Acute renal failure requiring renal replacement therapy in the intensive care unit: impact on prognostic assessment for shared decision making

Palliative Care for Patients with Kidney Disease

Interest in palliative care has increased in recent times, particularly in its multidisciplinary approach developed to meet the needs of patients with a life-threatening disease and their families. Although the modern concept of palliative simultaneous care postulates the adoption of these qualitative treatments early on during the life-threatening disease (and potentially just after the diagnosis), palliative care is still reserved for patients at the end of their life in most of the clinical realities, and thus is consequently mistaken for hospice care. Patients with acute or chronic kidney disease (CKD) usually experience poor quality of life and decreased survival expectancy and thus may benefit from palliative care. Palliative care requires close collaboration among multiple health care providers, patients, and their families to share the diagnosis, prognosis, realistic treatment goals, and treatment decisions. Several approaches, such as conservative management, extracorporeal, and peritoneal palliative dialysis, can be attempted to globally meet the needs of patients with kidney disease (e.g., physical, social, psychological, or spiritual needs). Particularly for frail patients, pharmacologic management or peritoneal dialysis may be more appropriate than extracorporeal treatment. Extracorporeal dialysis treatment may be disproportionate in these patients and associated with a high burden of symptoms correlated with this invasive procedure. For those patients undergoing extracorporeal dialysis, individualized goal setting and a broader concept of adequacy should be considered as the foundations of extracorporeal palliative dialysis. Interestingly, little evidence is available on palliative and end of life care for acute kidney injury (AKI) patients. In this review, the main variables influencing medical decision-making about palliative care in patients with kidney disease are described, as well as the different approaches that can fulfill the needs of patients with CKD and AKI.

Hospital Variation in Renal Replacement Therapy for Sepsis in the United States

OBJECTIVES

Acute renal replacement therapy in patients with sepsis has increased dramatically with substantial costs. However, the extent of variability in use across hospitals-and whether greater use is associated with better outcomes-is unknown.

DESIGN

Retrospective cohort study.

SETTING

Nationwide Inpatient Sample in 2011.

PATIENTS

Eighteen years old and older with sepsis and acute kidney injury admitted to hospitals sampled by the Nationwide Inpatient Sample in 2011.

INTERVENTIONS

We estimated the risk- and reliability-adjusted rate of acute renal replacement therapy use for patients with sepsis and acute kidney injury at each hospital. We examined the association between hospital-specific renal replacement therapy rate and in-hospital mortality and hospital costs after adjusting for patient and hospital characteristics.

MEASUREMENTS AND MAIN RESULTS

We identified 293,899 hospitalizations with sepsis and acute kidney injury at 440 hospitals, of which 6.4% (n = 18,885) received renal replacement therapy. After risk and reliability adjustment, the median hospital renal replacement therapy rate for patients with sepsis and acute kidney injury was 3.6% (interquartile range, 2.9-4.5%). However, hospitals in the top quintile of renal replacement therapy use had rates ranging from 4.8% to 13.4%. There was no significant association between hospital-specific renal replacement therapy rate and in-hospital mortality (odds ratio per 1% increase in renal replacement therapy rate: 1.03; 95% CI, 0.99-1.07; p = 0.10). Hospital costs were significantly higher with increasing renal replacement therapy rates (absolute cost increase per 1% increase in renal replacement therapy rate: $1,316; 95% CI, $157-$2,475; p = 0.03).

CONCLUSIONS

Use of renal replacement therapy in sepsis varied widely among nationally sampled hospitals without associated differences in mortality. Improving renal replacement standards for the initiation of therapy for sepsis may reduce healthcare costs without increasing mortality.

Ageism vs. the technical imperative, applying the GRADE framework to the evidence on hemodialysis in very elderly patients

Purpose

Treatment intensity for elderly patients with end-stage renal disease has escalated beyond population growth. Ageism seems to have given way to a powerful imperative to treat patients irrespective of age, prognosis, or functional status. Hemodialysis (HD) is a prime example of this trend. Recent articles have questioned this practice. This paper aims to identify existing pre-synthesized evidence on HD in the very elderly and frame it from the perspective of a clinician who needs to involve their patient in a treatment decision.

Patients and methods

A comprehensive search of several databases from January 2002 to August 2012 was conducted for systematic reviews of clinical and economic outcomes of HD in the elderly. We also contacted experts to identify additional references. We applied the rigorous framework of decisional factors of the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) to evaluate the quality of evidence and strength of recommendations.

Results

We found nine eligible systematic reviews. The quality of the evidence to support the current recommendation of HD initiation for most very elderly patients is very low. There is significant uncertainty in the balance of benefits and risks, patient preference, and whether default HD in this patient population is a wise use of resources.

Conclusion

Following the GRADE framework, recommendation for HD in this population would be weak. This means it should not be considered standard of care and should only be started based on the well-informed patient’s values and preferences. More studies are needed to delineate the true treatment effect and to guide future practice and policy.

Acute lung injury and acute respiratory distress syndrome requiring tracheal intubation and mechanical ventilation in the intensive care unit: impact on managing uncertainty for patient-centered communication

A case of acute lung injury (ALI) progressing to acute respiratory distress syndrome (ARDS) requiring tracheal intubation and mechanical ventilation (ETMV) is presented. The palliative medicine service was asked to address concerns expressed by the patient's spouse reflecting uncertainty regarding outcome expectations. Acknowledging and confronting the uncertainties of a critical illness is an essential component of patient-centered communication. Addressing and managing uncertainty for the case scenario requires consideration of both short- and long-term outcomes including mortality, ventilator independence, and adverse effects on quality of life for survivors. In this paper, ALI/ARDS requiring ETMV in the ICU was used as a focal point for preparing a prognostic assessment incorporating these issues. This assessment was based on a review of recently published literature regarding mortality and ventilator independence of survivors for adult patients receiving ETMV for ALI/ARDS in the ICU. In the studies reviewed, long-term survival reported at 60 days to 1 year was 50-73% with greater than 84% of the survivors in each study breathing independently. Selected articles discussing outcomes other than mortality or recovery of respiratory function, particularly quality of life implications for ALI/ARDS survivors, were also reviewed. A case of of ALI/ARDS requiring ETMV in the ICU is used to illustrate the situation of an incapacitated critically ill patient where the outcome is uncertain. Patient-centered communication should acknowledge and address this uncertainty. Managing uncertainty consists of effectively expressing a carefully formulated prognostic assessment and using sound communication principles to alleviate the distress associated with the uncertain outcome probabilities.