Renal disease

RENAL DISEASE

Cancer patients may develop renal impairment e.g.

•  ureteric obstruction caused by compression by a pelvic tumour, or

•  as a consequence of a concurrent illness

If clinically appropriate  the origin of the renal impairment should be investigated and corrected if possible

e.g. stenting in ureteric obstruction

As previously described the cause of pain and other symptoms should be identified and treated appropriately.

In patients with End Stage Renal Disease (ESRD) specific causes of pain may be due to:

•  Underlying disease e.g. polycystic kidney disease, diabetic neuropathy

•  Renal disease and its treatment eg. calciphylaxis (tissue ischaemia due to calcification of tissue and small arteries in dialysis patients); ischaemic neuropathies due to A-V fistulae; peritonitis due to peritoneal dialysis

 

ANALGESIA IN PATIENTS WITH RENAL DISEASE

Many analgesics are excreted by the kidneys and any degree of renal impairment can reduce drug clearance, and therefore the dose of drug required. Glomerular filtration rate (GFR) gives an indication of how much drug clearance will be affected by renal impairment. Renal dysfunction can also influence the absorption, metabolism, distribution and pharmacodynamics of many drugs.

End Stage Renal Disease (ESRD) correlates to

•  GFR of less than 15mls/min or

•  Stage 5 (UK CKD Guidelines 2005)

Stages of CKD1

Stage eGFR Description
1 >90 mL/min Normal renal function
2 60–89 mL/min Mildly reduced renal function
3 30–59 mL/min Moderately reduced renal function
4 15 –29 mL/min Severely reduced renal function
5 <15 mL/min Very severe or ESRD

eGFR estimated glomerular filtration rate

Patients with GFR 15-29mls/min (Stage 4) will also be more safely managed with medication dose reductions recommended for Stage 5 disease.


CREATININE CLEARANCE

Creatinine clearance is used as an approximation of GFR. Medicine dosing medications in patients with renal disease are made using the creatinine clearance. Creatinine clearance is calculated using the Cockcroft and Gault formula.

Palliative-Care-Guidlines_Page_100Palliative-Care-Guidlines_Page_101Palliative-Care-Guidlines_Page_102NB For doses and conversions  mentioned in above and below tables please see relative doses of opioids
Palliative-Care-Guidlines_Page_103

Palliative-Care-Guidlines_Page_104Palliative-Care-Guidlines_Page_105Palliative-Care-Guidlines_Page_106Palliative-Care-Guidlines_Page_107NB For doses and conversions  mentioned in above and below tables please see relative doses of opioids