Palliative Medicine Referral in Patients Undergoing Continuous Renal Replacement Therapy for Acute Kidney Injury

Figures & data

Figure 1. Flow diagram of the participants into the study; PMC distribution (n = 55). Mean age = 66.0 years (±14.5, median 68.8). Males = 61.3%. Females = 38.7%. Mean BUN before CRRT = 63.6 ± 34.2 mg/dL (median 55.5 mg/dL). Mean creatinine before CRRT 3.7 ± 1.8 mg/dL (median 3.5 mg/dL). Mean CCF score at CRRT initiation = 9.12 ± 2.8 (median 9). BUN, blood urea nitrogen; CRRT, continuous renal replacement therapy; NPMC, number of patients included in the palliative referral study; CCF, Cleveland Clinic Foundation; PMC, palliative medicine consultation.

Table 1. Baseline patient demographics and clinical characteristics.

	Overall (n = 230)	No-PMC (n = 175)	PMC (n = 55)	p-Value for no-PMC versus PMC
Age (mean ± std)	66.0 ± 14.5; median = 68.8	64.8 ± 14.4; median = 67.9	69.7 ± 14.3; median = 74.4	<0.01
Male (%)	61.3	61.7	60.0	0.82
BUN (mean ± std)	63.6 ± 34.2; median = 55.5	62.5 ± 34.1; median = 55.0	67.1 ± 34.6; median = 58.0	0.36
Creatinine (mean ± std)	3.7 ± 1.8; median = 3.5	3.7 ± 2.0; median = 3.4	3.7 ± 1.3; median = 3.9	0.47
Initial CCF score (mean ± std)	9.12 ± 2.8; median = 9.0	9.0 ± 2.7; median = 9.0	9.5 ± 2.9; median = 10.0	0.21

Note: BUN, blood urea nitrogen; CCF, Cleveland Clinic Foundation; PMC, palliative medicine consultation.

Table 2. Initial and follow-up (pre-PMC referral) CCF scores.

	All PMC (n = 55)	PMC and alive (n = 9)	PMC and died (n = 46)	p-Value (alive vs. died)
Initial CCF score (mean ± std)	9.5 ± 2.9; n = 55; median = 10.0	8.2 ± 3.7; n = 9; median = 8.0	9.7 ± 2.7; n = 46; median = 10.5	0.11
F/U (pre-PMC) CCF score	9.9 ± 3.6; n = 43; median = 10.0	5.6 ± 1.1; n = 5; median = 6.0	10.5 ± 3.4; n = 38; median = 10.5	<0.01

Note: CCF, Cleveland Clinic Foundation; PMC, palliative medicine consultation.

Figure 2. Annual trends in CRRT and PMC between 1999 and February 2006, percentages denote the proportion of all CRRT patients referred for PMC in a given year. CRRT, continuous renal replacement therapy; PMC, palliative medicine consultation.

Table 3. Treatment duration according to median initial CCF scores.

	All PMC (n = 55)	PMC and CCF ≥ 12 (n = 13)	PMC and CCF < 12 (n = 42)	p-Value (CCF > 12 vs. CCF < 12)
Median CCF	10.0	13.0	9.0	<0.01
CRRT–PMC (median of days between initiation of CRRT and PMC referral)	9.0	5.0	9.5	0.09
CRRT duration prior to PMC (median days of CRRT prior to PMC)	5.0	4.0	5.5	0.19
A-PMC (median total hospitalization days before PMC)	15	10	16	0.12
ICU–PMC (median ICU days prior to PMC)	13.0	9.0	13.5	0.24

Note: CCF, Cleveland Clinic Foundation; CRRT, continuous renal replacement therapy; ICU, intensive care unit; PMC, palliative medicine consultation.

Table 4. Length of hospitalization and ICU days prior to PMC relative to mortality outcomes.

	PMC alive (n = 9)	PMC died (n = 46)	p-Value
CRRT–PMC	4.0	10.0	0.05
A-PMC (median hospitalization days before PMC)	8.0	16.5	0.14
Hospital LOS days (median)	26.0	18.5	0.34
ICU days (median)	6.0	11.5	0.37
CRRT days (median)	3.0	5.5	0.28
CCF (median)	8.0	10.0	0.11

Note: CCF, Cleveland Clinic Foundation; CRRT, continuous renal replacement therapy; ICU, intensive care unit; LOS, length of stay; PMC, palliative medicine consultation.

Table 5. Multivariate logistic regression analysis of mortality factors among all CRRT patients.

Factor	Odds ratio	95% Wald confidence	p-Value
Absence of renal recovery	55.84	(16.28,191.59)	<0.01
Presence of DNR order	12.96	(5.06, 33.18)	<0.01
Vascular cause for AKI	3.11	(1.02, 9.49)	0.05
Neurological complications	7.38	(1.87, 29.18)	<0.01
Use of pressors by third day of CRRT	2.77	(1.10, 6.97)	0.031
Creatinine at baseline^a	3.39	(1.60, 7.16)	<0.01

Notes: Definition of “vascular cause for AKI”: renal artery stenosis, vasculitis, peripheral vascular disease.

Definition of “neurological complication”: new cerebrovascular accident-ischemic/intracranial bleed, encephalopathy.

AKI, acute kidney injury; CRRT, continuous renal replacement therapy; DNR, Do not resuscitate.

^aWhere variable “Creatinine at baseline” had 3 levels (2 = Creatinine ≤ 2.72, 1= 2.72 < Creatinine ≤ 5.44, and 0 = Creatinine > 5.44).

Figure 3. Mortality of patients with and without PMC within risk strata. p-Values for all three strata = 1.0 (Fisher’s test). PMC, palliative medicine consultation.

Table 6. Non-beneficial life-sustaining treatments (NBLST): CRRT, ICU, and total hospital days among all deceased patients.

	No PMC (n = 66)	PMC (n = 46)	p-Value
CRRT days (median)	3.0 (95% CI = 3–4)	5.5 (95% CI = 4–8)	<0.01
ICU days (median)	7.0 (95% CI = 6–9)	11.5 (95% CI = 9–15)	<0.01
Hospital days (median)	12.5 (95% CI = 9–17)	18.5 (95% CI = 15–25)	<0.01
Initial CCF (median)	10.0	10.0	0.98

Note: CCF, Cleveland Clinic Foundation; CRRT, continuous renal replacement therapy; ICU, intensive care unit; PMC, palliative medicine consultation.

Table 7. Comparison of patients with and without PMC who survived.

	No PMC (n = 109)	PMC (n = 9)	p-Value
CRRT days (median)	3.0	3.0	0.52
Hospital days (median)	23.0	26.0	0.74
ICU days (median)	8.0	6.0	0.99
CCF (median)	9.0	8.0	0.46

Note: CCF, Cleveland Clinic Foundation; CRRT, continuous renal replacement therapy; ICU, intensive care unit; PMC, palliative medicine consultation.

Table 8. CRRT utilization among patients with and without PMC referral.

	CRRT days with PMC	CRRT days without PMC	p-Value
Overall	n = 55; median CRRT days = 5.0	n = 175; median CRRT days = 3.0	<0.01
Died	n = 46; median CRRT days = 5.5	n = 66; median CRRT days = 3.0	<0.01
Alive	n = 9; median CRRT days = 3.0	n = 109; median CRRT days = 3.0	0.52

Note: CRRT, continuous renal replacement therapy; PMC, palliative medicine consultation.

Figure 4. Chronology of palliative medicine consultation (PMC) referrals in relation to other sentinel events [total hospital length of stay, total continuous renal replacement therapy (CRRT) days only, number of days from initiation of CRRT until PMC referral, number of days in intensive care until PMC referral].