Intensive Care in Nephrology
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Shared decision-making and advance directives play an important role guiding the physician as to what patient wishes are, and those decisions should be respected.
Palliative care for acute kidney injury patients in the intensive care unit
Intensive care unit ICU patients with acute kidney injury AKI have a high mortality rate and renal replacement therapy is not cost-effective in these patients[ 1 ]. Physicians in the ICU often face challenging situations when potentially inappropriate treatment has to be withdrawn in critically ill patients[ 2 ]. Various factors make these situations more complex; incapacitated state of ICU patients, the option of temporary dialysis due to reversible nature of AKI, and inadequate knowledge of surrogate decision-makers about the goals of care and prognosis[ 2 ]. Palliative medicine has a well-established role in many chronic disease states and principles of palliative care are well established for the management of end-stage disease symptoms.
However, the role of palliative medicine in the field of nephrology is not well defined and patients with AKI leading to fluid overload, acidosis, hyperkalemia, acute respiratory distress syndrome, respiratory failure and multisystem organ dysfunction with hypotension and sepsis in the ICU may not receive the most comprehensive or appropriate care surrounding their illness.
A multitude of factors contribute to this; lack of palliative care training among nephrologists, lack of epidemiological research on outcomes and scarcity of established palliative care guidelines for management of AKI patients in the ICU results in a substandard level of care. However, a multidisciplinary approach by involving palliative care physician early in the course of illness may help in comfort care of AKI patients in the ICU. In this review, we discuss the use of palliative medicine in this specific patient population. One of the main reasons why palliative care is rarely offered to AKI patients in the ICU setting is the lack of palliative medicine training in most nephrology programs.
As a result, most nephrologists may not feel comfortable or compelled to provide these services at an appropriate time. To help solve this issue, nephrology fellows in the future during their training should receive some exposure to palliative care, especially in the ICU setting. There are well-established prognostic indicators from multitudes of epidemiological research on disease progression and outcomes in end-stage renal disease ESRD patients.
Due to this, nephrologists frequently consult palliative medicine in situations when it may be appropriate for the ESRD patient to withdraw from chronic dialysis. The following discussion may serve as a guide to nephrologists for providing palliative care to patients with AKI in the ICU. Kao et al[ 3 ] conducted a retrospective cohort study to investigate in-hospital mortality and long-term survival rates in critically ill patients with AKI or ESRD receiving renal replacement therapy. This study found that overall in-hospital mortality was Hypertension was found to be a high-risk factor for in-hospital mortality in patients with AKI while older age, chronic liver disease and history of cancer were found to be independent risk factors for in-hospital mortality in both AKI and ESRD groups[ 3 ].
In addition, older age, coronary artery disease, and ICU admissions were found to be risk factors in AKI patients for long-term dialysis dependence[ 3 ].
Intensive Care Nephrology
Furthermore, a recent prospective cohort study involving septic AKI patients undergoing dialysis in the ICU found that norepinephrine use, hepatic failure, medical condition, blood lactate, and pre-dialysis creatinine level were associated with early mortality seven days [ 5 ]. Palliative care should be considered for all high-risk AKI patients in the ICU determined by the presence risk factors associated with poor outcome or high mortality rates as discussed earlier.
Three palliative care models have evolved over two decades with an aim to improve quality of care and reduce suffering in the ill patients[ 6 ]. Conventional model of care: This is also called as the traditional dichotomous model of palliative care where ICU patients receive curative or disease-specific care for AKI till it fails following which palliative care will be initiated[ 7 ]. The Conventional model of care is suitable for young AKI patients in the ICU without high-risk factors associated with the poor outcome such as septic shock, acidemia, hypertension, coronary artery disease, chronic liver disease and history of malignancy.
Given higher resolution rates in this patient population, curative or disease-specific therapy is given first for the management of AKI till it is unsuccessful and then palliative care is initiated. Comprehensive model of care: This is also called as the overlapping model of palliative care where ICU patients receive both curative or disease-specific care for AKI and palliative care simultaneously Figure 2 [ 7 ].
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However, both of these dichotomous models of care have the disadvantage of providing one model of care at the cost of the other[ 6 ]. The Comprehensive model of care is suitable for older AKI patients in the ICU with multiple comorbid conditions in addition to the presence of high-risk factors for the poor outcome such as septic shock, acidemia, hypertension, coronary artery disease, chronic liver disease, history of malignancy and history of prior ICU admissions. Due to the poor outcome and higher mortality rates in this patient population, concurrent initiation of palliative care early in the course of medical management helps to prevent and relieve suffering from pain and other physical, psychological, emotional and spiritual distress[ 7 ].
Conceptualization model of care: This is also called as the individualized integrated model of palliative care where ICU patients concurrently receive both palliative care and curative or disease-specific care for AKI, but individualized to suit the needs of the AKI patients and family members[ 7 ]. In this model of care, palliative care extends beyond the death of the patient to include bereavement care for the family members[ 7 ]. In addition, the intensity of palliative care varies based on the needs of the patient or family member during the course of management[ 7 ]. Conceptualization model of palliative care is best suited for poor prognostic AKI patients in the ICU with multiple comorbidities and multi-organ failure.
This model of care classifies all the interventions and options of care based on goals allowing more flexible management[ 6 ]. Once the palliative care is consulted for the impending death of a family member or friend that entails life-changing events and dynamics, the conceptual model helps in supportive intervention to educate family caregivers about stress coping strategies and creates a perception that they have necessary skills to confront problematic situations.
For example, treatment of sepsis, hypotension, acidosis, electrolyte imbalance, and underlying connective tissue and immunological disorders in AKI patients; 2 Life-extending care: Aim to prolong life in chronic disease states with the help of medical treatment while also enhancing the quality of life[ 6 ]. For examples, AKI patients with long-term dialysis dependence; 3 Quality of life and comfort maximizing care: Aim to improve function, reduce suffering and enhance the quality of life in AKI patients in the ICU, and these interventions may also prolong life[ 6 ]; 4 Family supportive care: Aim to address the grief and emotions of the family members from the time of diagnosis to past death[ 6 ].
The key variables that should be considered for supportive care interventions for family members are[ 8 ]; preparedness of the caregivers for the tasks and demands of the role, mastery to manage stress, competence to adapt more quickly to the situation, self-efficacy to manage a situation with coping behaviors, social support to the caregivers, positive emotions to reframe the stressful situations in a positive way, optimism of caregivers to neutralize some potentially negative aspects of caregiving[ 8 ]; 5 Healthcare staff supportive care: Aim to address the grief and emotions related to the management of these AKI patients in the ICU[ 6 ].
Patel et al[ 9 ] described outcomes and decision-making process for nephrologists in the management of AKI in the ICU setting. The highest prognostic indicators for mortality were concomitant multi-organ failure, mechanical ventilation, liver-failure, and malignancy[ 9 , 11 , 12 ]. These prognostic indicators aid physicians to offer palliative care at an appropriate time in this patient population.
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In these situations, it is appropriate to consult palliative care and develop a plan to proceed with the discontinuation of dialysis. Advance directives also play an important role in clinical decision-making. The presence of an advance directive gives clinicians a guide as to what patient wishes are, and those decisions should be respected[ 9 ].
However, one study involving cancer patients in the ICU demonstrated that the presence of an advance directive did not alter decision-making regarding life-supporting interventions[ 15 ].
In addition, we utilize point of care ultrasound POCUS on a daily basis as one of the tools to provide the best possible care for our patients. Here are some good references for introduction to the topic. The list of year critical care medicine fellowships where one can apply before or after nephrology fellowship is available at ERAS. As such, this seems to be just the beginning of nephrology-critical care and the possibilities are endless. I have been fortunate to have colleagues and mentors who have followed their passions through different pathways and have never shared regretting their decision to train in either of the sub-specialties.
I think most would agree that training in both specialites widened their world-view and refined their approach to helping those that need us the most — our patients. Very interesting post. After my training in internal medicine and nephrology, I decided to train and qualify as an Intensive Care specialist. I agree that training in both areas widened my view and refined my skills.
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The interest and job market in this specialty are still evolving, but several different pathways are starting to emerge: One can practice primarily as an intensivist or a nephrologist while using the knowledge gained in both specialties Some practices allow physicians to split time between practicing both as an intensivist and an acute care nephrologist. This content does not have an Arabic version.
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