Division of Nephrology, Department of Internal Medicine, New York University Grossman School of Medicine, New York, New York.
Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, New York University Grossman School of Medicine, New York, New York.
Clin J Am Soc Nephrol. 2022 Mar;17(3):342-349. doi: 10.2215/CJN.11030821. Epub 2022 Feb 24.
AKI is a common complication of coronavirus disease 2019 (COVID-19) and is associated with high mortality. Palliative care, a specialty that supports patients with serious illness, is valuable for these patients but is historically underutilized in AKI. The objectives of this paper are to describe the use of palliative care in patients with AKI and COVID-19 and their subsequent health care utilization.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a retrospective analysis of New York University Langone Health electronic health data of COVID-19 hospitalizations between March 2, 2020 and August 25, 2020. Regression models were used to examine characteristics associated with receiving a palliative care consult.
Among patients with COVID-19 (=4276; 40%), those with AKI (=1310; 31%) were more likely than those without AKI (=2966; 69%) to receive palliative care (AKI without KRT: adjusted odds ratio, 1.81; 95% confidence interval, 1.40 to 2.33; <0.001; AKI with KRT: adjusted odds ratio, 2.45; 95% confidence interval, 1.52 to 3.97; <0.001), even after controlling for markers of critical illness (admission to intensive care units, mechanical ventilation, or modified sequential organ failure assessment score); however, consults came significantly later (10 days from admission versus 5 days; <0.001). Similarly, 66% of patients initiated on KRT received palliative care versus 37% (<0.001) of those with AKI not receiving KRT, and timing was also later (12 days from admission versus 9 days; =0.002). Despite greater use of palliative care, patients with AKI had a significantly longer length of stay, more intensive care unit admissions, and more use of mechanical ventilation. Those with AKI did have a higher frequency of discharges to inpatient hospice (6% versus 3%) and change in code status (34% versus 7%) than those without AKI.
Palliative care was utilized more frequently for patients with AKI and COVID-19 than historically reported in AKI. Despite high mortality, consultation occurred late in the hospital course and was not associated with reduced initiation of life-sustaining interventions.
This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_24_CJN11030821.mp3.
急性肾损伤（AKI）是 2019 年冠状病毒病（COVID-19）的常见并发症，与高死亡率相关。姑息治疗是一种支持重病患者的专业治疗方法，对这些患者很有价值，但在 AKI 中历史上未得到充分利用。本文的目的是描述 AKI 和 COVID-19 患者中姑息治疗的使用情况及其随后的医疗保健利用情况。
设计、地点、参与者和测量：我们对 2020 年 3 月 2 日至 2020 年 8 月 25 日期间纽约大学朗格尼健康中心 COVID-19 住院患者的电子健康数据进行了回顾性分析。使用回归模型来研究与接受姑息治疗咨询相关的特征。
在 COVID-19 患者中（=4276；40%），与没有 AKI 的患者（=2966；69%）相比，有 AKI 的患者（=1310；31%）更有可能接受姑息治疗（无肾脏替代治疗的 AKI：调整后的优势比，1.81；95%置信区间，1.40 至 2.33；<0.001；有肾脏替代治疗的 AKI：调整后的优势比，2.45；95%置信区间，1.52 至 3.97；<0.001），即使在控制了危重病标志物（入住重症监护病房、机械通气或改良序贯器官衰竭评估评分）后也是如此；然而，咨询的时间明显较晚（入院后 10 天与 5 天；<0.001）。同样，接受肾脏替代治疗的 66%的患者接受了姑息治疗，而没有接受肾脏替代治疗的 AKI 患者中只有 37%（<0.001）接受了姑息治疗，时间也较晚（入院后 12 天与 9 天；=0.002）。尽管姑息治疗的使用率更高，但 AKI 患者的住院时间更长，入住重症监护病房的次数更多，机械通气的使用也更多。AKI 患者的住院临终关怀（6%比 3%）和更改医嘱（34%比 7%）的频率也高于没有 AKI 的患者。
与 AKI 中历史报告相比，COVID-19 合并 AKI 的患者更频繁地接受姑息治疗。尽管死亡率较高，但咨询发生在住院治疗过程的晚期，与减少生命支持干预的启动无关。
