What are the management recommendations for a patient with Chronic Kidney Disease (CKD) and impaired renal function, who refuses dialysis?

Management Recommendations for CKD Patients Who Refuse Dialysis

Comprehensive conservative management without dialysis is an appropriate and ethical option for patients with advanced CKD (creatinine 5) who refuse dialysis, focusing on symptom management, quality of life optimization, and supportive care.

Assessment and Planning

• Perform shared decision-making to understand the patient's values, priorities, and goals of care 1
• Document the patient's decision in advance directives and medical orders as appropriate 1
• Assess symptom burden using validated tools such as the Edmonton Symptom Assessment System-revised: Renal (ESAS-r:Renal) or Palliative Care Outcome Scale-Renal (POS-renal) 2
• Establish a clear communication pathway between the patient, family, and healthcare team

Symptom Management

Fluid Overload

• Use loop diuretics at optimal doses to maintain volume control 1
• Consider sodium restriction (2-3g/day) to help manage fluid retention 2
• Monitor for signs of dehydration when using diuretics

Uremic Symptoms

• Manage nausea/vomiting with antiemetics (metoclopramide, ondansetron)
• Address pruritus with topical emollients, antihistamines, or gabapentin
• Treat restless legs syndrome with gabapentin or low-dose dopamine agonists

Pain Management

• Use acetaminophen as first-line for pain control
• If opioids are needed, use with careful dose adjustment and monitoring 2
• Avoid NSAIDs due to nephrotoxicity 2

Psychological Support

• Screen for and treat depression, which affects 26.5% of CKD patients in stages 1-4 and 39.3% in advanced stages 2
• Provide access to psychological counseling and support groups
• Consider spiritual support based on patient preferences

Medical Management

Blood Pressure Control

• Target blood pressure <140/90 mmHg (without albuminuria) or <130/80 mmHg (with albuminuria) 2
• Continue ACE inhibitors or ARBs unless serum creatinine rises by more than 30% 2
• Monitor for hyperkalemia when using RAS blockers

Anemia Management

• Evaluate iron status before and during treatment 3
• Administer supplemental iron when serum ferritin is <100 mcg/L or transferrin saturation <20% 3
• Consider erythropoiesis-stimulating agents if hemoglobin <10 g/dL to reduce transfusion needs 3

Electrolyte and Metabolic Management

• Monitor and treat hyperkalemia with dietary modifications and potassium binders if needed
• Consider oral bicarbonate supplementation for serum bicarbonate <22 mmol/L 2
• Manage hyperphosphatemia with dietary phosphate restriction and phosphate binders

Cardiovascular Risk Reduction

• For adults ≥50 years with eGFR <60 ml/min/1.73m², use statin or statin/ezetimibe combination 1
• Consider low-dose aspirin for secondary prevention in patients with established cardiovascular disease 1

Nutritional Support

• Maintain protein intake of 0.8 g/kg body weight/day 2
• Avoid protein restriction in malnourished or sarcopenic patients 2
• Consider dietitian consultation for individualized nutritional plans

Monitoring and Follow-up

• Monitor eGFR and electrolytes every 1-3 months based on disease progression 2
• Adjust frequency of visits based on symptom burden and disease trajectory
• Increase monitoring frequency during periods of acute illness or symptom exacerbation

Palliative and End-of-Life Care

• Provide access to resources for advance care planning 1
• Establish goals of care and preferences regarding hospitalization
• Consider hospice referral when estimated prognosis is 6 months or less 1
• Studies show median survival of 6.3 to 23.4 months with conservative management 4

Patient and Family Education

• Educate about disease progression and expected symptoms
• Teach recognition of symptoms requiring medical attention
• Provide caregiver support and education

Pitfalls to Avoid

• Don't assume conservative management means "doing nothing" - it requires active symptom management and monitoring 1
• Avoid nephrotoxic medications including NSAIDs, aminoglycosides, and certain contrast agents 2
• Don't discontinue ACE inhibitors/ARBs solely based on eGFR falling below 30 ml/min/1.73m² 2
• Avoid overreliance on HbA1c in advanced CKD as it may be less accurate 2

Conservative management is a valid option that can provide months to years of quality life with appropriate supportive care 4. The focus should be on preserving function, managing symptoms, and honoring the patient's values and preferences.