​​General practitioners (GPs) are often the first port of call when patients with chronic kidney disease see a deterioration in kidney function – placing them in prime position to guide the patient journey and decision making process. Read all about how GPs in the primary care setting can start important conversations on long-term management, treat common symptoms, and identify when specialist referral for renal supportive care would be beneficial.

CHRONIC KIDNEY DISEASE

Increasing disease burden in Singapore

The burden of chronic kidney disease (CKD) among the Singaporean population has been increasing in recent years, contributed to by diabetes and an ageing population. Diabetic kidney disease is the main cause of kidney failure for patients on dialysis in Singapore.

The number of patients newly diagnosed with stage 5 chronic kidney disease (CKD5), as defined by an estimated glomerular filtration rate (eGFR) of < 15 ml/min/1.73m², serum creatinine ≥ 500 μmol/L or initiation of renal replacement therapy, has increased from 1,586 in 2011 to 2,079 in 2019.¹

Management of advanced chronic kidney disease

Patients with advanced CKD (CKD stage 4 to 5) are assessed by renal teams through a process of shared decision making, to determine a long-term treatment plan which may include:

• Dialysis

• Kidney transplant

• Comprehensive conservative care

While dialysis confers a significant survival advantage for patients with CKD5 in general, this advantage is lost in patients who are older (> 80 years old)², with poor functional status and/or a high comorbidity burden. Some patients may find dialysis to be burdensome and experience unacceptable reduction in their quality of life.

Therefore, it is important to recognise this group of patients and consider whether a supportive care approach would be more beneficial.

General practitioners (GPs) play an important role in the holistic management of patients with CKD. This will be even more so with the Ministry of Health's recommendation for each household to have their own family doctor from 2023.

This article shares the concept of renal supportive care and explores how GPs may support their patients who have advanced CKD.

WHAT IS RENAL SUPPORTIVE CARE?

Renal supportive care (RSC) is a clinical approach that aims to improve the quality of life for patients with advanced CKD by integrating palliative care principles, knowledge and skills into routine renal care.

RSC can be provided at any part of the patient journey, including for those who choose dialysis (Figure 1).

Figure 1 Renal supportive care encompasses all parts of the CKD5 patient journey³

Comprehensive conservative care^4-5 is a holistic patient-centric approach which supports patients who opt for non-dialytic therapy. For patients who are unlikely to benefit from dialysis or kidney transplantation as a treatment choice, comprehensive conservative care is an option that should be provided. Patients are assured of continued medical care so they do not go away with the notion that ‘nothing can be done’, and receive treatment plans that are aligned with their priorities and values.

Table 1 Definition of comprehensive conservative care^4-5

CASE STUDY

Background

Mdm T is an 80-year-old woman with CKD5 secondary to diabetic kidney disease and concomitant hypertension, hyperlipidaemia and gout. She was referred by her nephrologist to the RSC clinic for symptom management and psychosocial support.

Laboratory results:
• eGFR 7ml/min
• Creatinine 492 μmol/L
• Urea 28.4 mmol/L
• Potassium 3.8 mmol/L
• Bicarbonate 22.4 mmol/L
• Albumin 37 g/L
• Calcium 2.63 mmol/L
• Phosphate 1.63 mmol/L
• Hb 11.0 g/dL
• Transferrin saturation 31.3%

Symptom and psychosocial assessment

She had mild fatigue, low appetite and poor sleep. There were no symptoms of uraemia or fluid overload. She had low mood due to her husband’s cognitive decline and behavioural issues. While her mood gradually improved following her husband’s admission to a nursing home, her family still felt guilty about the decision.

Treatment decision and goals of care discussion

She was aware of her CKD5 status and the potential for complications. She readily stated that she did not want dialysis as she was old and life prolongation was not meaningful to her. She had loss of weight but was not keen on further investigations.

She preferred to focus on comfort and symptom control, but was willing to be hospitalised for treatment if deemed beneficial. She decided on inpatient hospice as her preferred place of care and death when her condition deteriorated.

Management plan

1. Her medication list was reviewed and adjusted, taking into consideration her symptoms, pill burden and whether she would have the time to benefit from taking the medications.

2. As her mood was improving, she did not require antidepressants.

3. She was planned for referral to Assisi Hospice Day Care.

4. The RSC team planned to follow up on Mdm T and her family’s coping during subsequent appointments

Case Progress

SGH Low Clearance Clinic and Renal Supportive Care Clinic

The SGH Department of Renal Medicine set up the multidisciplinary Low Clearance Clinic (LCC) in August 2015 with the aim of better preparing CKD patients for end-stage kidney failure and their long-term treatment plan.

Patients with GFR of < 20 ml/min are managed by a multidisciplinary team consisting of nephrologists, advanced practice/specialist nurses, dietitians, pharmacists, social workers and renal coordinators/case managers.

The Renal Supportive Care Clinic was started in August 2016 and is embedded in the multidisciplinary LCC service. The RSC clinic team consists of a palliative care consultant, renal nurse clinician with training in RSC, ACP coordinator and pharmacist.

Presently, patients who choose comprehensive conservative care with eGFR < 9 ml/min or who have significant supportive and palliative care needs such as poor symptom control and psychosocial issues are referred for a RSC clinic consult.

WHAT WE DO AT THE RSC CLINIC

After every RSC session, the team participates in a multidisciplinary team meeting to discuss and identify ‘worry board’ cases who need closer follow-up or interventions. The RSC team also participates in the multidisciplinary haemodialysis rounds to provide supportive care input for complicated dialysis patients.

Table 2
 

What GPs Can Do in Primary Care

GPs who have been following up on their patients with CKD are often the first port of call when their kidney function begins to decline. Having built strong doctor-patient relationships, GPs are well-placed to begin the conversation about their patients’ values and priorities. This will help patients to navigate the decision making process when it comes to considering whether dialysis or comprehensive conservative care is right for them.

Table 3

Table 4

Table 5

Referral process

Currently, the RSC clinic is only open to referrals for patients known to the Department of Renal Medicine, SGH.

If you have an advanced CKD patient who may benefit from a consult with a palliative care specialist, you may contact the SGH GP Appointment Hotline at 6326 6060 to make an appointment with the Internal Medicine Supportive and Palliative Care Service, which provides specialist palliative care support for the RSC clinic.

GPs who would like more information may contact the following palliative care physicians in the RSC team:

Dr Natalie Woong: natalie.woong.l.l@singhealth.com.sg
Dr Lee Guozhang: lee.guozhang@singhealth.com.sg

CONCLUSION

The burden of chronic kidney disease in our population is significant. With a better understanding of renal supportive care, GPs can play an important part in their patients' decision making process and journey by starting the conversation on long-term CKD management, reviewing chronic disease management and considering specialist referral for shared care. 

REFERENCES

1. Singapore Renal Registry Annual Report 2020

2. Verberne, W. R., Geers, A. B., Jellema, W. T., Vincent, H. H., van Delden, J. J., & Bos, W. J. (2016). Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis. Clinical journal of the American Society of Nephrology : CJASN, 11(4), 633–640. https://doi.org/10.2215/CJN.07510715

3. Hole, B., Hemmelgarn, B., Brown, E., Brown, M., McCulloch, M. I., Zuniga, C., Andreoli, S. P., Blake, P. G., Couchoud, C., Cueto-Manzano, A. M., Dreyer, G., Garcia Garcia, G., Jager, K. J., McKnight, M., Morton, R. L., Murtagh, F., Naicker, S., Obrador, G. T., Perl, J., Rahman, M., … Caskey, F. J. (2020). Supportive care for end-stage kidney disease: an integral part of kidney services across a range of income settings around the world. Kidney international supplements, 10(1), e86–e94. https://doi.org/10.1016/j.kisu.2019.11.008

4. Davison, S. N., Levin, A., Moss, A. H., Jha, V., Brown, E. A., Brennan, F., Murtagh, F. E., Naicker, S., Germain, M. J., O'Donoghue, D. J., Morton, R. L., Obrador, G. T., & Kidney Disease: Improving Global Outcomes (2015). Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care. Kidney international, 88(3), 447–459. https://doi.org/10.1038/ki.2015.110

5. Murtagh, F. E., Burns, A., Moranne, O., Morton, R. L., & Naicker, S. (2016). Supportive Care: Comprehensive Conservative Care in End-Stage Kidney Disease. Clinical journal of the American Society of Nephrology : CJASN, 11(10), 1909–1914. https://doi.org/10.2215/CJN.04840516

6. Murtagh, F. E., Addington-Hall, J., & Higginson, I. J. (2007). The prevalence of symptoms in end-stage renal disease: a systematic review. Advances in chronic kidney disease, 14(1), 82–99. https://doi.org/10.1053/j.ackd.2006.10.001

Dr Natalie Woong is a Consultant at the Department of Internal Medicine, Singapore General Hospital. She is an accredited palliative care specialist and works with the Department of Renal Medicine as part of the Renal Supportive Care team to provide care for patients with advanced kidney disease. 

Acknowledgements
Dr Lee Guozhang
Assoc Prof Jason Choo
Clin Asst Prof Alethea Yee
Clin Asst Prof Peh Tan Ying
Dr Kwek Jia Liang

GPs can call the SingHealth Duke-NUS Supportive & Palliative Care Centre for appointments at the following hotlines:

Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital 6930 6000
KK Women’s and Children’s Hospital: 6692 2984
National Cancer Centre Singapore 6436 8288
National Heart Centre Singapore 6704 2222
National Neuroscience Institute 6330 6363