This section is meant to assist in determining whether a patient with end-stage renal disease is appropriate for hospice care.
Absent other co-morbid conditions, the patient should not be seeking dialysis or renal transplant. Patients who do refuse dialysis or transplant are generally appropriate for hospice services if they fit dialysis criteria. When evaluating patients with end-stage renal disease (ESRD), a nephrology consultation may be helpful since individual patient variables can influence longevity.
Hospitalized patients may develop acute renal failure (ARF) following trauma or major surgery. Short-term survival may be difficult to predict during initial evaluation and treatment. However, factors listed in III below may be helpful in evaluating these acutely-ill patients for hospice admission.
Chronic renal failure (CRF) can be treated with either hemo - or chronic ambulatory peritoneal dialysis (CAPD), which prolongs survival indefinitely. If dialysis is discontinued, the chance of early death is greatly increased. An occasional patient with residual renal function after dialysis is discontinued may remain alive for a period of time, but survival beyond six months is highly unlikely.
Care should be taken in assessing patients with nephrotic syndrome. This illness often follows a protracted course; nephrology consultation can assist with prognosis.
I. Laboratory criteria for renal failure
These values may be used to assess patients with renal failure who are not dialyzed, as well as those who survive more than a week or two after dialysis is discontinued. Patients with this degree of renal failure can be expected to die shortly without dialysis. Bearing in mind individual differences in tolerance for very elevated creatinine levels, critical renal failure is defined as:
. Creatinine clearance of less than 10 cc/min (less than 15 cc/min for diabetics) AND
. Serum creatinine greater than 8.0 mg/dl (greater than 6.0 mg/dl for diabetics).
Creatinine clearance may be estimated by using the following formula, thus avoiding a 24-hour urine collection:
Ccreat = (140 - age in yrs.) x (body wt. in kg) - multiply by 0.85 for women - / (72) x (serum creat in mg/dl)
Blood urea nitrogen (BUN) values are not used in the determination of critical renal failure, since they can be extremely elevated from prerenal azotemia due to dehydration, hypovolemia or other causes.
II. Clinical signs and syndromes associated with renal failure
The following clinical signs are used as criteria for beginning dialysis. For patients with end-stage renal disease who are not to be dialyzed, the following may help define hospice appropriateness:
. Uremia: clinical manifestations of renal failure.
. Confusion, obtundation
. Intractable nausea and vomiting
. Generalized pruritis
. Restlessness, "restless legs"
. Oliguria: Urine output less than 400 cc/24 hrs.
. Intractable hyperkalemia: persistent serum potassium >7.0 not responsive to medical management.
. Uremic pericarditis.
. Hepatorenal syndrome.
. Intractable fluid overload.
III. In hospitalized patients with ARF, these co-morbid conditions predict early mortality
. Mechanical ventilation.
. Malignancy--other organ systems.
. Chronic lung disease.
. Advanced cardiac disease.
. Advanced liver disease.
. Immunosupression / AIDS.
. Albumin < 3.5 gm/dl.
. Platelet count < 25,000.
. Age > 75.
. Disseminated intravascular coagulation.
. Gastrointestinal bleeding.
Adapted from U.S. Department of Health and Human Services. Assistant Secretary for Planning and Evaluation. Important questions for hospice in the next century. Internet. Accessed on April 29, 2010.