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Chapter 58: Palliative Care Nephrology

While rounding the dialysis unit, you stop to speak with a long time dialysis patient who has been hospitalized three times in the last 3 months. He is an 80-year-old man with poor functional status, heart disease with stents, diabetes with peripheral vascular disease, and lower extremity amputations. His most recent admission for a nonhealing wound on his lower extremity was complicated by a prolonged stay due to the necessity for multiple debridement surgeries. Since discharge he now resides in a nursing home. He expresses that he is tired of being hospitalized and that he does not think dialysis is consistent with what he values in his life. He asks you if he stops dialysis how long could he survive. You respond:

A. “You seem depressed. Let me arrange an appointment for psychiatry to see you.”

B. “No one can predict how long you can live.”

C. “Have you spoken to anyone about your wishes to stop dialysis?”

D. “There is uncertainty regarding how long someone can survive, but usually it is about 7 days.”

The answer is D. Explanation: When a patient asks about prognosis, it is important to always clarify exactly what the patient is asking and if the patient really wants an estimate of time. For example, asking this question may be because the patient is wondering if he would live long enough to see his granddaughter graduate from high school. If a patient expresses that they wish to know time, the correct answer is D. Though uncertainty exists, literature suggests that average life expectancy after withdrawing from hemodialysis is about 7 days, though has ranged in one study from 0 to 40 days.

You are rounding on a 30-year-old woman with lupus nephritis who progressed to ESRD and now on dialysis. The dialysis nurses have alerted you that she seems sad recently, often tearful during treatments. During screening you determine that you think she is depressed. She agrees and asks you if you can start any medications to help her. First-line treatment for depression in patients with renal disease should be

A. Cognitive behavioral therapy

B. Selective serotonin reuptake inhibitors

C. Serotonin norepinephrine reuptake inhibitors

D. Monoamine oxidase inhibitors

E. Tricyclic antidepressants

The answer is B. Explanation: Altered pharmacokinetics have been described for various antidepressants in dialysis patients including for SNRI, MOAIs, and TCAs. These alterations include increased half life of either the parent drug or active metabolite and ...

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