Utilization of Palliative Care for Patients with COVID-19 and Acute Kidney Injury during a COVID-19 Surge

Abstract

Background and objectivesAKI is a common complication of coronavirus disease 2019 (COVID-19) and is associated with high mortality. Palliative care, a specialty that supports patients with serious illness, is valuable for these patients but is historically underutilized in AKI. The objectives of this paper are to describe the use of palliative care in patients with AKI and COVID-19 and their subsequent health care utilization.Design, setting, participants, & measurementsWe conducted a retrospective analysis of New York University Langone Health electronic health data of COVID-19 hospitalizations between March 2, 2020 and August 25, 2020. Regression models were used to examine characteristics associated with receiving a palliative care consult.ResultsAmong patients with COVID-19 (n=4276; 40%), those with AKI (n=1310; 31%) were more likely than those without AKI (n=2966; 69%) to receive palliative care (AKI without KRT: adjusted odds ratio, 1.81; 95% confidence interval, 1.40 to 2.33; P<0.001; AKI with KRT: adjusted odds ratio, 2.45; 95% confidence interval, 1.52 to 3.97; P<0.001), even after controlling for markers of critical illness (admission to intensive care units, mechanical ventilation, or modified sequential organ failure assessment score); however, consults came significantly later (10 days from admission versus 5 days; P<0.001). Similarly, 66% of patients initiated on KRT received palliative care versus 37% (P<0.001) of those with AKI not receiving KRT, and timing was also later (12 days from admission versus 9 days; P=0.002). Despite greater use of palliative care, patients with AKI had a significantly longer length of stay, more intensive care unit admissions, and more use of mechanical ventilation. Those with AKI did have a higher frequency of discharges to inpatient hospice (6% versus 3%) and change in code status (34% versus 7%) than those without AKI.ConclusionsPalliative care was utilized more frequently for patients with AKI and COVID-19 than historically reported in AKI. Despite high mortality, consultation occurred late in the hospital course and was not associated with reduced initiation of life-sustaining interventions.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_24_CJN11030821.mp3

Acute kidney injury in critical COVID-19: a multicenter cohort analysis in seven large hospitals in Belgium

“…The decision to initiate KRT may have been more conservative compared to a general ICU population. In view of the infectious hazard, doctors seem to be more reluctant to expose themselves and other healthcare professionals to COVID-19 patients which might delay consultation and hence treatment as shown by Scherer et al [ 23 ]. However, restrictive use of KRT has no impact on patient outcomes as shown in several large studies and a meta-analysis.…”

Circulating Soluble Urokinase Plasminogen Activator Receptor as a Predictive Indicator for COVID-19-Associated Acute Kidney Injury and Mortality: Clinical and Bioinformatics Analysis

“…Growing evidence indicates that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes a hypercoagulable state by contributing to pervasive micro-thrombotic occlusions, endothelial injury, coagulation dysfunction, and impairment of fibrinolysis, and that COVID-19 may be classified as a vascular disorder [ 4 ]. Nearly half of hospitalized COVID-19 patients have been associated with acute kidney injury (AKI) [ 5 ]. There are no preventative measures to lower AKI incidence, which is strongly associated with poor survival [ 6 ].…”

COVID-19 and Palliative Care

“…Other research efforts are targeted toward addressing issues that existed well before COVID-19, including the lack of treatment care choice among high-risk patients on dialysis, barriers to quality care and transplantation among underserved communities, and the utilization (or supposed underutilization) of palliative care. The paper titled “Utilization of Palliative Care for Patients with COVID-19 and Acute Kidney Injury during a COVID-19 Surge,” published in this issue of CJASN , addresses this issue on the basis of research findings within the New York Langone Health System (3).…”

“…Scherer et al (3) are honest in stating that their aspirational goal is to facilitate earlier use of palliative care and to encourage consideration of an AKI diagnosis as a trigger for system-based approaches that flag patients at risk for high mortality and suffering and for whom palliative care may have some appeal. They provide comparative data and observations related to the start of palliative care among patients with COVID-19 with and without AKI and among patients with AKI undergoing KRT, including data related to discharge to home, hospice, and death.…”

“…Its weaknesses include reliance on data sources subject to misclassification, limited focus on one health system, and a patient population that was limited to mostly White, non-Hispanic patients in New York City. As the authors state, the implications of their findings are unknown and “should be generalized cautiously to other settings,” but they do express hope that their work may be potentially applicable beyond the COVID-19 pandemic, within other medical systems, and across broader chronically ill populations (3).…”