Introduction

The Renal Physicians Association identifies two groups of children and young people (CYP) who may be considered unsuitable for dialysis and transplant:

  1. 1.

    Those who, often due to complex multi-system disease or co-morbidity, would not be suitable candidates for transplant and where dialysis is considered a significant burden without medium- to long-term benefit.

  2. 2.

    Those who have embarked on dialysis, but for whom transplant is no longer (or has never been) an option, where the burden of dialysis has become too great in relation to potential benefit [1].

The Renal Physicians Association has also published guidance for shared decision-making regarding the withholding and withdrawing of dialysis in paediatric patients. These recommendations include:

  1. 1.

    Forgoing dialysis if initiating or continuing dialysis is deemed to be harmful, of no benefit, or merely prolongs a child’s dying process.

  2. 2.

    Consider forgoing dialysis in a patient with a terminal illness whose long-term prognosis is poor if the patient and family agree with the physician that dialysis would not be of benefit or the burdens would outweigh the benefit.

  3. 3.

    Consider the use of a time-limited trial of dialysis in neonates, infants, children, and adolescents with acute kidney injury (AKI) or stage 5 chronic kidney disease (CKD 5) to allow for the assessment of extent of recovery from an underlying disorder.

  4. 4.

    Develop a palliative care plan for all paediatric patients with CKD 5 from the time of diagnosis and for children with AKI who forgo dialysis [1].

This article focuses on the palliative management of CYP with CKD 5 where kidney transplant is not an option and where a decision has been made to withdraw or withhold dialysis. The recommendations made are based on published literature combined with the clinical experience of a palliative care team working in a large tertiary centre.

Shared decision-making and advance care planning

When addressing significant kidney disease, professionals must have an open and honest, age and developmentally appropriate approach to communicating with CYP, working in partnership with parents. Studies indicate that any approach to discussion of the illness or management of care and treatment should reflect all individuals, especially the CYP’s preference for degree and timing of disclosure [2,3,4]. In circumstances where withholding or withdrawing dialysis is being considered, discussions should involve a palliative care specialist, where available, in addition to the renal physician, so the family can be given a full understanding of all the options for care [5]. In order to best support parental and CYP decision-making, it is important that they receive information about life on dialysis, or with a transplant, and the feasibility and likelihood of success [6], as well as what palliative management will involve, including what symptoms to expect, and where and how these can be managed. Attention should be given to the family’s thoughts on the impact of any intervention, on the child, their family life, and on their child’s prognosis, as well as what they consider the likely outcome, what they would like to see happen, and what they think will happen [7].

Enabling families to choose where and how they spend their time is a key component of palliative care. Some may choose a very hospital-focused approach to end of life care, but others may want most of their care to be at home or in a children’s hospice. If choosing to be at home, families will need clear guidance with regard to symptom assessment, management, and medication administration, and will require access to appropriate medication and equipment, 24-h palliative care, and the support of teams in their own community (e.g. children’s community nurses, family doctor, paediatrician). After death, it may be possible for ongoing care to be provided at home or in a hospice, regardless of where the CYP died, as an alternative to a funeral home or mortuary. If families choose for the CYP to move after death, transport plans should be put in place in advance.

The presence of both palliative care and renal teams for these discussions ensures continuity of care and joined-up work, preventing families from feeling that the renal team has ‘given up’ on their child. Both teams present together assures the family in a concrete and substantive manner that the child and family will not be abandoned, often a major concern of parents [7].

These discussions are part of the advance care planning process: a process in which the parents/CYP and clinical teams discuss what the future may look like, the options available, and their priorities and goals [8]. It allows consideration of medical interventions, resuscitation, place of death, and care after death as well as wishes for life [8]. Decisions made and wishes voiced should be clearly recorded, for example in an advance care plan document such as the Children and Young Person’s Advance Care Plan (www.cypacp.uk), and shared with relevant professionals.

It is important to recognise that parents/CYP often strive to keep their options open [8] and responses like ‘I’ll decide at the time’ are not atypical. Advance care planning discussions will usually, and appropriately, require a series of conversations over time, with plans reviewed and adapted as the CYP’s condition changes.

Symptom management

CKD 5 is associated with a significant symptom burden. One adult study reported over 50% of adult patients experienced lack of energy, itch, drowsiness, dyspnoea, poor concentration, pain, poor appetite, swelling of arms/legs, and dry mouth [9]. A study in children with CKD 5 reported pain in over 50% and a high incidence (20–40%) of other symptoms, including fatigue, nausea, dyspnoea, agitation, and pruritis [10].

Prevention of symptoms

Consideration should be given to management of blood pressure, fluid balance, anaemia, acidosis, hyperkalaemia, magnesium, and phosphate. Any interventions require regular review, incorporating the views of the CYP and parents, to avoid continuing those that have no or minimal benefit, or where the burden (such as hospital attendance) outweighs perceived benefit.

Holistic management

A holistic approach to symptom management is essential, addressing psychological, social, and spiritual factors that influence symptom experience and response. Non-pharmacological approaches such as massage, relaxation techniques, and guided imagery should be used both alongside or in place of medication. A psychologist and/or Child Life specialist should be part of the team caring for the CYP and family and CYP should have opportunities to explore and express their understanding, fears, and wishes through other modalities such as art, music, or drama therapy.

Medication dosing

CKD 5 significantly alters the effects of medications, promoting potential toxicity [11]. Estimation of glomerular filtration rates and creatinine clearance are the most common tools used when determining appropriate dosing. However, this does not account for the influence of tubular secretion or for the effects of CKD 5 on pharmacokinetic variables such as absorption, distribution, metabolism, and elimination [12].

Prescribers must be aware of potential toxicity and prescribe according to a recognised formulary, such as the Association for Paediatric Palliative Medicine Drug Formulary [13], the British National Formulary for Children (BNFc), or other relevant local or national formularies, and make the recommended dose adjustments.

Recommendations in this article are based on a combination of existing evidence for dose modification, known pharmacokinetic parameters, and clinical experience.

Pain (Table 1)

Pain is a common, often underestimated, symptom in CKD 5 [10, 31] and may include musculoskeletal, neuropathic, and bone pain, as well as discomfort due to a renal mass or ascites.

Table 1 Summary of pain management in stage 5 chronic kidney disease (CKD 5)
Full size table

Paracetamol is the non-opioid analgesic of choice. Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided, unless the benefits of therapy are deemed to outweigh risks.

Opioids have been poorly studied within paediatrics, particularly in CKD 5. Fentanyl, alfentanyl, and methadone appear to be the safest opioids, due to hepatic metabolism to inactive metabolites [23, 32]. Fentanyl and alfentanyl uses are limited by the lack of appropriate enteral formulations and clinical experience. The complex pharmacokinetic profile of methadone plus lack of experience outside specialist units makes methadone a less than ideal choice. Hydromorphone, not commonly used in the UK, is not recommended due to the potential accumulation of neurotoxic metabolites [23]. However, we acknowledge that where clinicians are experienced in the use of hydromorphone it could be used cautiously on an ‘as needed’ basis.

Despite many reference sources suggesting the avoidance of oxycodone or morphine, there is evidence to suggest careful introduction and dosing may be safe and effective [14, 18], particularly following bolus dose administration. Morphine and oxycodone are therefore generally the opioids of choice in paediatric CKD 5, particularly for enteral use. We recommend increasing the dosing interval rather than reducing the dose, to ensure adequate analgesia, but with sufficient time for clearance to reduce accumulation. Risk of accumulation increases with repeated doses; in this instance, dose reduction may also be needed but should be titrated carefully to ensure good analgesic effect.

Peripheral neuropathy and neuropathic pain are not unusual in CKD 5 [33] but most medications commonly used to treat neuropathic pain should be avoided or used at significantly reduced doses.

Recommendations for management are given in Table 1.

Agitation (Table 2)

Agitation is often attributed to the accumulation of toxic metabolites, but factors such as pain, breathlessness, fear, and drug toxicity should be considered. Where medication is required, cautious use of haloperidol with dose reduction, or levomepromazine with slow careful dose titration, is likely to be the best option, although midazolam may have a role in some situations.

Table 2 Summary of symptom management medication recommendations
Full size table

Dyspnoea (Table 2)

Dyspnoea is most frequently due to infection, anaemia, or pulmonary oedema. Interventions directed at treating an underlying cause may be appropriate, alongside symptomatic management. The benefits of fluid restriction may be limited and an unnecessary burden, and diuretics may have limited response. Blood transfusion can be burdensome and exacerbate fluid overload. For symptomatic relief, non-pharmacological interventions, such as a hand-held fan directed at the face, can be effective [45]. An opioid should be the first-choice medication, given at 25–50% of the dose used for pain management [46] on an ‘as needed’ basis. Using midazolam alongside an opioid may give additional benefit [47], but this should be used cautiously.

Nausea and vomiting (Table 2)

Nausea and vomiting can result from raised urea levels and metabolic disturbance, but also gastrointestinal fluid retention, gastric stasis, reflux, pain, and anxiety. Allowing CYP to eat ‘little and often' or reducing nasogastric/gastrostomy feed volumes may bring relief without recourse to medication. First-choice anti-emetics are haloperidol, with dose reduction, or levomepromazine, starting at a low dose and titrating up slowly [40].

Metoclopramide is an option where gastric stasis is a factor, but accumulation may occur in kidney impairment so dose reduction is required [40, 41]. Ondansetron is safe for use, without dose modification.

Pruritis (Table 2)

Regular skin care, using emollients, is essential. Phosphate binders can be effective if phosphate levels are high. In uraemic itch, antihistamines may have little benefit and low-dose gabapentinoids are likely to be preferable [48]. The benefit of ondansetron is negligible [49]. Amongst the less frequently used drugs, there is conflicting evidence for the role of naltrexone [50, 51] but evidence for the benefit of thalidomide [52], which can be used without dose adjustment, though experience of use in paediatrics is extremely limited [53].

Fatigue

Fatigue may be due to or exacerbated by anaemia. For some, regular transfusion may be appropriate, but this needs to be considered against the burden of hospitalisation and need for intravenous access, as well as the risk of fluid overload exacerbating dyspnoea. Maintaining haemoglobin with an erythropoiesis stimulator can be a helpful compromise, but will have limited benefit in advancing disease. Practical approaches to managing fatigue should not be overlooked. Maintaining a good day/night pattern, with activities during the day and a good bedtime routine, is important. Good management of symptoms will aid undisturbed sleep, as well as addressing anxieties and fears, which can often be exacerbated overnight.

Secretions (Table 2)

As conscious levels reduce, CYP become less able to manage oral secretions. Hyoscine hydrobromide crosses the blood–brain barrier and may cause increased drowsiness, delirium, or paradoxical agitation, particularly in CKD 5 where uraemia increases the permeability of the blood–brain barrier [40]. Glycopyrronium (glycopyrrolate) is generally the drug of choice, with dose reduction required and careful dose titration [44]. Hyoscine butylbromide can also be used and is safe for use in CKD 5 without dose reduction.

Key summary points

  1. 1.

    Decisions to commence or forgo dialysis and transplant should be made jointly between the clinical teams, parents, and, where appropriate, the CYP.

  2. 2.

    Advance care planning is the process through which clinicians, parents, and CYP discuss and document their priorities and goals for future care. It should include, but not be limited to, agreement of treatment limitations.

  3. 3.

    CKD 5 is associated with a significant symptom burden that includes pain, agitation, and dyspnoea. The prevalence of physical and psychological symptoms may be greater than those in patients with advanced cancer.

  4. 4.

    CKD 5 significantly alters the effects of medications, often promoting toxicity; however, information regarding the extent of dose reduction for many drugs is limited. It is essential that prescribers are aware of potential toxicity, prescribe using a recognised formulary, observe patients closely, and adjust doses cautiously (considering both reducing doses and increasing dosing intervals) in response to effect and observed toxicity.

Multiple choice questions (answers are provided following the reference list)

  1. 1.

    Advance care planning discussions

    1. a)

      Should result in an agreement regarding resuscitation and limitations of treatment.

    2. b)

      Are often a series of conversations over a period of time and decisions may change.

    3. c)

      Must be led by a palliative care physician.

    4. d)

      Should only involve the CYP in exceptional circumstances

  2. 2.

    When involving CYP in decision-making

    1. a)

      Child/young person’s age is the most important consideration.

    2. b)

      Clinician should meet with the child/young person alone.

    3. c)

      Child/young person’s wishes should take precedence over the wishes of parents.

    4. d)

      Child/young person should determine degree and timing of disclosure of information about care, treatment, condition, and prognosis.

  3. 3.

    When selecting an opioid for pain management in CKD 5

    1. a)

      Morphine should be avoided due to accumulation.

    2. b)

      Oxycodone is a good option for a long-acting opioid.

    3. c)

      Fentanyl or alfentanyl are the preferred option for a continuous infusion.

    4. d)

      The opioid dosing interval should generally be reduced.

  4. 4.

    When treating neuropathic pain in CKD 5

    1. a)

      Ketamine should be used cautiously, with dose reduction.

    2. b)

      Gabapentin is safe to use without dose reduction.

    3. c)

      Tricyclics can be used cautiously.

    4. d)

      Pregabalin can be used but with dose reduction and a long dosing interval.

  5. 5.

    The following medications can be used to manage agitation

    1. a)

      Haloperidol at 50% dose reduction.

    2. b)

      Levomepromazine at lowest recommended starting dose.

    3. c)

      Bolus doses of midazolam, without dose reduction.

    4. d)

      All of the above.