Symptoms in CKD, with or without dialysis, are common and independent of cancer diagnosis . These patients suffer from a substantial burden of debilitating physical and psychological symptoms resulting in significant impairment in their quality of life [49–52]. Yet, over 50 % of these symptoms are undertreated [53]. Fatigue and pain are the most commonly encountered symptoms, others being pruritus, depression, nausea and vomiting, sleep disturbances, muscle cramps, anorexia and sexual dysfunction [54–56]. Data suggest primary care providers may prescribe pharmacologic therapy, particularly for emotional symptoms, rather than nephrologists [53]. Considering the increasing prevalence of end-stage kidney disease (ESKD), the momentous burden of distressing symptoms in these patients and their impact on overall quality of life, it is crucial for both nephrologists and primary care providers to have a better understanding of symptom management in order to provide patient-centered care. Tables 17.3 and 17.4 briefly outline the guidelines for symptom management in advanced CKD [55–58]. Additional attention must be paid to medication dosing with appropriate adjustments for the degree of renal impairment .

One of the important components of the comprehensive treatment plan for patients with kidney disease, particularly those with cancer, is ACP . ACP encompasses dynamic, ongoing communication among physicians, patients, and their families addressing the patient’s goals for care, including preferences for end of life care [59]. The limited life expectancy in patients with ESKD, either with or without dialysis, warrants early initiation of ACP [60]. Timely instituted discussions regarding goals of care allow patients to better understand their illness and develop a realistic perspective about the role of intensive medical interventions. Patients who engage in these discussions tend to undergo less intensive care and fewer life-prolonging therapies and are more likely to enroll in hospice care in their final week of life. Furthermore, longer hospice stays (> 1 week) are associated with better quality of life in patients, which in turn is associated with an improvement in self-reported quality of life and lower incidence of depression among surviving caregivers during the bereavement phase [61] .

Despite the increasing recognition of the need for ACP in the dialysis population, only a minority of them have written advance directives [62, 63]. The end-of-life experience for dialysis patients is likely a reflection of inadequate ACP. Wong et al. [64] examined treatment intensity and outcomes in dialysis patients during the last month of life. Dialysis patients were more likely to undergo intensive therapies, including admission to ICU, and less likely to receive appropriate hospice services compared to those with cancer and heart failure.