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Kidney Week

Abstract: TH-PO054

Patterns of Healthcare Resource Utilization and Goals of Care Discussions in Patients With Cirrhosis and AKI

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical‚ Outcomes‚ and Trials

Authors

  • Petrosyan, Romela, Massachusetts General Hospital Division of Nephrology, Boston, Massachusetts, United States
  • Endres, Paul, Massachusetts General Hospital Division of Nephrology, Boston, Massachusetts, United States
  • Ufere, Nneka, Massachusetts General Hospital, Liver Center and Gastrointestinal Division, Boston, Massachusetts, United States
  • St. Hillien, Shelsea A., Massachusetts General Hospital Division of Nephrology, Boston, Massachusetts, United States
  • Krinsky, Scott, Massachusetts General Hospital Division of Nephrology, Boston, Massachusetts, United States
  • Kalim, Sahir, Massachusetts General Hospital Division of Nephrology, Boston, Massachusetts, United States
  • Nigwekar, Sagar U., Massachusetts General Hospital Division of Nephrology, Boston, Massachusetts, United States
  • Allegretti, Andrew S., Massachusetts General Hospital Division of Nephrology, Boston, Massachusetts, United States
Background

Patients with cirrhosis and acute kidney injury (AKI) are critically ill and have high health care resource utilization (HCRU) during hospitalizations. The timing and impact of goals of care discussions on code status changes and rates of HCRU are not well described.

Methods

Medical records of 221 patients who previously enrolled in a prospective cohort study of patients hospitalized with AKI and cirrhosis at the Massachusetts General Hospital were reviewed. Documentation and timing of goals of care discussions were analyzed as predictors of high HCRU, defined as a composite outcome of either intubation, initiation of renal replacement therapy, or admission to the ICU.

Results

Median MELD score was 26 [IQR 19, 33]. 63/221 (29%) patients were listed for liver transplant and 41/221 (18.5%) patients later received liver transplant. 90-day mortality was 61%. 51% patients had at least one high HCRU episode. For all patients, code status on admission was 91% full code, 7% do not resuscitate, 0% comfort measures. By discharge, this changed to 68% full code, 14% do not resuscitate, 18% comfort measures (p <0.001). 28% patients underwent goals of care discussions, with change in code status at a median of 16 [9,22] days into their admission. However, only 18% of these discussions were prior to a high HCRU episode. Being listed for liver transplant was not associated with whether goals of care discussions occurred (23% listed vs. 31% non-listed, p = 0.24) but was associated with higher HCRU (69% vs. 43%; p <0.001).

Conclusion

Goals of care discussions occurred late into the hospital course, generally after an episode of high HCRU. Efforts to engage in these discussions earlier in a hospital stay, may decrease HCRU in this critically ill population and provide more goal-concordant care.