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Patients with acute kidney injury who require outpatient dialysis after being discharged from the hospital receive the same treatment as patients with the more common end-stage renal disease, according to a study led by the University of California, San Francisco.
However, while patients with the latter diagnosis (usually caused by long-standing hypertension or diabetes) must remain on dialysis or receive a new kidney for the rest of their lives, some patients on dialysis due to acute kidney injury Researchers have reported that there is a possibility of recovery.of American Society of Nephrology Journal September 28, 2023.
For people who may recover, continuing dialysis can expose them to unnecessary risks such as heart disease, infection, organ damage, and death. ”
“For those who have the potential to recover, continuing dialysis may expose them to unnecessary risks such as heart disease, infection, organ damage, and death,” the first author said. Ian E. McCoyMD, of the UCSF Department of Nephrology.
In a typical mid-sized dialysis center, less than a quarter of patients suffer from acute kidney injury. This can be caused by an acute infection or shock that causes decreased blood flow to the kidneys, as well as extensive surgery or chemotherapy drugs that are toxic to the kidneys.
In the study, researchers tracked data from 1,754 patients with acute kidney injury and 6,197 patients with end-stage renal disease in outpatient dialysis centers. Although clinical tests suggested that patients with acute kidney injury required less dialysis, treatment for the two groups was similar. Both groups started dialysis three times a week, but the majority of patients in both groups did not have renal function tests during their first month of treatment.
Many patients quit without weaning
Researchers said 10% of patients with acute kidney injury died during the three-month study period, mostly from symptoms that required dialysis. Of his 41% of patients whose kidney function recovered, about three-quarters discontinued dialysis without changing dose, frequency, or duration. This suggests that these patients may have been able to wean earlier, the researchers noted.
“More research is needed on safe weaning strategies,” McCoy says. “If patients are weaned too soon, they can develop shortness of breath and electrolyte abnormalities that increase the risk of dangerous heart rhythms.
“On the other hand, there are also risks in continuing dialysis unnecessarily, as patients experience higher rates of heart disease, infection and mortality,” he said.
For nephrologists who treat patients with acute kidney injury and dialysis providers who operate outpatient centers, there are strong disincentives to wean patients off dialysis, McCoy said. “While discontinuing prescriptions benefits the health care system, it does not benefit dialysis providers. Dialysis providers have vacancies that cannot be easily filled. At the same time, patients can discontinue dialysis. If the patient recovers, nephrologists will lose their multidisciplinary support team of nurses, nutritionists, and social workers.
“Managing patients with borderline kidney function takes longer and carries higher risks than managing patients on thrice-weekly dialysis, yet nephrologists also receive reduced reimbursement for non-dialysis treatment.” For these reasons, the default path of least resistance may be to continue dialysis.”
Weaning from dialysis after cancer treatment
Melissa “Liddy” Lawson underwent dialysis three times a week after being treated for leukemia. She had been told she would have to continue on dialysis for the rest of her life or wait for a donor for her kidney.
Dr. Chi-yuan Hsu was successfully weaned from dialysis after cancer treatment, allowing him to resume his life without treatment.
3 months of dialysis could mean dialysis indefinitely
About half of the patients did not die or stop dialysis by the end of the study.The future seemed uncertain to them. Su Qiyuan, MD, senior author and head of the UCSF Division of Nephrology. “After about three months of dialysis, in most cases they are treated as if they would continue on dialysis indefinitely,” he said.
“Doctors don’t seem to be paying the most attention to monitoring for early, subtle signs of recovery. It’s clear that if your kidney function is 30%, you don’t need dialysis, but if your kidney function is 30%… The delicate 15% requires skill, attentiveness, careful discussion with the patient and a willingness to take on some risk in the weaning process,” said Sue. “Many doctors suspect that they only stop dialysis when the signs are visibly obvious.”
The worst-case scenario is a patient who continues on dialysis even though their kidney function has recovered to the point where they can be weaned. The drop in blood pressure caused by repeated dialysis can further damage the fragile kidneys, dropping kidney function below the threshold considered necessary for weaning, McCoy said. “Even if patients are healthy enough to be candidates, they may need dialysis for the rest of their lives or eventually a transplant.”
Co-author: Dr. Eric Weinhandle of Satellite Healthcare and the University of Minnesota; Wael Hussein, MBBS, MRCPI, Satellite Healthcare and Stanford University School of Medicine;
Disclosure: Doctors. Mr. Weinhandle and Mr. Hussain are employees of Satellite Healthcare, a nonprofit dialysis provider.
Funding: This research was funded in part by grants K23DK128605 and K24DK92291 and from Satellite Healthcare.
