Renal supportive care and palliative care: revision and proposal in kidney replacement therapy

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Leiva-Santos, ROSA SANCHEZ HERNANDEZ, Rosa Sánchez-Hernández, HELENA GARCÍA-LLANA, Helena García-Llana, MARÍA JOSÉ FERNÁNDEZ-REYES, M. José Fernández-Reyes, MANUEL HERAS BENITO, Manuel Heras-Benito, ÁLVARO Molina Ordas, Álvaro Molina-Ordas, ASTRID Rodríguez, Astrid Rodríguez, FERNANDO Álvarez-Ude, Fernando Álvarez-Ude" "autores" => array:16 [ 0 => array:2 [ "nombre" => "JUAN PABLO" "apellidos" => "LEIVA-SANTOS" ] 1 => array:2 [ "nombre" => "Juan P." "apellidos" => "Leiva-Santos" ] 2 => array:2 [ "nombre" => "ROSA" "apellidos" => "SANCHEZ HERNANDEZ" ] 3 => array:2 [ "nombre" => "Rosa" "apellidos" => "Sánchez-Hernández" ] 4 => array:2 [ "nombre" => "HELENA" "apellidos" => "GARCÍA-LLANA" ] 5 => array:2 [ "nombre" => "Helena" "apellidos" => "García-Llana" ] 6 => array:2 [ "nombre" => "MARÍA JOSÉ" "apellidos" => "FERNÁNDEZ-REYES" ] 7 => array:2 [ "nombre" => "M. 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Leiva-Santos, ROSA SANCHEZ HERNANDEZ, Rosa Sánchez-Hernández, HELENA GARCÍA-LLANA, Helena García-Llana, MARÍA JOSÉ FERNÁNDEZ-REYES, M. José Fernández-Reyes, MANUEL HERAS BENITO, Manuel Heras-Benito, ÁLVARO Molina Ordas, Álvaro Molina-Ordas, ASTRID Rodríguez, Astrid Rodríguez, FERNANDO Álvarez-Ude, Fernando Álvarez-Ude" "autores" => array:16 [ 0 => array:4 [ "nombre" => "JUAN PABLO" "apellidos" => "LEIVA-SANTOS" "email" => array:1 [ 0 => "eliopabav@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:4 [ "nombre" => "Juan P." "apellidos" => "Leiva-Santos" "email" => array:1 [ 0 => "eliopabav@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "ROSA" "apellidos" => "SANCHEZ HERNANDEZ" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 3 => array:3 [ "nombre" => "Rosa" "apellidos" => "Sánchez-Hernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] 4 => array:3 [ "nombre" => "HELENA" "apellidos" => "GARCÍA-LLANA" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "affe" ] ] ] 5 => array:3 [ "nombre" => "Helena" "apellidos" => "García-Llana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "afff" ] ] ] 6 => array:3 [ "nombre" => "MARÍA JOSÉ" "apellidos" => "FERNÁNDEZ-REYES" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 7 => array:3 [ "nombre" => "M. José" "apellidos" => "Fernández-Reyes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] 8 => array:3 [ "nombre" => "MANUEL" "apellidos" => "HERAS BENITO" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 9 => array:3 [ "nombre" => "Manuel" "apellidos" => "Heras-Benito" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] 10 => array:3 [ "nombre" => "ÁLVARO" "apellidos" => "Molina Ordas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 11 => array:3 [ "nombre" => "Álvaro" "apellidos" => "Molina-Ordas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] 12 => array:3 [ "nombre" => "ASTRID" "apellidos" => "Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 13 => array:3 [ "nombre" => "Astrid" "apellidos" => "Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] 14 => array:3 [ "nombre" => "FERNANDO" "apellidos" => "Álvarez-Ude" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 15 => array:3 [ "nombre" => "Fernando" "apellidos" => "Álvarez-Ude" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "CUIDADOS PALIATIVOS, HOSPITAL GENERAL DE SEGOVIA, SEGOVIA, SEGOVIA, Spain, " "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Cuidados Paliativos-MIR MFyC, Hospital General de Segovia, Segovia, " "etiqueta" => "b" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "NEFROLOGÍA, HOSPITAL GENERAL DE SEGOVIA, SEGOVIA, SEGOVIA, Spain, " "etiqueta" => "c" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital General de Segovia, Segovia, " "etiqueta" => "d" "identificador" => "affd" ] 4 => array:3 [ "entidad" => "NEFROLOGÍA, Hospital Universitario La Paz. IdiPAZ, MADRID, MADRID, Spain, " "etiqueta" => "e" "identificador" => "affe" ] 5 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario La Paz, IdiPAZ, Madrid, " "etiqueta" => "f" "identificador" => "afff" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cuidados de soporte renal y cuidados paliativos renales: revisión y propuesta en terapia renal sustitutiva" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11065_16025_25899_en_t1_11065.jpg" "Alto" => 1042 "Ancho" => 1080 "Tamanyo" => 1052674 ] ] "descripcion" => array:1 [ "en" => "The four principles of modern bioethics" ] ] ] "textoCompleto" => "INTRODUCTIONThe 21st century should be second nature to health professional has two obligations when performing his/her job: to cure disease, and to alleviate suffering.1 In the case of chronic incurable diseases, the objective of treatment is to improve or preserve body function so as to avoid a premature death. This objective is carried out through palliative care (PC), defined by the World Health Organisation (WHO) in 20022 as total, active, and continued care of the patient and the patient’s family by a multi-professional team when the medical expectation is no longer one of curing the disease. The primary objective of this medicine field is not to prolong survival, but to achieve the highest possible quality of life for patients and their families. As such, PC practitioners must cover their patients’ physical, psychological, social, and spiritual needs.2 If necessary, this support must also be extended to the grieving process. Palliative medicine (PM) is not synonymous with terminal illness, although it does include it. There is a large knowledge base for the application of PM, but this experience is not benefiting the majority of people that have a need for it. Despite the efforts made in the last two decades, the majority of patients that require PC do not receive it.3 Recently, dramatic changes have occurred in the demographics of patients with advanced chronic kidney disease (ACKD).4 In 2009, the incidence of RRT in Spain was 126 patients per million population (pmp).5 Currently, approximately 1.5 million patients are receiving haemodialysis globally, and this value is growing at a 7% yearly rate in those populations that have the privilege of access to this type of treatment.6Chronic kidney disease (CKD) follows a progressive deterioration through various stages, in which RRT is the final stage that only a small portion of CKD patients arrive at7; with this in mind, we performed a review focusing on the development of renal palliative care (RPC) and renal supportive care (RSC), areas of new and growing interest for nephrology in Spain.For a better analysis of the subject, we will focus on the following aspects:1) Concepts of RSC and RPC2) Bioethics: fundamental basis for RRT3) Progression and stages of the disease4) Organisational models5) Guidelines for training in PC for nephrology residents6) Pain and symptom control7) Psychological aspects and counselling A NEW CONCEPT: RENAL SUPPORTIVE CARE The term RSC is emerging as a central topic in nephrology. It deals with a concept that is similar to PC, end of life care, and conservative patient management,8 but with several differences. Although very similar, they are not synonymous, and as such it requires a definition. To tell a patient that he/she has advanced renal failure and needs dialysis involves very bad news that shatters the concept of life expectancy previously held by the patient, placing them in a scenario of uncertainty where the perception of control is lost and quality of life is threatened. However, this psychological situation is rarely recognised or discussed. Experts in PM should work together with nephrologists in order to provide the best possible care and quality of life for patients and their families.9The future course of this type of treatment will involve integrating the principles and practices of PC in the different areas of nephrology including haemodialysis, peritoneal dialysis, renal transplants when necessary, dealing with patients with CKD where the indicated approach is a conservative treatment, and, of course, patients that require end of life care. The objective is to ensure that all renal patients with a limited life expectancy receive high quality care with the help of the most appropriate professionals.The concept of RSC has been analysed by Noble et al, using the Rogers method, which is based on the idea that concepts are dynamic, with constant modification and change. With this in mind, the following attributes of the concept of RSC were laid down8:1) RSC must be available from the moment of diagnosis to patient death, with emphasis on a clear prognosis and the impact of the advanced renal disease. One difference with respect to oncology is that, in the case of oncology, some patients may recover but CKD patients have a very high probability of death due to the complications associated with their disease.2) Interdisciplinary approach to treatment. This facilitates avoiding the medicalisation of the psychological and existential needs associated with RRT patients.In addition, the concept of a nephrologist with extensive training in RPC has emerged, with great importance at centres where palliative care units (PCU) do not cover all the patients with non-oncological pathologies.3) Attention given to the patient’s caretaker and family. The support of patient caretakers is essential in RSC. The pressures felt by financial budgets are one important factor, making the patient the central focus.10 In family renal disease, unaffected caretakers tend to have an added emotional burden that may go unnoticed at first.11 4) Therapeutic communication skills, which ensure proper and opportune shared decision making. The objectives of RSC are not reachable without proper training in communication skills.12 BIOETHICS: A FUNDAMENTAL BASIS FOR RENAL REPLACEMENT THERAPY Within the sphere of RPC interventions, we must pay special attention to certain clinical situations with a high emotional impact that can generate difficulties in shared decision making, such as the withdrawal of a patient from dialysis or the decision not to start it, among others.6 At this point in the development of the field of nephrology, we know that not all that is technically possible is ethically admissible. Modern bioethics is based on the development of four fundamental principles that should be second nature to doctors attending to patients on RRT (Table 1). A detailed study of these principles falls outside the aims of this review. PROGRESSION AND STAGES OF DISEASE Most of patients with ACKD die due to non-renal causes, and although the renal disease may contribute to exitus, it is not directly responsible.12 Four different progressions have been described for disease (Figure 1).13,141) Sudden death may occur at any point during the progression of the disease, with no previous diagnosis (Figure 1A).2) Following diagnosis of the terminal disease, function is preserved initially, followed by a rapid deterioration in advanced stages (Figure 1B); which is the typical pattern in oncology.3) This pattern involves recurrences of acute episodes, requiring hospitalisation occasionally, with no recovery of previous functional states (Figure 1C), which poses a risk of death. This is the typical pattern in organ failure.4) There is a gradual decrease in function prior to death, which is characteristic of dementia and advanced age (Figure 1D). These patterns may overlap in a patient on RRT. Implications of the disease progressions For ACKD patients and their families, as well as for the health professionals that treat them, it is of vital importance to understand these disease progressions towards death.12 This is consistently becoming more important for nephrologists, who currently manage patients on RRT at more advanced ages and with more associated comorbidities. The disease progressions allow health care providers to: realise that “to do all that one can do may be the wrong choice,” carry out a practical plan for a good death, support both the patients and their caregivers, and avoid a “prognostic paralysis”.15 These implications lead us to the following conclusions: 1) that one single model does not work for all cases: the typical oncological PC model may not be adjustable to gradual and progressive patient decline with unpredictable exacerbations. Patients with non-malignant diseases may have more prolonged needs than, although similar in nature to, those of cancer patients; 2) transferable lessons: PC in oncology provides experiences that we can benefit from; 3) challenges for research: patients receiving PC are an especially vulnerable group, for which there is not usually a “second opportunity” that allows for improving the care given to them. As such, the idea of assigning patients to sub-optimal conditions of health care is unacceptable.15 Research is difficult to carry out in this field of medicine, but even so should be given more emphasis. ORGANISATIONAL MODELS Spanish authors have proposed a PC programme for terminal uraemia in patients with stage 5 CKD that do not respond to dialysis, with glomerular filtration rates (GFR) <15ml/min and who refuse RRT.16 In the model we propose in this review, we extend this concept, considering clinical and psychological criteria to be paramount above laboratory parameters for including a patient on RSC and RPC programmes; for example, a patient with a functioning renal graft and a GFR of 60ml/min but with musculoskeletal pain may benefit from the aid of an expert, multi-disciplinary team that manages this pain and immunosuppression therapy without compromising the patient’s GFR. A PC programme for terminal uraemia patients is only part of the proposed approach (Figure 2). Tejedor et al also propose the creation of a PCU for ACKD patients. We believe it to more economically sound, safer, and more effective to train nephrology teams in RSC and RPC. Anyway, the essential step is to incorporate expert doctors in PM and psychologists, who can offer RSC and RPC from the hospital PCU, in the context of the nephrology department. They can provide aid to the patients and their families, as well as direct support for the nephrologist.9 As such, it is essential to adapt the PM model to the nephrology context and to incorporate RSC.4 This proposed model is in accordance with a recent publication in nephrology regarding the sustainability and equity of RRT in Spain,17 and is a humble addition to this shared task. PC could be developed and carried out by interdisciplinary teams that would also include the patient’s family and friends (Figure 3),4 who appreciate and recognise the importance of this type of care before and after the death of the patient.18In some countries such as in Canada and the United States, the approval of recent guidelines and national publications have established the role of PC in the field of nephrology.19 Similar experiences have been described in England, Poland, Australia, Portugal, and Hong Kong. GUIDELINES FOR TRAINING NEPHROLOGY RESIDENTS IN PALLIATIVE CARE In Spain there are no recommendations from the national committee on nephrology for residents to carry out a specific rotation period for PC. A Canadian study concluded that residents that had contact with PM specialists had better training in situations dealing with the final stages of disease and are considered more competent for providing necessary end of life care,20 and proposed a programme for PM training directed towards nephrology residents that covers the following aspects21:1) Impact on the patient upon reaching the final stage of renal disease: life expectancy, survival, mortality, and comorbidity2) PM-based focus in haemodialysis units3) Living wills and cardiopulmonary resuscitation4) Communication skills: counselling5) Pain management in renal patients6) Controlling symptoms in renal patients7) Transferral to specialised PC units and grieving support8) Clinical, ethical, and legal issues when starting and withdrawing dialysis treatment PAIN AND SYMPTOM CONTROL Pain Chronic pain is suffered by 50%-63% of dialysis patients, and 42%-55% of them classify their pain as severe.22 The evidence provided by dialysis guidelines suggest that little recognition is given to this pain and other symptoms in dialysis patients, with consequent under-treatment.23 The use of opioid analgesics is not very widespread, due to the threat of toxicity and a lack of experience in their use. This leads to inadequate treatment of pain in CKD patients. In a recent review on the use of opioids and benzodiazepines in dialysis patients, the effectiveness of treatment was variable and low; in 17%-38% of patients, the years spent on dialysis were correlated with the presence of pain, and 72%-84% of patients with severe pain did not receive any analgesia.24 Recent research into the use of cannabinoids has motivated the evaluation of their potential use in controlling symptoms in renal patients on RRT. Although they had promising results, at the moment this option is limited due to the absence of long-term results.25 Evaluation of pain  The quantification and later follow-up of pain using scales should be an added parameter for monitoring the management of renal patients. Several different validated pain measurement scales have been applied to groups of haemodialysis patients: the Visual Analogue Scale (VAS), the Pain Management Index (PMI), the McGill Pain Questionnaire (MGPQ), and the Brief Pain Inventory (BPI). The most common aetiology of pain observed during dialysis is ischaemic pain, and the most common extra-dialysis pain is chronic musculoskeletal pain. The prevalence and intensity of pain during dialysis is higher than outside of dialysis, according to the VAS scale.26 The revised Edmonton Staging System (rESS),27 designed for the evaluation of oncological pain, could be a clinically useful tool for the study and treatment of pain in renal patients. This system has the advantage of predicting analgesic response, considering that a “difficult” pain does not necessarily mean that it cannot be controlled. In order to make a simple of effective evaluation, it is enough to know whether the pain is neuropathic, incidental episodes, or if it associated with emotional suffering and/or altered cognitive state, or drug abuse.27Arteriovenous fistulas are punctured an average of 300 times per year in haemodialysis patients, and are qualified as medium-intensity pain using the VAS scale.28 The postoperative treatment of pain in patients with ACKD poses a problem due to the fear of accumulating metabolites that would depress the respiratory system. This also has been described by anaesthesiologists, and several drugs are being researched for their efficacy and safety in postoperative ACKD patients.29 Opioids in chronic kidney disease We have dedicated this section solely to opioid compounds listed for analgesia by the WHO, given the difficulty in their use and their notable usefulness in renal patients. The complex pharmacokinetics of opioid analgesics in patients with kidney disease, as well as a lack of familiarity with the medical use of these drugs, presents a barrier to the effective alleviation of pain.30 The development of renal failure as a consequence of opioid use has not been described.31 A prospective study performed with 12 patients on haemodialysis concluded that hydromorphone could provide a safe and effective option in certain patients on haemodialysis.32 Similar conclusions were reached in a study comparing the use of hydromorphone in patients with normal urea and creatinine vs patients with renal failure.33 The pharmacokinetic and pharmacodynamic profiles of hydromorphone, methadone, and fentanyl are apparently safe in patients with renal failure, making them recommendable in these cases. The dose should be adjusted when GFR<10ml/min.31 It has also been recommended to reduce the dose and/or increase the dosing interval in renal failure patients on dialysis. Frequent patient monitoring is also indicated, and may even include home telephone follow-up. It is also recommended not to use morphine or codeine due to the difficulty of managing the adverse effects and complications produced in these patients.31 Morphine metabolites could accumulate between dialysis sessions. Methadone metabolites are inactive and are not dialysed, and so do not require adjusted doses in dialysis patients.31 These studies are limited to populations with poor statistical significance, and so we must use the recommended drugs under close monitoring and perform a complete clinical/laboratory evaluation of our patients. Symptom control The general load of symptoms in CKD patients is high and similar to those produced at the end of life in cancer patients.34In patients with stage 5 CKD that are treated without the use of dialysis, the prevalence and severity of symptoms during the last month prior to death have been studied using the Memorial Symptom Assessment Scale-Short Form (MSAS-SF)35; of the 74 patients that participated in the study, with a mean age of 81 years, 86% had severe asthenia, 84% had pruritus, 82% had somnolence, 80% had dyspnoea, 76% had difficulties concentrating, 73% suffered from pain, 71% had reduced appetite, 71% had oedema of the arms or legs, 69% had dry mouth, 65% had constipation, and 59% had nausea. The SMILE (Symptom Management Involving End-Stage Renal Disease) randomised clinical trial demonstrated that patients suffered from pain, sexual dysfunction, and depression when on haemodialysis, these being under-diagnosed symptoms even though they are very prevalent.36 PSYCHOLOGICAL ASPECTS AND COUNSELLING The interest in incorporating psychological aspects into the care of these patients and their families has been part of PC since its beginning. However, the integration of psychologists into nephrology teams is not widespread. As such, the importance of these variables in PC of renal patients is shown at an earlier stage at the end of their lives. The field of RPC poses an ideal space in which psychologists could exercise their specialty.37Depression is a psychological issue with a very high prevalence (10%-66%) in ACKD patients, and can be approached through psychological and/or combined intervention.38 In certain scenarios, such as in peritoneal dialysis units, depression is under-diagnosed and difficult to treat.38 Few controlled studies and even fewer randomised studies have considered this issue. Renal patients at the end of their lives are a special high-risk group, given their high vulnerability and dependence.39In a similar manner, anxiety disorders can be quite common among renal patients at the end of their lives if preventative treatment is not given. The prevalence rate of anxiety disorders in haemodialysis patients is approximately 45.7%, with negative effects on patient quality of life.40According to Cukor et al, ACKD entails a large number of stressors that the patient and his/her close friends and relatives must face (Table 2). Preventative measures in RPC must be the gold standard for avoiding psychopathologyzation at the end of patients’ lives.Renal patients have a history of disease associated with multiple losses that intensifies upon reaching advanced phases. It is normal to encounter scenarios such as those in hospital haemodialysis units, where “biographical death,” associated with reduced quality of life, can occur before “biological death.” In order to deal with these differences, psychological intervention in chronic advanced diseases requires protocols for maximising resources rather than models orientated towards psychological pathologies.41Psychological therapies in RPC include support for the family and after the patient has died.23 In 10%-20% of cases, those grieving can have significant difficulties and even associated physical comorbidities in the process of adapting to the loss.42One therapeutic tool that has demonstrated its effectiveness in PC is counselling, since this is an ideal method for therapeutic communication in circumstances of intense emotional reactions.43There are several definitions of counselling available. According to Dietrich,44 at its core, it is a form of a helpful, interventional, and preventative relationship in which an advisor, through communication, attempts in a relatively short span of time to provoke an active process of cognitive-emotional learning in a disorientated or overloaded person, during the course of which this person can improve his/her disposition towards self-help, his/her capacity for self-direction, and operational competence.To our knowledge, there is no term in Spanish that translates the full conceptual richness of the English word. Counselling is not an assessment, nor is it assisted or clinical advice, but it is the opposite of giving advice. Perhaps the most closely related term would be “helping relationship.”Counselling is not just an interventional tool based on problem solving and emotional management, but also a way of conceiving interpersonal relationships through an ethical concept based on recognising the capacity in others to make their own decisions. Counselling is the art and science of making open, focused questions in order to explore threats and detect resources. It is based on listening rather than talking, empathy rather than judgement, and a fundamental respect of the patient’s values rather than imposing our own. All of this is of the utmost importance during the end of a renal patient’s life. CONCLUSIONS It has been clearly demonstrated that the application of the principles of PC in the field of nephrology generates major benefits for the patient, the patient’s family, and the nephrologist. We are faced with a significant challenge in carrying out studies that offer better safety in the use of pain-controlling drugs and those used to treat other symptoms in these patients. The nephrologist also should learn to masterfully use the different options available for managing pain and suffering in advanced phases of renal disease, as well as communication skills for supporting the patients and their families. The development of PC in nephrology departments is a large and important development that we must strive for, involving the dedication of several different disciplines. KEY CONCEPTS <li>The introduction of PC and its values within the field of nephrology generates a significant impact on the quality of life of renal patients and their families.</li><li>Clinical, psychological, and laboratory criteria are orientated towards including patients in RSC and RPC programmes, although this is not exclusively for terminal stage patients.</li><li>RSC and RPC involve a multidisciplinary team and can be improved by the inclusion of lessons learned in other fields of PC.</li><li>Training in PC for nephrology residents should be promoted within the teaching and research areas.</li><li>The study and management of pain in renal patients is a priority that should be promoted both within clinical practice and research.</li><li>Nephrology teams should be trained to develop communication skills such as counselling. </li><a href="grande/11065_16025_25899_en_t1_11065.jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25899_en_t1_11065.jpg" alt="The four principles of modern bioethics"></img></a>Table 1. The four principles of modern bioethics<a href="grande/11065_16025_25900_en_t2_11065.jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25900_en_t2_11065.jpg" alt="Stressors in advanced chronic kidney disease treatable through psychological interventions "></img></a>Table 2. Stressors in advanced chronic kidney disease treatable through psychological interventions <a href="grande/11065_16025_25901_en_f1_110652.jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25901_en_f1_110652.jpg" alt="Typical progressions of disease, identified in different patients"></img></a>Figure 1. Typical progressions of disease, identified in different patients<a href="grande/11065_16025_25902_en_f2_110652.jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25902_en_f2_110652.jpg" alt="Proposed model for the application of renal supportive care and renal palliative care "></img></a>Figure 2. Proposed model for the application of renal supportive care and renal palliative care <a href="grande/11065_16025_25903_en_f3_110652_copy2.jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25903_en_f3_110652_copy2.jpg" alt="Diagram of the interactions amongst the multi-disciplinary team in renal palliative care"></img></a>Figure 3. Diagram of the interactions amongst the multi-disciplinary team in renal palliative care" "pdfFichero" => "P1-E532-S3382-A11065-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439009" "palabras" => array:1 [ 0 => "Cuidados paliativos renales" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439011" "palabras" => array:1 [ 0 => "Organización en cuidados paliativos renales" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439013" "palabras" => array:1 [ 0 => "Opioides en insuficiencia renal" ] ] ] "en" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439010" "palabras" => array:1 [ 0 => "Renal Palliative Care" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439012" "palabras" => array:1 [ 0 => "Renal Palliative Care and Organization" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439014" "palabras" => array:1 [ 0 => "Opioids and Renal Failure" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "El paciente con enfermedad renal crónica es susceptible de recibir tratamiento de soporte y cuidados paliativos renales (CPR) desde el diagnóstico de la enfermedad, durante las distintas etapas de tratamiento sustitutivo renal (TSR), en el cese de dicho TRS y también si se decide tratamiento conservador o no inicio de TRS. Este artículo revisa la literatura referente al desarrollo de cuidados CPR y los modelos propuestos. Exponemos la trayectoria de la enfermedad en el fallo de órgano, que marca diferencias respecto a otros campos de los cuidados paliativos (CP). Se describen componentes de formación importantes para el residente de nefrología en CP. Abordamos el manejo del dolor y el control de síntomas, así como habilidades de comunicación y otros aspectos psicológicos y éticos en el paciente renal. Concluimos que en la atención al paciente renal crónico, un enfoque desde la medicina paliativa puede suponer un provechoso impacto en la calidad de vida del paciente y su familia, además de optimizar el complejo tratamiento nefrológico del paciente." ] "en" => array:1 [ "resumen" => "Patients with chronic kidney disease may receive sustained renal supportive care and renal palliative care (RPC) starting with the diagnosis of the disease, throughout the various stages of renal replacement therapy (RRT), the cessation of the RRT, and in the decision of whether to provide conservative treatment or non-initiation of RRT. This article reviews the literature on the development of renal palliative care and proposed RPC models. We describe the progression of disease in organ failure, which is very different from other areas of palliative care (PC). We describe important components of resident nephrology training in PC. We discuss the management of pain and symptom control, as well as communication skills and other psychological and ethical aspects in the renal patient. We conclude that in chronic renal patients, a palliative care approach can provide a positive impact on the quality of life of patients and their families, as well as optimizing the complex treatment of the renal patient." ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11065_16025_25899_en_t1_11065.jpg" "Alto" => 1042 "Ancho" => 1080 "Tamanyo" => 1052674 ] ] "descripcion" => array:1 [ "en" => "The four principles of modern bioethics" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11065_16025_25900_en_t2_11065.jpg" "Alto" => 630 "Ancho" => 1058 "Tamanyo" => 844673 ] ] "descripcion" => array:1 [ "en" => "Stressors in advanced chronic kidney disease treatable through psychological interventions" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11065_16025_25901_en_f1_110652.jpg" "Alto" => 1020 "Ancho" => 1020 "Tamanyo" => 844758 ] ] "descripcion" => array:1 [ "en" => "Typical progressions of disease, identified in different patients" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11065_16025_25902_en_f2_110652.jpg" "Alto" => 633 "Ancho" => 1012 "Tamanyo" => 828163 ] ] "descripcion" => array:1 [ "en" => "Proposed model for the application of renal supportive care and renal palliative care" ] ] 4 => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11065_16025_25903_en_f3_110652_copy2.jpg" "Alto" => 725 "Ancho" => 1017 "Tamanyo" => 874976 ] ] "descripcion" => array:1 [ "en" => "Diagram of the interactions amongst the multi-disciplinary team in renal palliative care" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:44 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Callahan D. Death and the research imperative. N Engl J Med 2000;342:654-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10699168" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "World Health Organisation. Cancer Pain relief and Palliative Care, Technical Report Series 804. Geneva: Worl Health Organisation; 1990." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Stjernswärd\u{A0}J,\u{A0}Clark\u{A0}D. Palliative medicine: A global perspective. En:\u{A0}Doyle\u{A0}D,\u{A0}Hanks\u{A0}G,\u{A0}et al. Oxford Textbook of Palliative Medicine, 3rd ed.\u{A0}New York:\u{A0}Oxford University Press;\u{A0}2004. p. 1199-224." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lichodziejewska M, Rutkowski B. Paliative care in nephrology. J Nephrol 2008; 21 (suppl 13):S153-S157. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18446750" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Sociedad Española de Nefrología:\u{A0} Registros de diálisis y trasplante 2009, en: http://www.senefro.org/modules.php?name=webstructure&idwebstructure=128" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Smith C, Da Silva-Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K. Chooosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 2003;95(2):c40-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14610329" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Alcázar R, De Francisco ALM. Acción estratégica de la SEN frente a la enfermedad renal crónica. Nefrologia 2006;26(1):1-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17806214" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Noble H, Kelly D, Rawlings-Anderson K, Meyer J. A concept analysis of renal supportive care: the changing world of nephrology.\u{A0}J Adv Nurs 2007;59(6):644-53. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17727406" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Arnold RM, Solomon L. Editorial: Renal palliative care: supporting our colleagues, patients and family.\u{A0}J Palliat Med 2006;9(4):975-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16910812" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Moss AH. A new clinical practice guideline on initiation and withdrawal of dialisys that makes explicit the role of palliative medicine.\u{A0}J Palliat Med 2000;3:253-60. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15859665" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Álvarez-Ude F, Valdés C, Estébanez C, Rebollo P.\u{A0}Health-related quality of life of family caregivers of dialysis patients.\u{A0}FAMIDIAL Study Group. J Nephrol 2004;17(6):841-50." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Holley JL. Paliative care in end stage renal disease: illness trajectories, comunication and hospice use.\u{A0}Adv Chronic Kidney Dis 2007;14:402-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17904507" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life.\u{A0}JAMA 2003;289:2387-92. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12746362" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Murtagh FE, Murphy E, Sheerin NS. Illness trajectories: an important concept in the management of kidney failure.\u{A0}Nephrol Dial Transplant. 2008;23:3746-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18809974" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Holley JL. Palliative care in end-stage renal disease. Focus on advance care planning, hospice referral, and bereavement. Semin Dial 2005;18:154-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15771661" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Tejedor A, De las Cuevas X. Cuidado paliativo en el paciente con enfermedad renal crónica avanzada (Grado 5), no susceptible de tratamiento dialítico. Nefrologia 2008;3:129-36." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "De Francisco ALM. Sostenibilidad y equidad del tratamiento sustitutivo de la función renal en España. Nefrologia 2011;31:241-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21629331" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Levy JB, Chambers EJ, Brown EA. Supportive care for the renal patient. Nephrol Dial Transplant 2004;19(6):1357-60. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15004252" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Renal Physicians Association and American Society of Nephrology. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis: Clinical Practice Guideline: 2. Washington, DC: Renal Physicians Association; 2000." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Holley JL, Carmody SS, Moss AH, Cohen LM, Block SD, Arnold RM. The need for end of life training in nephrology: national survey results of nephrology. Am JKD, Vol 42, No 4 (October), 2003:pp 813-820" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Moss AH, Holley JL, Davidson SN, Dart AR, Germain MJ, Cohen L, et al. Core curriculum in Nephrology. Palliative Care.\u{A0}Am J Kidney Dis 2004;43(1):172-85." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "22.Moss AH. Revised dialysis clinical practice guidelines promoted more informed decision making. J AM Soc Nephrol. 2010;5,12: 2380-" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Calls J, Rodríguez Calero MA, Hernández Sánchez D. Evaluación del dolor en hemodiálisis mediante diversas escalas de medición validadas. Nefrologia 2009;29(3):236-43. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19554057" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 23 => array:3 [ "identificador" => "bib24" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wyne A, Rai R, Cuerden M, Clark WF, Suri RS. Opiodes and benzodiacepinas use in end stage renal disease: a systematic review.\u{A0}Clin J Am Soc Nephrol 2011;6:326-33. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21071517" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 24 => array:3 [ "identificador" => "bib25" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Davison SN, Davison JS. Is there a legitimate role for the therapeutic use of cannabinoids for symptomatic management in chronic kidney disease. J Pain Symptom Manage 2011;41(4):768-78. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21269798" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 25 => array:3 [ "identificador" => "bib26" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Calls J, Rodríguez Calero MA, Hernández Sánchez D. Evaluación del dolor en hemodiálisis mediante diversas escalas de medición validadas. Nefrologia 2009;29(3):236-43. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19554057" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 26 => array:3 [ "identificador" => "bib27" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Fainsinger RL, Nekolaichuck CL, Lawlor PG, Neumann CM, Hanson J, Vigano A. Multicenter study of the revised Edmonton staging system for calsifying cancer pain in advanced cancer patients.\u{A0}J Pain Symptom Manage 2005;29:224-37. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15781173" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 27 => array:3 [ "identificador" => "bib28" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Figueiredo AE, Viegas A, Monteiro M, Poli-de-Figuereido CE. Research into pain perception with arteriovenous fistula cannulation.\u{A0}Journal of Renal Care 2008;34(4):169-72. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19090894" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 28 => array:3 [ "identificador" => "bib29" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mimoz O, Chauvet S, Grégoire N, Marchand S, Le Guern ME, Saleh A, et al. Nefopam pharmacocinetic in patien with end stage renal disease.\u{A0}Anesth Analg 2010;111(5):1146-53. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20971961" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 29 => array:3 [ "identificador" => "bib30" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Davison SN. Pain in hemodialysis patients: Prevalence, cause, severity, and management.\u{A0}Am J Kidney Dis 2003;42:1239-47. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14655196" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 30 => array:3 [ "identificador" => "bib31" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Dean M. Opiods in renal failure and dialysis patients. J Pain Symptom Manage 2004;28:497-504. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15504625" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 31 => array:3 [ "identificador" => "bib32" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Davison SN, Mayo PR. Pain management in chronic kidney disease: The pharmacokinetics and pharmacodynamics of hidromorphone and hidromorphone-3-glucuronide in hemodialysis patients. J Opioid Manag 2008;4(6):335-44." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 32 => array:3 [ "identificador" => "bib33" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lee MA, Leng ME, Tiernan EJ. Restrospective study of the use of hydromorphone in palliative care patients with normal and abnormal urea and creatinine. Palliat Med 2001;15:26-34. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11212464" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 33 => array:3 [ "identificador" => "bib34" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Davison SN, Jhangri GS, Johnson JA. Cross-sectional validity of modified Edmonton symptom assessment of symptom burden.\u{A0}Kidney Int 2006;69:1621-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16672923" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 34 => array:3 [ "identificador" => "bib35" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Murtagh FE, Addington-Hall J, Edmonds P, Donohoe P, Carey I, Jenkins K, et al. Symptoms in advanced renal disease: a cross sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis.\u{A0}J Palliat Med 2007;10(6):1266-76. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18095805" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 35 => array:3 [ "identificador" => "bib36" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Weisbord SD, Shields AM, Mor MK, Sevick MA, Peternel J, Porter P, et al. Methodology of randomized clinical trial of symptom management strategies in patients receiving chronic hemodialysis: The SMILE study.\u{A0}Contemp Clin Trials 2010;31(5):491-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20601163" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 36 => array:3 [ "identificador" => "bib37" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Barbero J. Psicólogos en cuidados paliativos. El largo camino de la extrañeza a la integración. Clínica Contemporánea 2010;1:39-48." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 37 => array:3 [ "identificador" => "bib38" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wuerth D, Finkelstein SH, Kliger AS, Finkelstein FO. Chronic peritoneal dialysis patients diagnosed with clinical depression: results of pharmacologic therapy. Semin Dial 2003;16:424-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14629600" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 38 => array:3 [ "identificador" => "bib39" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cohen LM, Poppel DM, Cohn GM, Reiter GS. A very good death: measuring quality of diying in end-stage renal disease. J Palliat Med 2001;4(2):167-72. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11441625" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 39 => array:3 [ "identificador" => "bib40" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cukor D, Cohen SD, Peterson RA, Kimmel P. Psychosocial aspects of chronic disease. ESRD as a paradigmatic illness: J Am Soc Nephrol 2007;18:3042-3055. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18003775" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 40 => array:3 [ "identificador" => "bib41" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Albee GW. A competency model to replace the defect model. En: Gibbs MS, Lachenmeyer JR, Sigal J (eds.). Community psychology. Nueva York: Gardner Press; 1980. p. 213-38." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 41 => array:3 [ "identificador" => "bib42" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Prigerson HG, Bierhals AJ, Kasl SV, Reynolds CF, Shear MK, Day N, et al. Traumatic grief as a risk factor for mental and physical morbidity. Am J Psychiatry 1997;154(5):616-23. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9137115" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 42 => array:3 [ "identificador" => "bib43" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Arranz P. La comunicación en cuidados paliativos. Medicina Paliativa (Madrid) 2001;8(1):26-3." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 43 => array:3 [ "identificador" => "bib44" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Dietrich G. Psicología general del Counseling. Barcelona: Herder; 1986." 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Cuidados de soporte renal y cuidados paliativos renales: revisión y propuesta en terapia renal sustitutiva

JUAN PABLO LEIVA-SANTOSa, Juan P. Leiva-Santosb, ROSA SANCHEZ HERNANDEZc, Rosa Sánchez-Hernándezd, HELENA GARCÍA-LLANAe, Helena García-Llanaf, MARÍA JOSÉ FERNÁNDEZ-REYESc, M. José Fernández-Reyesd, MANUEL HERAS BENITOc, Manuel Heras-Benitod, ÁLVARO Molina Ordasc, Álvaro Molina-Ordasd, ASTRID Rodríguezc, Astrid Rodríguezd, FERNANDO Álvarez-Udec, Fernando Álvarez-Uded

a CUIDADOS PALIATIVOS, HOSPITAL GENERAL DE SEGOVIA, SEGOVIA, SEGOVIA, Spain,

b Cuidados Paliativos-MIR MFyC, Hospital General de Segovia, Segovia,

c NEFROLOGÍA, HOSPITAL GENERAL DE SEGOVIA, SEGOVIA, SEGOVIA, Spain,

d Servicio de Nefrología, Hospital General de Segovia, Segovia,

e NEFROLOGÍA, Hospital Universitario La Paz. IdiPAZ, MADRID, MADRID, Spain,

f Servicio de Nefrología, Hospital Universitario La Paz, IdiPAZ, Madrid,

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As such&#44; PC practitioners must cover their patients&#8217; physical&#44; psychological&#44; social&#44; and spiritual needs&#46;<span class="elsevierStyleSup">2</span> If necessary&#44; this support must also be extended to the grieving process&#46; Palliative medicine &#40;PM&#41; is not synonymous with terminal illness&#44; although it does include it&#46; There is a large knowledge base for the application of PM&#44; but this experience is not benefiting the majority of people that have a need for it&#46; Despite the efforts made in the last two decades&#44; the majority of patients that require PC do not receive it&#46;<span class="elsevierStyleSup">3</span> Recently&#44; dramatic changes have occurred in the demographics of patients with advanced chronic kidney disease &#40;ACKD&#41;&#46;<span class="elsevierStyleSup">4</span> In 2009&#44; the incidence of RRT in Spain was 126 patients per million population &#40;pmp&#41;&#46;<span class="elsevierStyleSup">5</span> Currently&#44; approximately 1&#46;5 million patients are receiving haemodialysis globally&#44; and this value is growing at a 7&#37; yearly rate in those populations that have the privilege of access to this type of treatment&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">Chronic kidney disease &#40;CKD&#41; follows a progressive deterioration through various stages&#44; in which RRT is the final stage that only a small portion of CKD patients arrive at<span class="elsevierStyleSup">7</span>&#59; with this in mind&#44; we performed a review focusing on the development of renal palliative care &#40;RPC&#41; and renal supportive care &#40;RSC&#41;&#44; areas of new and growing interest for nephrology in Spain&#46;</p><p class="elsevierStylePara">For a better analysis of the subject&#44; we will focus on the following aspects&#58;</p><p class="elsevierStylePara">1&#41; Concepts of RSC and RPC</p><p class="elsevierStylePara">2&#41; Bioethics&#58; fundamental basis for RRT</p><p class="elsevierStylePara">3&#41; Progression and stages of the disease</p><p class="elsevierStylePara">4&#41; Organisational models</p><p class="elsevierStylePara">5&#41; Guidelines for training in PC for nephrology residents</p><p class="elsevierStylePara">6&#41; Pain and symptom control</p><p class="elsevierStylePara">7&#41; Psychological aspects and counselling</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A NEW CONCEPT&#58; RENAL SUPPORTIVE CARE</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The term RSC is emerging as a central topic in nephrology&#46; It deals with a concept that is similar to PC&#44; end of life care&#44; and conservative patient management&#44;<span class="elsevierStyleSup">8</span> but with several differences&#46; Although very similar&#44; they are not synonymous&#44; and as such it requires a definition&#46; To tell a patient that he&#47;she has advanced renal failure and needs dialysis involves very bad news that shatters the concept of life expectancy previously held by the patient&#44; placing them in a scenario of uncertainty where the perception of control is lost and quality of life is threatened&#46; However&#44; this psychological situation is rarely recognised or discussed&#46; Experts in PM should work together with nephrologists in order to provide the best possible care and quality of life for patients and their families&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">The future course of this type of treatment will involve integrating the principles and practices of PC in the different areas of nephrology including haemodialysis&#44; peritoneal dialysis&#44; renal transplants when necessary&#44; dealing with patients with CKD where the indicated approach is a conservative treatment&#44; and&#44; of course&#44; patients that require end of life care&#46; The objective is to ensure that all renal patients with a limited life expectancy receive high quality care with the help of the most appropriate professionals&#46;</p><p class="elsevierStylePara">The concept of RSC has been analysed by Noble et al&#44; using the Rogers method&#44; which is based on the idea that concepts are dynamic&#44; with constant modification and change&#46; With this in mind&#44; the following attributes of the concept of RSC were laid down<span class="elsevierStyleSup">8</span>&#58;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">1&#41; RSC must be available from the moment of diagnosis to patient death&#44; with emphasis on a clear prognosis and the impact of the advanced renal disease&#46; </span>One difference with respect to oncology is that&#44; in the case of oncology&#44; some patients may recover but CKD patients have a very high probability of death due to the complications associated with their disease&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">2&#41; Interdisciplinary approach to treatment&#46;</span> This facilitates avoiding the medicalisation of the psychological and existential needs associated with RRT patients&#46;</p><p class="elsevierStylePara">In addition&#44; the concept of a nephrologist with extensive training in RPC has emerged&#44; with great importance at centres where palliative care units &#40;PCU&#41; do not cover all the patients with non-oncological pathologies&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">3&#41; Attention given to the patient&#8217;s caretaker and family&#46; </span>The support of patient caretakers is essential in RSC&#46; The pressures felt by financial budgets are one important factor&#44; making the patient the central focus&#46;<span class="elsevierStyleSup">10</span> In family renal disease&#44; unaffected caretakers tend to have an added emotional burden that may go unnoticed at first&#46;<span class="elsevierStyleSup">11<span class="elsevierStyleBold">&#160;</span></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">4&#41; Therapeutic communication skills&#44; which ensure proper and opportune shared decision making&#46;</span> The objectives of RSC are not reachable without proper training in communication skills&#46;<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">BIOETHICS&#58; A FUNDAMENTAL BASIS FOR RENAL REPLACEMENT THERAPY</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Within the sphere of RPC interventions&#44; we must pay special attention to certain clinical situations with a high emotional impact that can generate difficulties in shared decision making&#44; such as the withdrawal of a patient from dialysis or the decision not to start it&#44; among others&#46;<span class="elsevierStyleSup">6</span> At this point in the development of the field of nephrology&#44; we know that not all that is technically possible is ethically admissible&#46; Modern bioethics is based on the development of four fundamental principles that should be second nature to doctors attending to patients on RRT &#40;Table 1&#41;&#46; A detailed study of these principles falls outside the aims of this review&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PROGRESSION AND STAGES OF DISEASE</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Most of patients with ACKD die due to non-renal causes&#44; and although the renal disease may contribute to exitus&#44; it is not directly responsible&#46;<span class="elsevierStyleSup">12</span> Four different progressions have been described for disease &#40;Figure 1&#41;&#46;<span class="elsevierStyleSup">13&#44;14</span></p><p class="elsevierStylePara">1&#41; Sudden death may occur at any point during the progression of the disease&#44; with no previous diagnosis &#40;Figure 1A&#41;&#46;</p><p class="elsevierStylePara">2&#41; Following diagnosis of the terminal disease&#44; function is preserved initially&#44; followed by a rapid deterioration in advanced stages &#40;Figure 1B&#41;&#59; which is the typical pattern in oncology&#46;</p><p class="elsevierStylePara">3&#41; This pattern involves recurrences of acute episodes&#44; requiring hospitalisation occasionally&#44; with no recovery of previous functional states &#40;Figure 1C&#41;&#44; which poses a risk of death&#46; This is the typical pattern in organ failure&#46;</p><p class="elsevierStylePara">4&#41; There is a gradual decrease in function prior to death&#44; which is characteristic of dementia and advanced age &#40;Figure 1D&#41;&#46; These patterns may overlap in a patient on RRT&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Implications of the disease progressions</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">For ACKD patients and their families&#44; as well as for the health professionals that treat them&#44; it is of vital importance to understand these disease progressions towards death&#46;<span class="elsevierStyleSup">12</span> This is consistently becoming more important for nephrologists&#44; who currently manage patients on RRT at more advanced ages and with more associated comorbidities&#46; The disease progressions allow health care providers to&#58; realise that &#8220;to do all that one can do may be the wrong choice&#44;&#8221; carry out a practical plan for a good death&#44; support both the patients and their caregivers&#44; and avoid a &#8220;prognostic paralysis&#8221;&#46;<span class="elsevierStyleSup">15</span> These implications lead us to the following conclusions&#58; 1&#41; <span class="elsevierStyleBold">that one single model does not work for all cases</span>&#58; the typical oncological PC model may not be adjustable to gradual and progressive patient decline with unpredictable exacerbations&#46; Patients with non-malignant diseases may have more prolonged needs than&#44; although similar in nature to&#44; those of cancer patients&#59; 2&#41; <span class="elsevierStyleBold">transferable lessons</span>&#58; PC in oncology provides experiences that we can benefit from&#59; 3&#41; <span class="elsevierStyleBold">challenges for research</span>&#58; patients receiving PC are an especially vulnerable group&#44; for which there is not usually a &#8220;second opportunity&#8221; that allows for improving the care given to them&#46; As such&#44; the idea of assigning patients to sub-optimal conditions of health care is unacceptable&#46;<span class="elsevierStyleSup">15 </span>Research is difficult to carry out in this field of medicine&#44; but even so should be given more emphasis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ORGANISATIONAL MODELS</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Spanish authors have proposed a PC programme for terminal uraemia in patients with stage 5 CKD that do not respond to dialysis&#44; with glomerular filtration rates &#40;GFR&#41; &#60;15ml&#47;min and who refuse RRT&#46;<span class="elsevierStyleSup">16</span> In the model we propose in this review&#44; we extend this concept&#44; considering clinical and psychological criteria to be paramount above laboratory parameters for including a patient on RSC and RPC programmes&#59; for example&#44; a patient with a functioning renal graft and a GFR of 60ml&#47;min but with musculoskeletal pain may benefit from the aid of an expert&#44; multi-disciplinary team that manages this pain and immunosuppression therapy without compromising the patient&#8217;s GFR&#46; A PC programme for terminal uraemia patients is only part of the proposed approach &#40;Figure 2&#41;&#46; Tejedor et al also propose the creation of a PCU for ACKD patients&#46; We believe it to more economically sound&#44; safer&#44; and more effective to train nephrology teams in RSC and RPC&#46; Anyway&#44; the essential step is to incorporate expert doctors in PM and psychologists&#44; who can offer RSC and RPC from the hospital PCU&#44; in the context of the nephrology department&#46; They can provide aid to the patients and their families&#44; as well as direct support for the nephrologist&#46;<span class="elsevierStyleSup">9</span> As such&#44; it is essential to adapt the PM model to the nephrology context and to incorporate RSC&#46;<span class="elsevierStyleSup">4</span> This proposed model is in accordance with a recent publication in nephrology regarding the sustainability and equity of RRT in Spain&#44;<span class="elsevierStyleSup">17</span> and is a humble addition to this shared task&#46; PC could be developed and carried out by interdisciplinary teams that would also include the patient&#8217;s family and friends &#40;Figure 3&#41;&#44;<span class="elsevierStyleSup">4</span> who appreciate and recognise the importance of this type of care before and after the death of the patient&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">In some countries such as in Canada and the United States&#44; the approval of recent guidelines and national publications have established the role of PC in the field of nephrology&#46;<span class="elsevierStyleSup">19</span> Similar experiences have been described in England&#44; Poland&#44; Australia&#44; Portugal&#44; and Hong Kong&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">GUIDELINES FOR TRAINING NEPHROLOGY RESIDENTS IN PALLIATIVE CARE</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In Spain there are no recommendations from the national committee on nephrology for residents to carry out a specific rotation period for PC&#46; A Canadian study concluded that residents that had contact with PM specialists had better training in situations dealing with the final stages of disease and are considered more competent for providing necessary end of life care&#44;<span class="elsevierStyleSup">20</span> and proposed a programme for PM training directed towards nephrology residents that covers the following aspects<span class="elsevierStyleSup">21</span>&#58;</p><p class="elsevierStylePara">1&#41; Impact on the patient upon reaching the final stage of renal disease&#58; life expectancy&#44; survival&#44; mortality&#44; and comorbidity</p><p class="elsevierStylePara">2&#41; PM-based focus in haemodialysis units</p><p class="elsevierStylePara">3&#41; Living wills and cardiopulmonary resuscitation</p><p class="elsevierStylePara">4&#41; Communication skills&#58; counselling</p><p class="elsevierStylePara">5&#41; Pain management in renal patients</p><p class="elsevierStylePara">6&#41; Controlling symptoms in renal patients</p><p class="elsevierStylePara">7&#41; Transferral to specialised PC units and grieving support</p><p class="elsevierStylePara">8&#41; Clinical&#44; ethical&#44; and legal issues when starting and withdrawing dialysis treatment</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">PAIN AND SYMPTOM CONTROL</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Pain</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Chronic pain is suffered by 50&#37;-63&#37; of dialysis patients&#44; and 42&#37;-55&#37; of them classify their pain as severe&#46;<span class="elsevierStyleSup">22</span> The evidence provided by dialysis guidelines suggest that little recognition is given to this pain and other symptoms in dialysis patients&#44; with consequent under-treatment&#46;<span class="elsevierStyleSup">23</span> The use of opioid analgesics is not very widespread&#44; due to the threat of toxicity and a lack of experience in their use&#46; This leads to inadequate treatment of pain in CKD patients&#46; In a recent review on the use of opioids and benzodiazepines in dialysis patients&#44; the effectiveness of treatment was variable and low&#59; in 17&#37;-38&#37; of patients&#44; the years spent on dialysis were correlated with the presence of pain&#44; and 72&#37;-84&#37; of patients with severe pain did not receive any analgesia&#46;<span class="elsevierStyleSup">24</span> Recent research into the use of cannabinoids has motivated the evaluation of their potential use in controlling symptoms in renal patients on RRT&#46; Although they had promising results&#44; at the moment this option is limited due to the absence of long-term results&#46;<span class="elsevierStyleSup">25</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Evaluation of pain</span></span><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The quantification and later follow-up of pain using scales should be an added parameter for monitoring the management of renal patients&#46; Several different validated pain measurement scales have been applied to groups of haemodialysis patients&#58; the Visual Analogue Scale &#40;VAS&#41;&#44; the Pain Management Index &#40;PMI&#41;&#44; the McGill Pain Questionnaire &#40;MGPQ&#41;&#44; and the Brief Pain Inventory &#40;BPI&#41;&#46; The most common aetiology of pain observed during dialysis is ischaemic pain&#44; and the most common extra-dialysis pain is chronic musculoskeletal pain&#46; The prevalence and intensity of pain during dialysis is higher than outside of dialysis&#44; according to the VAS scale&#46;<span class="elsevierStyleSup">26</span> The revised Edmonton Staging System &#40;rESS&#41;&#44;<span class="elsevierStyleSup">27</span> designed for the evaluation of oncological pain&#44; could be a clinically useful tool for the study and treatment of pain in renal patients&#46; This system has the advantage of predicting analgesic response&#44; considering that a &#8220;difficult&#8221; pain does not necessarily mean that it cannot be controlled&#46; In order to make a simple of effective evaluation&#44; it is enough to know whether the pain is neuropathic&#44; incidental episodes&#44; or if it associated with emotional suffering and&#47;or altered cognitive state&#44; or drug abuse&#46;<span class="elsevierStyleSup">27</span></p><p class="elsevierStylePara">Arteriovenous fistulas are punctured an average of 300 times per year in haemodialysis patients&#44; and are qualified as medium-intensity pain using the VAS scale&#46;<span class="elsevierStyleSup">28</span> The postoperative treatment of pain in patients with ACKD poses a problem due to the fear of accumulating metabolites that would depress the respiratory system&#46; This also has been described by anaesthesiologists&#44; and several drugs are being researched for their efficacy and safety in postoperative ACKD patients&#46;<span class="elsevierStyleSup">29</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Opioids in chronic kidney disease</span></span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">We have dedicated this section solely to opioid compounds listed for analgesia by the WHO&#44; given the difficulty in their use and their notable usefulness in renal patients&#46; The complex pharmacokinetics of opioid analgesics in patients with kidney disease&#44; as well as a lack of familiarity with the medical use of these drugs&#44; presents a barrier to the effective alleviation of pain&#46;<span class="elsevierStyleSup">30</span> The development of renal failure as a consequence of opioid use has not been described&#46;<span class="elsevierStyleSup">31</span> A prospective study performed with 12 patients on haemodialysis concluded that hydromorphone could provide a safe and effective option in certain patients on haemodialysis&#46;<span class="elsevierStyleSup">32</span> Similar conclusions were reached in a study comparing the use of hydromorphone in patients with normal urea and creatinine vs patients with renal failure&#46;<span class="elsevierStyleSup">33</span> The pharmacokinetic and pharmacodynamic profiles of hydromorphone&#44; methadone&#44; and fentanyl are apparently safe in patients with renal failure&#44; making them recommendable in these cases&#46; The dose should be adjusted when GFR&#60;10ml&#47;min&#46;<span class="elsevierStyleSup">31 </span>It has also been recommended to reduce the dose and&#47;or increase the dosing interval in renal failure patients on dialysis&#46; Frequent patient monitoring is also indicated&#44; and may even include home telephone follow-up&#46; It is also recommended not to use morphine or codeine due to the difficulty of managing the adverse effects and complications produced in these patients&#46;<span class="elsevierStyleSup">31</span> Morphine metabolites could accumulate between dialysis sessions&#46; Methadone metabolites are inactive and are not dialysed&#44; and so do not require adjusted doses in dialysis patients&#46;<span class="elsevierStyleSup">31</span> These studies are limited to populations with poor statistical significance&#44; and so we must use the recommended drugs under close monitoring and perform a complete clinical&#47;laboratory evaluation of our patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Symptom control</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The general load of symptoms in CKD patients is high and similar to those produced at the end of life in cancer patients&#46;<span class="elsevierStyleSup">34</span></p><p class="elsevierStylePara">In patients with stage 5 CKD that are treated without the use of dialysis&#44; the prevalence and severity of symptoms during the last month prior to death have been studied using the Memorial Symptom Assessment Scale-Short Form &#40;MSAS-SF&#41;<span class="elsevierStyleSup">35</span>&#59; of the 74 patients that participated in the study&#44; with a mean age of 81 years&#44; 86&#37; had severe asthenia&#44; 84&#37; had pruritus&#44; 82&#37; had somnolence&#44; 80&#37; had dyspnoea&#44; 76&#37; had difficulties concentrating&#44; 73&#37; suffered from pain&#44; 71&#37; had reduced appetite&#44; 71&#37; had oedema of the arms or legs&#44; 69&#37; had dry mouth&#44; 65&#37; had constipation&#44; and 59&#37; had nausea&#46; The SMILE &#40;Symptom Management Involving End-Stage Renal Disease&#41; randomised clinical trial demonstrated that patients suffered from pain&#44; sexual dysfunction&#44; and depression when on haemodialysis&#44; these being under-diagnosed symptoms even though they are very prevalent&#46;<span class="elsevierStyleSup">36</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PSYCHOLOGICAL ASPECTS AND COUNSELLING</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The interest in incorporating psychological aspects into the care of these patients and their families has been part of PC since its beginning&#46; However&#44; the integration of psychologists into nephrology teams is not widespread&#46; As such&#44; the importance of these variables in PC of renal patients is shown at an earlier stage at the end of their lives&#46; The field of RPC poses an ideal space in which psychologists could exercise their specialty&#46;<span class="elsevierStyleSup">37</span></p><p class="elsevierStylePara">Depression is a psychological issue with a very high prevalence &#40;10&#37;-66&#37;&#41; in ACKD patients&#44; and can be approached through psychological and&#47;or combined intervention&#46;<span class="elsevierStyleSup">38</span> In certain scenarios&#44; such as in peritoneal dialysis units&#44; depression is under-diagnosed and difficult to treat&#46;<span class="elsevierStyleSup">38</span> Few controlled studies and even fewer randomised studies have considered this issue&#46; Renal patients at the end of their lives are a special high-risk group&#44; given their high vulnerability and dependence&#46;<span class="elsevierStyleSup">39</span></p><p class="elsevierStylePara">In a similar manner&#44; anxiety disorders can be quite common among renal patients at the end of their lives if preventative treatment is not given&#46; The prevalence rate of anxiety disorders in haemodialysis patients is approximately 45&#46;7&#37;&#44; with negative effects on patient quality of life&#46;<span class="elsevierStyleSup">40</span></p><p class="elsevierStylePara">According to Cukor et al&#44; ACKD entails a large number of stressors that the patient and his&#47;her close friends and relatives must face &#40;Table 2&#41;&#46; Preventative measures in RPC must be the gold standard for avoiding <span class="elsevierStyleItalic">psychopathologyzation </span>at the end of patients&#8217; lives&#46;</p><p class="elsevierStylePara">Renal patients have a history of disease associated with multiple losses that intensifies upon reaching advanced phases&#46; It is normal to encounter scenarios such as those in hospital haemodialysis units&#44; where &#8220;biographical death&#44;&#8221; associated with reduced quality of life&#44; can occur before &#8220;biological death&#46;&#8221; In order to deal with these differences&#44; psychological intervention in chronic advanced diseases requires protocols for maximising resources rather than models orientated towards psychological pathologies&#46;<span class="elsevierStyleSup">41</span></p><p class="elsevierStylePara">Psychological therapies in RPC include support for the family and after the patient has died&#46;<span class="elsevierStyleSup">23</span> In 10&#37;-20&#37; of cases&#44; those grieving can have significant difficulties and even associated physical comorbidities in the process of adapting to the loss&#46;<span class="elsevierStyleSup">42</span></p><p class="elsevierStylePara">One therapeutic tool that has demonstrated its effectiveness in PC is counselling&#44; since this is an ideal method for therapeutic communication in circumstances of intense emotional reactions&#46;<span class="elsevierStyleSup">43</span></p><p class="elsevierStylePara">There are several definitions of counselling available&#46; According to Dietrich&#44;<span class="elsevierStyleSup">44</span> at its core&#44; it is a form of a helpful&#44; interventional&#44; and preventative relationship in which an advisor&#44; through communication&#44; attempts in a relatively short span of time to provoke an active process of cognitive-emotional learning in a disorientated or overloaded person&#44; during the course of which this person can improve his&#47;her disposition towards self-help&#44; his&#47;her capacity for self-direction&#44; and operational competence&#46;</p><p class="elsevierStylePara">To our knowledge&#44; there is no term in Spanish that translates the full conceptual richness of the English word&#46; Counselling is not an assessment&#44; nor is it assisted or clinical advice&#44; but it is the opposite of giving advice&#46; Perhaps the most closely related term would be &#8220;helping relationship&#46;&#8221;</p><p class="elsevierStylePara">Counselling is not just an interventional tool based on problem solving and emotional management&#44; but also a way of conceiving interpersonal relationships through an ethical concept based on recognising the capacity in others to make their own decisions&#46; Counselling is the art and science of making open&#44; focused questions in order to explore threats and detect resources&#46; It is based on listening rather than talking&#44; empathy rather than judgement&#44; and a fundamental respect of the patient&#8217;s values rather than imposing our own&#46; All of this is of the utmost importance during the end of a renal patient&#8217;s life&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSIONS</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">It has been clearly demonstrated that the application of the principles of PC in the field of nephrology generates major benefits for the patient&#44; the patient&#8217;s family&#44; and the nephrologist&#46; We are faced with a significant challenge in carrying out studies that offer better safety in the use of pain-controlling drugs and those used to treat other symptoms in these patients&#46; The nephrologist also should learn to masterfully use the different options available for managing pain and suffering in advanced phases of renal disease&#44; as well as communication skills for supporting the patients and their families&#46; The development of PC in nephrology departments is a large and important development that we must strive for&#44; involving the dedication of several different disciplines&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara">&#160;</p><li>The introduction of PC and its values within the field of nephrology generates a significant impact on the quality of life of renal patients and their families&#46;</li><li>Clinical&#44; psychological&#44; and laboratory criteria are orientated towards including patients in RSC and RPC programmes&#44; although this is not exclusively for terminal stage patients&#46;</li><li>RSC and RPC involve a multidisciplinary team and can be improved by the inclusion of lessons learned in other fields of PC&#46;</li><li>Training in PC for nephrology residents should be promoted within the teaching and research areas&#46;</li><li>The study and management of pain in renal patients is a priority that should be promoted both within clinical practice and research&#46;</li><li>Nephrology teams should be trained to develop communication skills such as counselling&#46; </li><p class="elsevierStylePara"><a href="grande&#47;11065&#95;16025&#95;25899&#95;en&#95;t1&#95;11065&#46;jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25899_en_t1_11065.jpg" alt="The four principles of modern bioethics"></img></a></p><p class="elsevierStylePara">Table 1&#46; The four principles of modern bioethics</p><p class="elsevierStylePara"><a href="grande&#47;11065&#95;16025&#95;25900&#95;en&#95;t2&#95;11065&#46;jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25900_en_t2_11065.jpg" alt="Stressors in advanced chronic kidney disease treatable through psychological interventions "></img></a></p><p class="elsevierStylePara">Table 2&#46; Stressors in advanced chronic kidney disease treatable through psychological interventions </p><p class="elsevierStylePara"><a href="grande&#47;11065&#95;16025&#95;25901&#95;en&#95;f1&#95;110652&#46;jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25901_en_f1_110652.jpg" alt="Typical progressions of disease&#44; identified in different patients"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Typical progressions of disease&#44; identified in different patients</p><p class="elsevierStylePara"><a href="grande&#47;11065&#95;16025&#95;25902&#95;en&#95;f2&#95;110652&#46;jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25902_en_f2_110652.jpg" alt="Proposed model for the application of renal supportive care and renal palliative care "></img></a></p><p class="elsevierStylePara">Figure 2&#46; Proposed model for the application of renal supportive care and renal palliative care </p><p class="elsevierStylePara"><a href="grande&#47;11065&#95;16025&#95;25903&#95;en&#95;f3&#95;110652&#95;copy2&#46;jpg" class="elsevierStyleCrossRefs"><img src="11065_16025_25903_en_f3_110652_copy2.jpg" alt="Diagram of the interactions amongst the multi-disciplinary team in renal palliative care"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Diagram of the interactions amongst the multi-disciplinary team in renal palliative care</p>"
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        "resumen" => "<p class="elsevierStylePara">El paciente con enfermedad renal cr&#243;nica es susceptible de recibir tratamiento de soporte y cuidados paliativos renales &#40;CPR&#41; desde el diagn&#243;stico de la enfermedad&#44; durante las distintas etapas de tratamiento sustitutivo renal &#40;TSR&#41;&#44; en el cese de dicho TRS y tambi&#233;n si se decide tratamiento conservador o no inicio de TRS&#46; Este art&#237;culo revisa la literatura referente al desarrollo de cuidados CPR y los modelos propuestos&#46; Exponemos la trayectoria de la enfermedad en el fallo de &#243;rgano&#44; que marca diferencias respecto a otros campos de los cuidados paliativos &#40;CP&#41;&#46; Se describen componentes de formaci&#243;n importantes para el residente de nefrolog&#237;a en CP&#46; Abordamos el manejo del dolor y el control de s&#237;ntomas&#44; as&#237; como habilidades de comunicaci&#243;n y otros aspectos psicol&#243;gicos y &#233;ticos en el paciente renal&#46; Concluimos que en la atenci&#243;n al paciente renal cr&#243;nico&#44; un enfoque desde la medicina paliativa puede suponer un provechoso impacto en la calidad de vida del paciente y su familia&#44; adem&#225;s de optimizar el complejo tratamiento nefrol&#243;gico del paciente&#46;</p>"
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      "titulo" => "Bibliography"
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          "bibliografiaReferencia" => array:44 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Callahan D. Death and the research imperative. N Engl J Med 2000;342:654-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10699168" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "World Health Organisation. Cancer Pain relief and Palliative Care, Technical Report Series 804. Geneva: Worl Health Organisation; 1990."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Stjernswärd\u{A0}J,\u{A0}Clark\u{A0}D. Palliative medicine: A global perspective. En:\u{A0}Doyle\u{A0}D,\u{A0}Hanks\u{A0}G,\u{A0}et al. Oxford Textbook of Palliative Medicine, 3rd ed.\u{A0}New York:\u{A0}Oxford University Press;\u{A0}2004. p. 1199-224."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Lichodziejewska M, Rutkowski B. Paliative care in nephrology. J Nephrol 2008; 21 (suppl 13):S153-S157. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18446750" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Sociedad Española de Nefrología:\u{A0} Registros de diálisis y trasplante 2009, en: http://www.senefro.org/modules.php?name=webstructure&idwebstructure=128"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Smith C, Da Silva-Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K. Chooosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 2003;95(2):c40-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14610329" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Alcázar R, De Francisco ALM. Acción estratégica de la SEN frente a la enfermedad renal crónica. Nefrologia 2006;26(1):1-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17806214" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Noble H, Kelly D, Rawlings-Anderson K, Meyer J. A concept analysis of renal supportive care: the changing world of nephrology.\u{A0}J Adv Nurs 2007;59(6):644-53. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17727406" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Arnold RM, Solomon L. Editorial: Renal palliative care: supporting our colleagues, patients and family.\u{A0}J Palliat Med 2006;9(4):975-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16910812" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Moss AH. A new clinical practice guideline on initiation and withdrawal of dialisys that makes explicit the role of palliative medicine.\u{A0}J Palliat Med 2000;3:253-60. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15859665" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Álvarez-Ude F, Valdés C, Estébanez C, Rebollo P.\u{A0}Health-related quality of life of family caregivers of dialysis patients.\u{A0}FAMIDIAL Study Group. J Nephrol 2004;17(6):841-50."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Holley JL. Paliative care in end stage renal disease: illness trajectories, comunication and hospice use.\u{A0}Adv Chronic Kidney Dis 2007;14:402-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17904507" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life.\u{A0}JAMA 2003;289:2387-92. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12746362" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Murtagh FE, Murphy E, Sheerin NS. Illness trajectories: an important concept in the management of kidney failure.\u{A0}Nephrol Dial Transplant. 2008;23:3746-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18809974" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Holley JL. Palliative care in end-stage renal disease. Focus on advance care planning, hospice referral, and bereavement. Semin Dial 2005;18:154-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15771661" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Tejedor A, De las Cuevas X. Cuidado paliativo en el paciente con enfermedad renal crónica avanzada (Grado 5), no susceptible de tratamiento dialítico. Nefrologia 2008;3:129-36."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "De Francisco ALM. Sostenibilidad y equidad del tratamiento sustitutivo de la función renal en España. Nefrologia 2011;31:241-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21629331" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Levy JB, Chambers EJ, Brown EA. Supportive care for the renal patient. Nephrol Dial Transplant 2004;19(6):1357-60. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15004252" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Renal Physicians Association and American Society of Nephrology. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis: Clinical Practice Guideline: 2. Washington, DC: Renal Physicians Association; 2000."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Holley JL, Carmody SS, Moss AH, Cohen LM, Block SD, Arnold RM. The need for end of life training in nephrology: national survey results of nephrology. Am JKD, Vol 42, No 4 (October), 2003:pp 813-820"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Moss AH, Holley JL, Davidson SN, Dart AR, Germain MJ, Cohen L, et al. Core curriculum in Nephrology. Palliative Care.\u{A0}Am J Kidney Dis 2004;43(1):172-85."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "22.Moss AH. Revised dialysis clinical practice guidelines promoted more informed decision making. J AM Soc Nephrol. 2010;5,12: 2380-"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Calls J, Rodríguez Calero MA, Hernández Sánchez D. Evaluación del dolor en hemodiálisis mediante diversas escalas de medición validadas. Nefrologia 2009;29(3):236-43. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19554057" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib24"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Wyne A, Rai R, Cuerden M, Clark WF, Suri RS. Opiodes and benzodiacepinas use in end stage renal disease: a systematic review.\u{A0}Clin J Am Soc Nephrol 2011;6:326-33. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21071517" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib25"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Davison SN, Davison JS. Is there a legitimate role for the therapeutic use of cannabinoids for symptomatic management in chronic kidney disease. J Pain Symptom Manage 2011;41(4):768-78. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21269798" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib26"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Calls J, Rodríguez Calero MA, Hernández Sánchez D. Evaluación del dolor en hemodiálisis mediante diversas escalas de medición validadas. Nefrologia 2009;29(3):236-43. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19554057" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib27"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Fainsinger RL, Nekolaichuck CL, Lawlor PG, Neumann CM, Hanson J, Vigano A. Multicenter study of the revised Edmonton staging system for calsifying cancer pain in advanced cancer patients.\u{A0}J Pain Symptom Manage 2005;29:224-37. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15781173" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib28"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Figueiredo AE, Viegas A, Monteiro M, Poli-de-Figuereido CE. Research into pain perception with arteriovenous fistula cannulation.\u{A0}Journal of Renal Care 2008;34(4):169-72. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19090894" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib29"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Mimoz O, Chauvet S, Grégoire N, Marchand S, Le Guern ME, Saleh A, et al. Nefopam pharmacocinetic in patien with end stage renal disease.\u{A0}Anesth Analg 2010;111(5):1146-53. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20971961" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
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                  "host" => array:1 [
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            29 => array:3 [
              "identificador" => "bib30"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Davison SN. Pain in hemodialysis patients: Prevalence, cause, severity, and management.\u{A0}Am J Kidney Dis 2003;42:1239-47. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14655196" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
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              ]
            ]
            30 => array:3 [
              "identificador" => "bib31"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Dean M. Opiods in renal failure and dialysis patients. J Pain Symptom Manage 2004;28:497-504. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15504625" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib32"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Davison SN, Mayo PR. Pain management in chronic kidney disease: The pharmacokinetics and pharmacodynamics of hidromorphone and hidromorphone-3-glucuronide in hemodialysis patients. J Opioid Manag 2008;4(6):335-44."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib33"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Lee MA, Leng ME, Tiernan EJ. Restrospective study of the use of hydromorphone in palliative care patients with normal and abnormal urea and creatinine. Palliat Med 2001;15:26-34. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11212464" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
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            ]
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              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Davison SN, Jhangri GS, Johnson JA. Cross-sectional validity of modified Edmonton symptom assessment of symptom burden.\u{A0}Kidney Int 2006;69:1621-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16672923" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
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            ]
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              "identificador" => "bib35"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Murtagh FE, Addington-Hall J, Edmonds P, Donohoe P, Carey I, Jenkins K, et al. Symptoms in advanced renal disease: a cross sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis.\u{A0}J Palliat Med 2007;10(6):1266-76. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18095805" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
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              ]
            ]
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              "identificador" => "bib36"
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              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Weisbord SD, Shields AM, Mor MK, Sevick MA, Peternel J, Porter P, et al. Methodology of randomized clinical trial of symptom management strategies in patients receiving chronic hemodialysis: The SMILE study.\u{A0}Contemp Clin Trials 2010;31(5):491-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20601163" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib37"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Barbero J. Psicólogos en cuidados paliativos. El largo camino de la extrañeza a la integración. Clínica Contemporánea 2010;1:39-48."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib38"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Wuerth D, Finkelstein SH, Kliger AS, Finkelstein FO. Chronic peritoneal dialysis patients diagnosed with clinical depression: results of pharmacologic therapy. Semin Dial 2003;16:424-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14629600" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib39"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Cohen LM, Poppel DM, Cohn GM, Reiter GS. A very good death: measuring quality of diying in end-stage renal disease. J Palliat Med 2001;4(2):167-72. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11441625" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib40"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Cukor D, Cohen SD, Peterson RA, Kimmel P. Psychosocial aspects of chronic disease. ESRD as a paradigmatic illness: J Am Soc Nephrol 2007;18:3042-3055. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18003775" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib41"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Albee GW. A competency model to replace the defect model. En: Gibbs MS, Lachenmeyer JR, Sigal J (eds.). Community psychology. Nueva York: Gardner Press; 1980. p. 213-38."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib42"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Prigerson HG, Bierhals AJ, Kasl SV, Reynolds CF, Shear MK, Day N, et al. Traumatic grief as a risk factor for mental and physical morbidity. Am J Psychiatry 1997;154(5):616-23. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9137115" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib43"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Arranz P. La comunicación en cuidados paliativos. Medicina Paliativa (Madrid) 2001;8(1):26-3."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib44"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Dietrich G. Psicología general del Counseling. Barcelona: Herder; 1986."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
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Article information

ISSN: 20132514
Original language: English

DOI:10.3265/Nefrologia.pre2011.Nov.11065

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	11	10	21
2024 October	68	75	143
2024 September	67	112	179
2024 August	74	74	148
2024 July	64	58	122
2024 June	97	74	171
2024 May	71	47	118
2024 April	63	58	121
2024 March	55	41	96
2024 February	29	53	82
2024 January	62	39	101
2023 December	35	45	80
2023 November	52	57	109
2023 October	102	60	162
2023 September	273	53	326
2023 August	222	24	246
2023 July	72	58	130
2023 June	95	45	140
2023 May	80	52	132
2023 April	41	50	91
2023 March	58	28	86
2023 February	43	20	63
2023 January	47	38	85
2022 December	45	30	75
2022 November	70	40	110
2022 October	65	52	117
2022 September	70	74	144
2022 August	110	56	166
2022 July	87	59	146
2022 June	76	60	136
2022 May	58	40	98
2022 April	91	79	170
2022 March	118	78	196
2022 February	77	75	152
2022 January	91	38	129
2021 December	60	50	110
2021 November	44	41	85
2021 October	79	53	132
2021 September	54	51	105
2021 August	63	57	120
2021 July	68	41	109
2021 June	44	38	82
2021 May	72	45	117
2021 April	186	90	276
2021 March	103	59	162
2021 February	87	52	139
2021 January	66	26	92
2020 December	60	49	109
2020 November	58	27	85
2020 October	51	28	79
2020 September	51	17	68
2020 August	78	29	107
2020 July	60	20	80
2020 June	67	25	92
2020 May	66	17	83
2020 April	75	20	95
2020 March	60	16	76
2020 February	70	28	98
2020 January	83	25	108
2019 December	98	36	134
2019 November	119	44	163
2019 October	61	35	96
2019 September	118	38	156
2019 August	74	20	94
2019 July	105	46	151
2019 June	93	42	135
2019 May	80	33	113
2019 April	147	64	211
2019 March	67	31	98
2019 February	39	16	55
2019 January	35	20	55
2018 December	164	45	209
2018 November	209	17	226
2018 October	147	15	162
2018 September	198	15	213
2018 August	123	22	145
2018 July	114	17	131
2018 June	136	9	145
2018 May	123	19	142
2018 April	143	10	153
2018 March	119	6	125
2018 February	85	6	91
2018 January	101	4	105
2017 December	102	14	116
2017 November	122	15	137
2017 October	102	8	110
2017 September	77	11	88
2017 August	85	15	100
2017 July	103	18	121
2017 June	81	10	91
2017 May	110	10	120
2017 April	101	8	109
2017 March	98	9	107
2017 February	229	11	240
2017 January	72	15	87
2016 December	125	12	137
2016 November	170	15	185
2016 October	228	19	247
2016 September	482	11	493
2016 August	422	14	436
2016 July	310	22	332
2016 June	164	0	164
2016 May	182	0	182
2016 April	190	0	190
2016 March	132	0	132
2016 February	130	0	130
2016 January	140	0	140
2015 December	137	0	137
2015 November	118	0	118
2015 October	130	0	130
2015 September	93	0	93
2015 August	83	0	83
2015 July	119	0	119
2015 June	53	0	53
2015 May	77	0	77
2015 April	5	0	5

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