RESUMEN
Identifying modifiable predictors of outcomes for cases of acute kidney injury requiring hemodialysis (AKI-D) will allow better care of patients with AKI-D. All patients with AKI-D discharged to University of Virginia (UVA) outpatient HD units between 1 January 2017 to 31 December 2019 (n = 273) were followed- for up to six months. Dialysis-related parameters were measured during the first 4 weeks of outpatient HD to test the hypothesis that modifiable factors during dialysis are associated with AKI-D outcomes of recovery, End Stage Kidney Disease (ESKD), or death. Patients were 42% female, 67% Caucasian, with mean age 62.8 ± 15.4 years. Median number of dialysis sessions was 11 (6-15), lasting 3.6 ± 0.6 h. At 90 days after starting outpatient HD, 45% recovered, 45% were declared ESKD and 9.9% died, with no significant changes noted between three and six months. Patients who recovered, died or were declared ESKD experienced an average of 9, 10 and 16 intradialytic hypotensive (IDH) episodes, respectively. More frequent IDH episodes were associated with increased risk of ESKD (p = 0.01). A one liter increment in net ultrafiltration was associated with 54% increased ratio of ESKD (p = 0.048). Optimizing dialysis prescription to decrease frequency of IDH episodes and minimize UF, and close monitoring of outpatient dialysis for patients with AKI-D, are crucial and may improve outcomes for these patients.
RESUMEN
Background: Despite evidence that advance care planning (ACP) benefits patients with serious illnesses, there is a dearth of information about "who" is referred for palliative care (PC) consultation, the rate of PC consultation, and the outcomes of referrals in patients with advanced chronic kidney disease/end-stage kidney disease (aCKD/ESKD). Objectives: (1) To describe patient characteristics associated with PC consultations and (2) to determine the frequency and outcome of PC consultation on documented ACP discussions for patients with aCKD/ESKD. Methodology/Design: This is retrospective observational electronic health record cohort review. Settings: University of Virginia (UVA) hospital, clinics, and dialysis units. Participants: Patients were studied along two time intervals. Time period January 1, 2015 to June 30, 2017 included all patients admitted to UVA during that time period with estimated glomerular filtration rate (eGFR) <60 mL/minute. Time period January 1, 2018 to March 31, 2019 included two cohorts: patients with eGFR <15 mL/minute who had died during study period excluding those who withdrew from dialysis and those who were dialysis dependent and withdrew from dialysis. Results: Aside from higher rates of PC consultation in patients with heart failure, none of the demographic and comorbidity data studied affected whether or not a patient is referred to PC in patients with aCKD/ESKD. PC consultation rates were low among all patients studied: 14.7% in patients with eGFR <60 mL/minute, 28.9% in dialysis patients withdrawing from dialysis, and 57.1% in terminally ill patients with eGFR <15 mL/minute. In all cohorts, PC consultations were associated with improved ACP. Conclusion: PC consultation is significantly associated with better end-of-life outcomes with more completion of ACP and hospice referral in patients with aCKD/ESKD. PC consultation rates remain low. Even in terminally ill patients with more aCKD, >40% were never seen by PC. Until policies and curricula better prepare nephrologists to independently address ACP, collaboration between nephrologists and PC specialists is recommended.