The landscape of options for treating people with kidney failure is shifting. It used to be that the “only” robust option in the US was dialysis. You can listen to our prior podcast with Keren Ladin talking about patients who viewed dialysis as their only option, and structural issues that led to this point (including this takedown of for profit dialysis companies by John Oliver). One of the problems was a lack of an alternative robust option to offer patients. As one of our guests says, you have to offer them something viable as an alternative to dialysis.

Today we interviewed Sam Gelfand, dually trained in nephrology and palliative care, Kate Sciacca, a nurse practitioner (fellowship trained in palliative care), and Josh Lakin, palliative care doc, who together with a social worker and other team members started KidneyPal at DFCI/BWH, a palliative care consult service for people with advanced kidney disease. As a team, they provide a robust alternative to dialysis for patients with kidney failure: conservative kidney management.

And “conservative,” as they note, can mean not only a “conservative approach,” as in non-invasive/less aggressive, but also an effort to “conserve” what kidney function remains.

We get right down to the nitty gritty of kidney supportive care techniques they incorporate in clinic, including:

Communication about the choice between dialysis and conservative kidney management: what are the tradeoffs? Function often declines after initiating dialysis, at least among nursing home residents. Dialysis may extend life, but those “additional” days are often spent in the hospital or dialysis, away from home. Symptoms are common in both options, though more anxiety and cramping in dialysis, more pruritus and nausea in conservative kidney management..
Introducing the idea of hospice early, at the time of diagnosis with kidney failure. Listen also to our prior podcast with Melissa Wachterman on hospice and dialysis.
Approaches to treating fatigue
Approaches to treating pain - the second most common symptom (!) - and the answer isn’t tramadol (or tramadon’t) - rather think buprenorphine patch or methadone, and how to dose gabapentin and pregabalin. Also, don’t count out the NSAIDS!
Approaches to treating itching/pruritus
Approaches to treating nausea

Our guests were deeply grateful to their colleagues Dr. Frank Brennan, Dr. Mark Brown, and clinical nurse consultant Elizabeth Josland of the renal supportive care team at St. George Hospital in Sydney, Australia (down under) for teaching them the ropes of palliative care in kidney failure. And we got to learn some new vocabulary, including the meaning of “chunder.”

Enjoy!

-@AlexSmithMD

Palliative Care for Kidney Failure: Sam Gelfand, Kate Sciacca, and Josh Lakin

GeriPal - A Geriatrics and Palliative Medicine Podcast