Cuidados paliativos em DRC terminal - controle de sintomas

Pain — As mentioned, pain is the most frequently reported symptom in the dying patient with chronic kidney disease [2,32]. Moreover, pain remains undertreated in many hemodialysis patients [33,34]. This is particularly the case when patients die in an institution versus the home [32,33,35].

The use of specific analgesics in this patient population must be guided by the observation that, because of impaired renal excretion, many such agents and/or their breakdown proteins accumulate in those with renal disease, resulting in significant adverse effects [36,37]. As an example, meperidine should not be used in those with chronic kidney dysfunction because its metabolite, normeperidine, accumulates, leading to central nervous system excitability and seizures. Similarly, prolonged use of morphine in patients with chronic kidney disease may lead to the accumulation of morphine-3-glucuronide and morphine-6-glucuronide, which may contribute to the development of myoclonic jerks (see "Cancer pain management with opioids: Prevention and management of side effects", section on 'Myoclonus'). The accumulation of morphine-6-glucuronide may also lead to prolonged narcosis in those with kidney disease. However, for short term use (days), morphine is an excellent analgesic for dying patients with end stage renal disease and is also useful in the treatment of dyspnea [1,38]. In general, it is recommended that morphine and codeine be avoided in dialysis patients, that hydromorphone and oxycodone be used with caution, and that fentanyl and methadone appear to be relatively safe to use [36,37]. The World Health Organization pain ladder is an effective tool in the management of pain in dialysis patients [39]. (See "Cancer pain management with opioids: Optimizing analgesia", section on 'Use in renal failure'.)

Constipation — Constipation almost invariably occurs with the use of opiates. Thus, stool softeners, dietary measures, and laxatives should be used when needed. When opiates are prescribed, docusate sodium 100 mg po twice daily and/or senna should be started. For constipation, lactulose (10 g/15 mL syrup) 15 to 30 mL po once or twice daily or bisacodyl 30 mg po or 10 mg rectal suppository once daily are usually effective. Saline enemas or glycerine rectal suppositories may also be used. (See "Cancer pain management with opioids: Optimizing analgesia", section on 'Rectal'.)

Myoclonus, muscle twitching, and seizures — As previously noted, myoclonus and muscle twitching may occur with the use of opioids, as well as agitation and confusion. Drug-induced or uremic-associated muscle twitching or myoclonus may be treated with benzodiazepines, such as clonazepam. (See "Cancer pain management with opioids: Optimizing analgesia".)

Benzodiazepines and haloperidol are also useful in treating anxiety.

Less than 10 percent of patients who withdraw from dialysis develop seizures [1]. Thus, the routine, prophylactic use of anticonvulsants is not recommended.

Hypervolemia — Symptoms of volume overload are uncommon in patients who withdraw from dialysis [2,28]. When it occurs, isolated ultrafiltration without dialysis is an effective intervention.

Others — Other symptoms such as nausea and vomiting and delirium may also be treated with medications dosed for the level of renal function

Fonte: Jean L Holley, MD, et al. Palliative care in end-stage renal disease. Uptodate, Oct 18, 2012.