Moral Distress in Nephrology: Perceived Barriers to Ethical Clinical Care.

Moral distress occurs when individuals are unable to act in accordance with what they believe to be ethically correct or just. It results from a discrepancy between a clinician's perception of "the right thing to do" and what is actually happening and is perpetuated by perceived constraints that limit the individual from speaking up or enacting change. Moral distress is reported by many clinicians in caring for patients with serious illness, including chronic kidney disease and kidney failure. If left unidentified, unexpressed, or unaddressed, moral distress may cause burnout, exhaustion, detachment, and ineffectiveness. At an extreme, moral distress may lead to a desire to abandon the speciality entirely. This article offers an international perspective on moral distress in nephrology in diverse contexts and health care systems. We examine and discuss the sociocultural factors that contribute to moral distress in nephrology and offer suggestions for interventions from individual provider, facility, and health care systems perspectives to reduce the impact of moral distress on nephrology providers.

Cardiac high-sensitivity troponin T measurement: a layer of complexity in managing haemodialysis patients.

AIM: To determine: (i) the proportion of stable asymptomatic haemodialysis patients with elevated troponin; (ii) stability of troponin values after dialysis and over a 2-week interval; and (iii) whether high-sensitivity troponin T (hsTnT) was associated with higher prevalence of cardiovascular risk factors or cardiovascular disease in these patients. METHODS: We measured hsTnT and the fourth generation troponin I before and after dialysis in 103 stable in-centre haemodialysis patients without ischaemic symptoms. Patients were divided into quartiles to test for associations with established cardiovascular risk factors or disease. RESULTS: hsTnT was above the 99th percentile for the general population in 99% of haemodialysis patients compared with only 13% elevation for the troponin I assay (P < 0.001). Median pre-dialysis hsTnT concentrations were unchanged after a 2-week interval (69 vs 69 ng/L, P = 0.55) but fell slightly immediately following dialysis (69 vs 61 ng/L, P < 0.001). Established coronary artery disease (59% vs 22%), peripheral vascular disease (38% vs 4%) and diabetes (18% vs 7%) were more prevalent (P < 0.05) in those in the highest quartile for hsTnT compared with those in the lowest quartile. CONCLUSION: Almost all in-centre haemodialysis patients have elevated troponin T in their baseline stable state and this appears unchanged over a 2-week interval. Such a high rate of baseline elevation of hsTnT may lead to confusion in managing acute coronary syndrome in this group of patients, particularly when symptoms are atypical. We recommend that if Troponin I assay is unavailable then baseline hsTnT concentrations are measured periodically in all haemodialysis patients.

Efficacy and safety of gabapentin for uremic pruritus and restless legs syndrome in conservatively managed patients with chronic kidney disease.

CONTEXT: Pruritus and restless legs syndrome (RLS) frequently affect patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD), impacting the quality of life. Gabapentin (1-aminomethyl cyclohexane acetic acid) alleviates these symptoms in hemodialysis (HD) patients, but data are lacking for patients on the conservative pathway. OBJECTIVES: To determine the safety and effectiveness of gabapentin for pruritus or RLS in conservatively managed patients (n = 34) with CKD and ESKD. METHODS: This was a single-center retrospective cohort study. We compared dosing and side effects in 34 CKD/ESKD patients with similar patients receiving HD (n = 15). RESULTS: Forty-four percent of conservatively managed patients complained of RLS and/or pruritus; 18% were excluded for a nonuremic cause of symptom. Thirty-four patients were included in the final analysis. The most common starting daily dose of gabapentin was the equivalent of 50 mg (44.1%) or 100 mg (38.2%) daily, with the median daily dose of 100 mg (range 39-455 mg). Side effects occurred in 47% of patients, with 17% discontinuing gabapentin. Gabapentin reduced symptoms of pruritus (P < 0.001) and RLS (P < 0.05). There was no statistical difference when comparing HD and conservatively managed patients for daily starting dose (P = 0.88), median dose (P = 0.84), and final dose (P = 0.18). Patients conservatively managed were more likely to manifest side effects compared with HD patients (47.1% vs. 14.3%, P = 0.023). Dose was not found to be a factor associated with side effects in univariate analysis. CONCLUSION: Gabapentin is a viable treatment for conservatively managed CKD and ESKD patients with pruritus and/or RLS, but side effects are common. Gabapentin should be used with caution although higher doses do not appear to be a factor associated with side effects.

CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life.

BACKGROUND AND OBJECTIVES: Survival, symptom burden, and quality of life (QOL) are uncertain for elderly patients with advanced CKD managed without dialysis. We examined these outcomes in patients managed with renal supportive care without dialysis (RSC-NFD) and those planned for or commencing dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this prospective observational study, symptoms were measured using the Memorial Symptom Assessment Scale and the Palliative care Outcomes Scale - Symptoms (renal) inventory and QOL was measured using the Short Form-36 survey. This study comprised 273 predialysis patients who had usual nephrology care and 122 nondialysis pathway patients who also attended a renal supportive care clinic adding the skills of a palliative medicine team. A further 72 patients commenced dialysis during this period without attending either clinic. RESULTS: Nondialysis patients were older than the predialysis group (82 versus 67 years; P<0.001) but had similar eGFR at the first clinic visit (16 ml/min per 1.73 m(2); P=0.92). Of the predialysis patients, 92 (34%) commenced dialysis. Compared with the RSC-NFD group, the death rate was lower in the predialysis group who did not require dialysis (hazard ratio, 0.23; 95% confidence interval, 0.12 to 0.41] and in those requiring dialysis (0.30; 0.13 to 0.67) but not in dialysis patients who had not attended the predialysis clinic (0.60; 0.35 to 1.03). Median survival in RSC-NFD patients was 16 (interquartile range, 9, 37) months and 32% survived >12 months after eGFR fell below 10 ml/min per 1.73 m(2). For the whole group, age, serum albumin, and eGFR <15 ml/min per 1.73 m(2) were associated with poorer survival. Of the nondialysis patients, 57% had stable or improved symptoms over 12 months and 58% had stable or improved QOL. CONCLUSIONS: Elderly patients who choose not to have dialysis as part of shared decision making survive a median of 16 months and about one-third survive 12 months past a time when dialysis might have otherwise been indicated. Utilizing the skills of palliative medicine helps provide reasonable symptom control and QOL without dialysis.