Patients with chronic kidney disease can complain of several symptoms that are related to their illness. Questions about management of these conditions frequently appear on Medical Council of Canada examinations and assessments, as well as on Royal Colleges licensing examinations. The following discuss management steps of these symptoms:
Fatigue
- treat anemia
- optomize heart function & attain adequate diuretic dosage
- decrease ß-blockers dosage
- incorporate exercise regimen
- improve nutrition
Dyspnea
- decrease salt & fluid intake
- in case of volume overload, give higher doses of furosemide if GFR decreases
- manage anemia
Pain
- withheld enteral and parentral NSAIDs, however, topical preparations may be used with caution
- acetominophin have limited efficacy
- neuropathic agents e.g. gabapentinoids (start gabapentin at 100 mg orally OD)
- monitor fall risk
- opioids may be used for unremitting pain, hydromorphone is the preferred opioid (start with 0.5-1 mg orally Q4h or Q6h, as needed)
- there is limited evidence for cannabinoid use in chronic kidney disease
Nausea
- treat constipation
- avoid large meals & strong smells
- prescribe metoclopramide (2.5 mg orally Q4h, as needed) & ondansetron (4-8 mg orally every 8 hours, as necessary(
- atypical antipsychotics (olanzapine 2.5 mg orally Q4h, as needed, or low-dose haloperidol 0.5 mg orally Q4h, as needed) can be helpful
Pruritus
- thick emollients should be first line for symptomatic relief
- avoid hot showers or baths that contribute to skin dryness
- use topical camphor & menthol-based compounds & low-potency steroids, as well as capsaicin-based creams when available
- gabapentinoids & SSRIs at low dosage
- avoid antihistamines, however, hydroxyzine may be used cautiously (10 mg BID, when needed)
- ultraviolet-B therapy may be considered
Sleep disturbance
- nonpharmacologic therapies include exercise, reducing caffeine and limiting fluid intake in the evening
- diuretics should be dosed earlier in the day (e.g., second dose of furosemide no later than 2 pm)
- treat benign prostatic hyperplasia if present
- treat pain, restless leg syndrome & pruritus
- consider melatonin (initiate at 3 mg at night) and mirtazapine (initiate at 3.75 mg-7.5 mg at night)
Restless leg syndrome or cramping
- manage modifiable factors such as iron deficiency and use antidepressants and dopamine antagonists
- low-dose magnesium supplementation may be helpful
- gabapentinoids (start gabapentin 100 mg PO at night and titrate up)
- consider dopamine agonists such as pramipexole (0.125-0.25 mg orally TID) or ropinirole (starting dose 0.25 mg per day)
Depression
- manage contributing symptoms (e.g. pain, insomnia, pruritus)
- optimize social support
- nonpharmacologic interventions include cognitive behaviour therapy & exercise
- antidepressants such as mirtazapine (consider dose adjustment)
Reference:
CMAJ 2023 May 1;195:E612-8. doi: 10.1503/cmaj.221427