Renal Replacement Therapy in Patients With Stage IV Cancer Admitted to the Intensive Care Unit With Acute Kidney Injury at a Comprehensive Cancer Center Was Not Associated With Survival

Abstract

Introduction:

In patients with advanced cancer, prolongation of life with treatment often incurs substantial emotional and financial expense. Among hospitalized patients with cancer since acute kidney injury (AKI) is known to be associated with much higher odds for hospital mortality, we investigated whether renal replacement therapy (RRT) use in the intensive care unit (ICU) was a significant independent predictor of worse outcomes.

Methods:

We retrospectively reviewed patients admitted in 2005 to 2014 who were diagnosed with stage IV solid tumors, had AKI, and a nephrology consult. The main outcomes were survival times from the landmark time points, inpatient mortality, and longer term survival after hospital discharge. Logistic regression and Cox proportional regression were used to compare inpatient mortality and longer term survival between RRT and non-RRT groups. Propensity score-matched landmark survival analyses were performed with 2 landmark time points chosen at day 2 and at day 7 from ICU admission.

Results:

Of the 465 patients with stage IV cancer admitted to the ICU with AKI, 176 needed RRT. In the multivariate logistic regression model after adjusting for baseline serum albumin and baseline maximum Sequential Organ Failure Assessment (SOFA), the patients who received RRT were not significantly different from non-RRT patients in inpatient mortality (odds ratio: 1.004 [95% confidence interval: 0.598-1.684], P = .9892). In total, 189 patients were evaluated for the impact of RRT on long-term survival and concluded that RRT was not significantly associated with long-term survival after discharge for patients who discharged alive. Landmark analyses at day 2 and day 7 confirmed the same findings.

Conclusions:

Our study found that receiving RRT in the ICU was not significantly associated with inpatient mortality, survival times from the landmark time points, and long-term survival after discharge for patients with stage IV cancer with AKI.

Keywords

dialysis stage IV cancer hospice ICU SOFA score palliative care

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References

Evans

Manninen

Garrison

, et al. The quality of life of patients with end-stage renal-disease. N Engl J Med. 1985;312(9):553–559.

Johansen

Smith

Unruh

Siroka

O’Connor

Palevsky

; VA/NIH Acute Renal Failure Trial Network. Predictors of health utility among 60-day survivors of acute kidney injury in the veterans affairs/national institutes of health acute renal failure trial network study. Clin J Am Soc Nephrol. 2010;5(8):1366–1372.

Investigators

RRTS

Bellomo

Cass

, et al. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009;361(17):1627–1638.

Network

VNARFT

Palevsky

Zhang

, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359(1):7–20.

Christiansen

Johansen

Langeberg

Fryzek

Sørensen

. Incidence of acute kidney injury in cancer patients: a Danish population-based cohort study. Eur J Intern Med. 2011;22(4):399–406.

Launay-Vacher

Oudard

Janus

, et al. Prevalence of renal insufficiency in cancer patients and implications for anticancer drug management: the renal insufficiency and anticancer medications (IRMA) study. Cancer. 2007;110(6):1376–1384.

Janus

Launay-Vacher

Byloos

, et al. Cancer and renal insufficiency results of the BIRMA study. Br J Cancer. 2010;103(12):1815–1821.

Salahudeen

Doshi

Pawar

Nowshad

Lahoti

Shah

. Incidence rate, clinical correlates, and outcomes of AKI in patients admitted to a comprehensive cancer center. Clin J Am Soc Nephrol. 2013;8(3):347–354.

Salahudeen

Kumar

Madan

, et al. Sustained low efficiency dialysis in the continuous mode (C-SLED): dialysis efficacy, clinical outcomes, and survival predictors in critically ill cancer patients. Clin J Am Soc Nephrol. 2009;4(8):1338–1346.

10.

Leavitt

. Medscape’s response to the institute of medicine report: crossing the quality chasm: a new health system for the 21st century. MedGenMed. 2001;3(2):2.

11.

Grubbs

Moss

Cohen

, et al. A palliative approach to dialysis care: a patient-centered transition to the end of life. Clin J Am Soc Nephrol. 2014;9(12):2203–2209.

12.

Cohen

Ruthazer

Moss

Germain

. Predicting six-month mortality for patients who are on maintenance hemodialysis. Clin J Am Soc Nephrol. 2010;5(1):72–79.

13.

Morgan

. Landmark analysis: a primer. J Nucl Cardiol. 2019;26(2):391–393.

14.

Dafni

. Landmark analysis at the 25-year landmark point. Circ Cardiovasc Qual Outcomes. 2011;4(3):363–371.

15.

Soares

Salluh

Carvalho

Darmon

Rocco

Spector

. Prognosis of critically ill patients with cancer and acute renal dysfunction. J Clin Oncol. 2006;24(24):4003–4010.

16.

Bagshaw

Adhikari

NKJ

Burns

KEA

, et al. Selection and receipt of kidney replacement in critically Ill older patients with AKI. Clin J Am Soc Nephrol. 2019;14(4):496–505.

17.

Moss

. Ethical principles and processes guiding dialysis decision-making. Clin J Am Soc Nephrol. 2011;6(9):2313–2317.

18.

Moss

. Revised dialysis clinical practice guideline promotes more informed decision-making. Clin J Am Soc Nephrol. 2010;5(12):2380–2383.

19.

Barrett

Parfrey

Morgan

, et al. Prediction of early death in end-stage renal disease patients starting dialysis. Am J Kidney Dis. 1997;29(2):214–222.

20.

Couchoud

Labeeuw

Moranne

, et al. A clinical score to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease. Nephrol Dial Transplant. 2009;24(5):1553–1561.

21.

Moss

Ganjoo

Sharma

, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3(5):1379–1384.

22.

Scherer

Holley

. The role of time-limited trials in dialysis decision making in critically Ill patients. Clin J Am Soc Nephrol. 2016;11(2):344–353.

23.

Quill

Abernethy

. Generalist plus specialist palliative care--creating a more sustainable model. N Engl J Med. 2013;368(13):1173–1175.

24.

Chong

Silver

Long

, et al. Infrequent provision of palliative care to patients with dialysis-requiring AKI. Clin J Am Soc Nephrol. 2017;12(11):1744–1752.

25.

Levit

Balogh

Nass

Ganz

. eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: National Academies Press; 2013.

26.

Manzano

Luo

Elting

George

Suarez-Almazor

. Patterns and predictors of unplanned hospitalization in a population-based cohort of elderly patients with GI cancer. J Clin Oncol. 2014;32(31):3527–3533.

27.

Obermeyer

Makar

Abujaber

Dominici

Block

Cutler

. Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA. 2014;312(18):1888–1896.

28.

Citko

Moss

Carley

Tolle

. The National POLST paradigm initiative, 2nd Edition #178. J Palliat Med. 2011;14(2):241–242.

29.

Meghani

Hinds

. Policy brief: the institute of medicine report dying in America: improving quality and honoring individual preferences near the end of life. Nurs Outlook. 2015;63(1):51–59.