KDIGO Controversies: Managing the symptom burden associated with maintenance dialysis

There is a growing recognition of the frequency and burden of symptoms experienced by individuals undergoing haemodialysis or peritoneal dialysis. A wide range of physical symptoms are reported, with fatigue being the most common and pain the most severe. Rates of anxiety and depression are also very high. 

Traditionally, nephrology care has focused largely on numerical targets for laboratory measures and on outcomes, such as cardiovascular disease and mortality, rather than on patient-reported outcomes, such as symptoms. When symptoms are identified, treatment is initiated infrequently and options are limited. In part, this is due to the limited evidence base and the complexities of medication interactions in the dialysis setting. 

In May 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference to identify the optimal means for diagnosing, managing and treating symptom-based complications in people undergoing dialysis. Participants included patients, physicians, behavioural therapists, nurses, pharmacists and clinical researchers. 

Foundational principles and consensus points related to identifying and addressing symptoms experienced by patients were outlined. These included: the individualisation of approach, with elicitation of patient symptoms; a focus on acknowledging and managing the symptoms that are most important to patients; consideration of the biological, psychological and social factors that surround the patient, and the resources available locally; and the role of healthcare delivery and education in addressing individualised symptom assessment and management, including improving existing pathways.

Gaps in the knowledge base, including in symptom management in kidney failure, were described. Real-world data should be used to supplement evidence from controlled trials to support decision-making on the effectiveness of interventions.

The conference participants concluded that particular attention should be paid to the relative effectiveness of management strategies, including the impact on outcomes most relevant to inpatients, such as overall symptom burden, physical function and health-related quality of life.

The full conclusions can be read here.