) Difelikefalin for treating pruritus in people having haemodialysis (TA890). NICE, London. Available at: https://www.nice.org.uk/guidance/ta890 (accessed 21.07.23)

Topf J, Wooldridge T, McCafferty K et al (2022) Efficacy of difelikefalin for the treatment of moderate to severe pruritus in hemodialysis patients: pooled analysis of KALM-1 and KALM-2 phase 3 studies. Kidney Med 4: 100512