Study examines use of palliative care for patients with COVID-19 and acute kidney injury

Acute kidney injury (AKI) is a common complication of COVID-19 and is associated with a higher risk of death. A new study published in CJASN has examined the use of palliative care in patients with COVID-19 and AKI.

Palliative care focuses on providing relief from the symptoms and stress of a serious illness. Unfortunately, patients with AKI often do not receive palliative care, but studies have not analyzed the use of palliative care for hospitalized patients with both AKI and COVID-19.

To investigate, Jennifer S. Scherer, MD (NYU Grossman School of Medicine) and her colleagues conducted a retrospective analysis of New York University Langone Health's electronic health data of COVID-19 hospitalizations between March 2, 2020 and August 25, 2020. These data pertained to three acute care hospitals located in Manhattan, Brooklyn, and Long Island.

Of 4,276 patients with COVID-19, 1,310 (31%) developed AKI. Among the major findings:

• Compared with those without AKI, individuals with AKI received more palliative care consults (42% vs. 7%), but they occurred significantly later (10 days from hospital admission vs. 5 days).
• Those with AKI had a 1.81-times higher odds of receiving palliative care than those without AKI, even after controlling for markers of critical illness (such as admission to intensive care units or the use of mechanical ventilation).
• 66% of patients with AKI who initiated kidney replacement therapy (KRT) such as dialysis received palliative care vs. 37% of those with AKI not receiving KRT.
• Palliative care consults also occurred later for those who were started on KRT compared with those who were not (12 days from admission vs. 9 days).
• Despite greater use of palliative care, patients with AKI had a significantly longer length of hospital stay, more intensive care unit admissions, and more use of mechanical ventilation.
• Compared with those without AKI, a higher proportion of those with AKI died during hospitalization (46% vs. 5%) or were discharged to inpatient hospice (6% vs. 3%), while a lower proportion were discharged home (24% vs. 77%).

"In this study, we found that, as expected, patients with AKI were seriously ill and had a high mortality rate, but what was not expected was that palliative care was often called later in the hospital course than for those without AKI despite having such a high mortality," said Dr. Scherer. "There are several clinical explanations for this, however given the high mortality it does suggest that patients and families could have benefited from earlier support from palliative care."

Dr. Scherer stressed that palliative care supports primary doctors in caring for seriously ill patients by managing emotional and physical symptoms while also assisting in advance care planning. Importantly, it can be incorporated into the care plan of someone who is pursuing curative care and can be helpful in an acute and possibly reversible situation.

An accompanying Patient Voice written by two members of the national patient and policy leadership team for the American Association of Kidney Patients cautions against the generalization or extrapolation of this research. "We do not question the sincerity of the authors and their desire to contribute to palliative care deliberations; however, the research lacks quantitative or qualitative patient insight data or patient and family perceptions of palliative care. The study does not meet the minimum standards of justification to support any system-wide changes that could interfere with the perceived viability of kidney patients, including AKI patients, and expected care norms during a medical crisis," they wrote.