Units in Australia and New Zealand should consider maintaining registers of ‘at risk’ patients to allow greater input into symptom management and

EOL support. CARI, KDIGO, the Renal Association and other groups around the world produce guidelines for nephrologists to follow when caring for their patients. These include areas such as biochemical targets, access guidelines and dialysis monitoring guidelines. Many of these may be inappropriate for those choosing the non-dialysis pathway where quality of life (QOL) is often the dominant issue in management. In this article, the availability of guidelines for renal supportive care (RSC) patients was examined and the level of evidence for any recommendations made in available literature. learn more The search strategy was to look at easily available, web-based guidelines this website from nationally accepted groups where English is the dominant language. What is available? Web-based guidelines fall into two categories – those dealing with specific clinical management issues such as pain, nausea, etc. those dealing with service needs and provision. Few web-based protocols for management of symptoms are available, though individual hospitals may have intraweb-based protocols. This may be

at least partially due to different prescriber limitations and formulary availability of medications in different centres leading to each group developing their own protocols and guidelines. 1. Targets No specific guidelines exist for the management of areas such as calcium/phosphate balance, Grape seed extract hyperparathyroidism, blood pressure control and anaemia in patients choosing not to dialyse and most doctors aim to meet the same targets as for patients with chronic kidney disease (CKD) still planning on dialysis (CARI, KDIGO guidelines). In the conservative pathway, these need to be balanced against QOL and it may

therefore be appropriate to have different targets which will alter as disease advances. This is a potential area for collaborative research to produce guidelines for management. 2. Trials of dialysis It is of note that most available guidelines, apart from a patient information section from Edinburgh Royal Infirmary (ERI),[1] suggest that a trial of dialysis may be appropriate for some patients. The ERI site states the reasons why it is not thought to be appropriate.[1] Neither position, either for or against trials of dialysis, is based on high level evidence and does potentially suggest an area requiring research, that is loss of residual function following initiation of dialysis. This also highlights potential areas of conflict in discussing palliative care in renal failure without higher level evidence to back up those discussions. 3. Medication The Liverpool Care Pathway (LCP)[2] is perhaps the most widely known set of guidelines available. These guidelines are not aimed at chronic management of RSC patients but are specifically targeted at EOL. They are available via The Renal Association website.