Haematological malignancies and acute kidney injury requiring nephrology consultation: challenging the worst of the worst

Abstract

BackgroundAcute kidney injury (AKI) often complicates the course of haematological malignancies (HMs) and confers a worse prognosis. The majority of these patients are managed by the attending physician, yet, a small group, mostly coincident with the worst presentation and outcomes, requires nephrology consultation, challenging the clinician with ethical issues regarding the decision to initiate or forgo renal support therapy. The purpose of this work is to identify the prognostic determinants for in-hospital mortality in this population.MethodsA retrospective, observational chart review was undertaken at a single tertiary referral oncological centre. We reviewed the medical records of in-hospital patients with AKI and HM between 1 January 1995 and 31 December 2014 who met the criteria for RIFLE (Risk, Injury, and Failure; and Loss; and End-stage kidney disease) classification of I or higher and were followed by a nephrologist.ResultsThree hundred and forty-five patients were included in the study. Predictors of in-hospital death in patients with HM and AKI were septic shock [odds ratio (OR) 4.290 (95% CI 2.058–8.943)], invasive mechanical ventilation (IMV) [OR 4.305 (95% CI 2.075–8.928)] and allogeneic stem cell transplantation (SCT) [OR 2.232 (95% CI 1.260–3.953)]. The combination of each risk factor was used to estimate the probability of dying. Patients with all three risk factors had a risk of death of 86%.ConclusionsSeptic shock, IMV and allogeneic SCT were identified as independent predictors of death in patients with HM and AKI, with only a small chance of survival if all three were present. Depending on the combination of risk factors, the indication for aggressive life support therapies, such as RST, might be questionable.

Trends in Health-Care Utilization at the End of Life Among Patients With Hematologic Malignancies in a Middle-Income Country: Challenges and Opportunities in Brazil

“…24 We identified that 10% of patients used ARRT near death. Although the diagnosis of HM by itself is not a reason to withhold ARRT, 25 hemodialysis is associated with increased health-care costs, longer length of stays, 11 (16) 16 (18) .16…”

“…24 We identified that 10% of patients used ARRT near death. Although the diagnosis of HM by itself is not a reason to withhold ARRT, 25 hemodialysis is associated with increased health-care costs, longer length of stays, aggressiveness of care, and late palliative care enrollment, especially in patients with multiple myeloma. 26,27 Our findings highlight the importance of advanced care planning documentation.…”

Adaptation of the Nursing Activities Score for oncologic care

“…In a study carried out in Portugal, the objective was to identify the prognostic determinants of in-hospital mortality of patients with hematological malignancies. The study concluded that the association of mechanical ventilation, septic shock, and allogeneic stem cell treatment was identified as an independent predictor of death in patients with hematological diseases and AKI, with only a small chance of survival if all three were present (21) .…”

The intersection of oncology, nephrology, and palliative care

“…The presence of all three conveyed an 86% probability of in-hospital death. 14 Multiple myeloma (MM), in particular, has the highest 5-year AKI incidence rate among all malignancies. 8 On presentation, up to 50% of patients will already have kidney involvement, 15 which is associated with higher mortality.…”