Supportive Care for the Renal Patient
Authors: Robin G Woolfson
Journal: Journal of the Royal Society of Medicine (2005)

The demographics of renal failure are horrific. The dialysis population is set to double in the next 10 years or so. This growth reflects the ageing of the population, the burgeoning of ethnic communities in whom end-stage renal failure (ESRF) is six times more common than in Caucasians, the increasing prevalence of diabetes mellitus and the improved survival of patients on dialysis. Although only 0.06% of the UK population require renal replacement therapy this group accounts for 3% of the annual National Health Service spend. This is not only an economic nightmare but also a personal disaster for the individuals affected. In 2000, the annual acceptance rate of new patients starting renal replacement therapy was 95 patients per million population, which compares with 50 pmp in 1987. This growth is most dramatic in the older age groups, with the incidence of ESRF in patients aged over 65 years having risen from 80 pmp to 280 pmp.

However, the overall take-on-rate for renal replacement therapy in the UK is eclipsed by those in most other developed countries—for example, Spain at 132 pmp, Greece at 154 pmp and the USA at 333 pmp. These data suggest continuing unmet need in the UK which is probably due to failure to diagnose renal failure as well as under-referral of affected patients to nephrologists. This under-referral, most likely of older patients, needs urgently to be quantified and explained. Some of it may reflect the perceived poor quality of life of patients receiving dialysis, particularly for those elderly patients with multiple comorbidities, and a misconception that nephrologists dialyse patients willy-nilly. And indeed, for many of these patients, dialysis is not an appropriate therapy. However, most renal units now provide a maximal medical therapy option by which the patient can benefit from all therapeutic interventions short of dialysis. Increasingly, the multi-professional nephrology team is engaged in the palliation of symptoms in patients with renal failure and part of their task is to identify those patients who will not benefit from renal replacement therapy as well as those who will benefit from stopping it.

For many of us, palliative therapy conjures up the image of hospice care and adequate analgesia at the end of life. But in reality, all chronic diseases are managed by palliation of symptoms and there are some excellent palliative therapies available for patients with renal failure. Probably the best example is correction of anaemia with erythropoietin: indeed, treatment guidelines now favour early palliation of anaemia—long before dialysis is required—to improve patient wellbeing and survival. The purpose of Supportive Care for the Renal Patient is to empower the multi-professional nephrology team. It recommends the development of timely management plans for renal patients with appropriate supportive measures for individual renal patients as they are needed and not belatedly. There are useful chapters devoted to the management of specific physical symptoms in uraemia, and others which address psychological and spiritual management. There is guidance as to how to identify those patients who may benefit from dialysis and those who are unlikely to do so. The chapter on measuring health-related quality of life shows us that it is possible to bring scientific rigour to our evaluation of how patients are doing, over and above the surrogate outcomes of death, haemoglobin, biochemical variables and blood pressure. Nephrology will surely have come of age when such measures are routinely included in the annual audit cycle and Renal Registry dataset.

This stylishly produced and modestly priced volume is essential reading for all members of the multiprofessional team concerned with the holistic management of patients with renal failure.