Chronic kidney disease (CKD) can be classified by cause, glomerular filtration rate (GFR), and by albuminuria.
For non-specialists, estimated GFR (EGFR) acts as the best overall marker of kidney function.
Disease specific causes of pain include:
- Underlying disease e.g. polycystic kidney disease, diabetic neuropathy
- Renal disease and its treatment e.g. 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
Stages of CKD based on estimated glomerular filtration rate (eGFR)
eGFR (ml/min/1.73m2)
Description of Renal Function
Stage 1
eGFR:
>90 mL/min
Normal
Stage 2
eGFR:
60-89 mL/min
Mild decrease
Stage 3
eGFR:
30-59 mL/min
Moderate decrease
Stage 4
eGFR:
15-29 mL/min
Severe decrease
Stage 5
eGFR:
<15 mL/min
Kidney failure / End stage kidney disease
EGFR should be interpreted with caution. It is standardised to a body surface area of 1.73m2 and may over-estimate true renal function.
The Cockcroft and Gault formula is the preferred method for estimating renal function or calculating drug doses in patients with renal impairment who are elderly or at extremes of muscle mass, and where the renal function is fluctuating rapidly.
Symptom control medications should be modified for patients with cancer and concurrent renal failure, as well as those with non-malignant conditions causing end stage kidney disease.
Renal impairment will affect the excretion of many drugs and therefore the main concern when prescribing is the increased risk of accumulation and toxicity. Some drugs are not effective when renal function is reduced e.g. nitrofurantoin
In patients with cancer, how medications are absorbed and processed in the body may also vary due to cachexia and low albumin state.
It is important to note patients with end-stage kidney disease will also be more likely to have complications of cardiovascular disease and anaemia of chronic disease.
Patients with cancer may develop acute kidney injury due to:
- Ureteric obstruction from compression by pelvic tumour
- Consequence of intercurrent illness (i.e. acute kidney injury in neutropenic sepsis)
- Complication of some chemotherapy/immunotherapy treatments
If clinically appropriate, the cause of renal impairment should be investigated and reversed if possible (e.g. stenting in ureteric obstruction).
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.