S OLENSKI1,2, H FARRELL1, P MARTIN1
1University Hospital Geelong, Geelong, Victoria; 2Royal Brisbane and Women’s Hospital, Brisbane, Queensland
Background: ESKD patients face many physical and psychosocial challenges related to their multiple symptoms and high mortality rates. Their symptom burden is on par with those with advanced malignancies, with uraemic pruritus affecting at least 40% of ESKD patients. Pruritus is a complicated symptom to manage and is associated with poor sleep, depression and a reduced quality of life.
Furthermore, issues relating to prognostication, communication and discussions about goals of care are of paramount importance to both patients and care-givers, given the high mortality rates associated with ESKD. Nevertheless, there is a paucity of evidence in the conservatively-managed population on how best to approach and achieve this.
Case Report: An 80 year old mother of 8 with ESKD presumed secondary to hypertension elected for a non-dialytic pathway. Prior to referral to Palliative Care, her nephrologist told the family that she had “weeks to months” left. Significant stress accumulated across the family unit in her final weeks, as they became fixed about the exact timing of her death.
She subsequently developed severe pruritus which only partially responded to gabapentin. Her pruritus contributed to a sleep disorder, which was additive in contributing to her terminal delirium. Terminal sedation with midazolam was the only way to relieve her of her suffering.
Conclusions: Pruritus is a difficult symptom to treat despite the availability of efficacious therapies. This case highlights one example of how uraemic symptoms can multiply and add to the symptom burden. Moreover, this case touches upon some of the subtleties of prognostication and the intrinsic difficulties in communicating survival predictions. More research into the development of prognostic tools is required to aid nephrologists caring for ESKD patients.