Abstract
Background
Patients with cirrhosis and acute kidney injury (AKI) are critically ill and have high health care resource utilization (HCRU). The impact and timing of goals of care discussions on HCRU are not well described.
Methods
221 patients enrolled in a prospective cohort study of patients admitted with AKI and cirrhosis were reviewed. Documentation and timing of a goals of care discussions were analyzed as predictors of HCRU, defined as a composite outcome of intubation, initiation of renal replacement therapy, and/or admission to the intensive care unit.
Results
Median MELD score was 26 [IQR 19, 33]. 29% patients were listed for liver transplant. 90-day mortality was 61%. 51% patients had at least one HCRU episode. Code status changed from admission to discharge from 91%/7%/0% to 68%/14%18% (full code/do not resuscitate/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 admission. Only 18% of discussions were within 7 days of admission and all were after an HCRU event. 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, after episodes of HCRU. Efforts should be made to engage in these discussions earlier in the hospital stay, which may decrease HCRU rates in this critically ill population and align with patients’ goals of care.
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Abbreviations
- AKI:
-
Acute kidney injury
- HCRU:
-
Health care resource utilization
- ICU:
-
Intensive care unit
- RRT:
-
Renal replacement therapy
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Acknowledgments
We appreciate the providers and support staff at Massachusetts General Hospital for their clinical care of this population. We extend a great thanks to the patients and their families for participating in this study.
Funding
ASA is supported by NIH award K23 DK128567.
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The study was approved by the Mass General Brigham Institutional Review Board. All procedures and practices abide by guidelines set forth by the Declarations of Helsinki and Istanbul. Patients (or their health care designee) provided written informed consent. All authors met International Committee of Medical Journal Editors criteria.
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Petrosyan, R., Endres, P., Ufere, N.N. et al. Healthcare Resource Utilization and Goals of Care Discussions in Patients with Cirrhosis and Acute Kidney Injury. Dig Dis Sci (2024). https://doi.org/10.1007/s10620-024-08317-9
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DOI: https://doi.org/10.1007/s10620-024-08317-9