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Kidney Week

Abstract: PO1381

Kidney Palliative Care in Transplant Recipients with a Failing Allograft

Session Information

Category: Geriatric Nephrology

  • 1100 Geriatric Nephrology

Authors

  • Gelfand, Samantha L., Brigham and Women's Hospital, Boston, Massachusetts, United States
  • Murakami, Naoka, Brigham and Women's Hospital, Boston, Massachusetts, United States
  • Adler, Joel T., Brigham and Women's Hospital, Boston, Massachusetts, United States
  • Lakin, Joshua R., Dana-Farber Cancer Institute, Boston, Massachusetts, United States
Background

Kidney transplantation provides longer survival and better quality of life than dialysis for patients with end-stage kidney disease. However, when allografts fail, navigating treatment options can be challenging as patients with allograft failure are older and sicker than when they were transplanted. Kidney palliative care, specialized interprofessional medical care working together with nephrology providers, providing communication, coordination, symptom management, and psychosocial support for seriously ill patients, has not yet been well-studied for those with kidney transplants.

Methods

We conducted a retrospective observational study comparing palliative care delivery, patient treatment choices, and clinical outcomes before and after creation of an inpatient kidney palliative care service (KidneyPal) at our institution. We included adult kidney transplant patients (age 18 or greater) who experienced allograft failure or death two years before and after the start of KidneyPal. Allograft failure was defined as imminent indication or chronic need for dialysis for more than 3 months.

Results

Fifty-four and fifty-nine patients were included before and after KidneyPal implementation, respectively. For the patients who experienced death with a functioning graft, inpatient palliative consultation frequency was similar before and after the creation of KidneyPal (40% and 33%, respectively). However, for the patients with allograft failure, palliative care consultation increased from 5.9% to 24.1%. Death in the ICU was common (15% vs. 17%), but death in hospice was more frequent (7% vs. 15%) after KidneyPal was created. While palliative care clinicians addressed code status, symptom management, and psychosocial issues throughout the study period, KidneyPal clinicians held more discussions about treatment options for allograft failure (20% vs. 41%). More patients chose dialysis as a time-limited trial or made a decision to forgo dialysis re-initiation after consultation with KidneyPal (3% vs. 17%).

Conclusion

Our observational study suggests that kidney palliative care may be useful in the context of allograft failure, particularly with regard to ensuring goal-directed shared decision making. Discussing prognosis, goals of care, and care options after graft failure are palliative skills that may be enhanced by collaboration with a specialty kidney palliative care team.