A 72-year-old man is hospitalized for respiratory failure caused by pneumonia acquired in the community. Blood cultures confirm pneumococcal infection. He receives appropriate antibiotics but requires intubation due to worsening hypotension despite IV fluids. Norepinephrine and vasopressin are initiated to manage the worsening hypotension. Over the next 72 hours, his creatinine levels elevate from 1.0 to 4.6 mg/dl, and his urine output decreases to 0–5 mL/hr. A family conference is scheduled to discuss the potential need for continuous renal replacement therapy (CRRT).
Wrong Answer: A. Palliative care consultation would be inappropriate because he has AKI rather than CKD. This statement is incorrect. Palliative care is not exclusive to end-of-life situations or chronic conditions like CKD. It is appropriate for managing complex, life-threatening conditions, including acute kidney injury (AKI), especially in critically ill patients. Palliative care can provide valuable support, including communication about difficult decisions, advance care planning, prognosis discussions, and symptom management. The patient’s critical condition and the need for decisions regarding CRRT make a palliative care consultation appropriate, regardless of the underlying cause of kidney injury.
Wrong Answer: B. A goals-of-care discussion is not indicated as most patients with AKI and respiratory failure survive. This statement is incorrect. While many patients with AKI and respiratory failure do survive, the prognosis in this specific case is poor due to factors like advanced age, critical illness, and multiorgan failure. A goals-of-care discussion is essential to align medical interventions with the patient’s values and preferences. Such discussions are critical in cases where the outcomes are uncertain and the interventions, such as CRRT, carry significant risks and implications for the patient's quality of life (QoL) and overall prognosis.
Wrong Answer: C. If the patient is started on RRT and survives the hospitalization, his quality of life (QoL) at 60 days is likely to return to his pre-hospitalization baseline. This statement is incorrect. Evidence suggests that survivors of severe AKI, especially those requiring RRT, often experience significant declines in QoL. Up to a quarter of survivors report a QoL similar to death at 60 days post-treatment. Factors such as prolonged critical illness, advanced age, and the severity of the initial illness all contribute to a decreased likelihood of returning to the pre-hospitalization baseline QoL. Therefore, it is overly optimistic to assume that his QoL will fully recover to baseline.
Wrong Answer:D. CRRT should not be offered even if desired by the family because it would constitute futile care in this case. This statement is incorrect. While the prognosis is poor, determining that CRRT is futile would require more specific evidence that it will not achieve the intended goals, such as improving survival or quality of life. In cases where the patient's condition is critical but not hopeless, CRRT can still be offered if it aligns with the patient’s or family’s goals. It is essential to discuss the potential benefits and limitations of CRRT with the family rather than unilaterally deciding that it constitutes futile care.
Right Answer:E. A time-limited trial of CRRT should be pursued in this case if CRRT is desired by the family. This statement is correct. A time-limited trial (TLT) of CRRT is a patient-centered approach that allows for the initiation of treatment with the understanding that it will be reassessed after a defined period. If the therapy proves beneficial and aligns with the patient’s goals, it can be continued. If not, it can be discontinued. This approach respects the family’s wishes while also setting realistic expectations and ensuring that the treatment remains aligned with the patient’s best interests. TLTs are increasingly recommended in situations where the prognosis is uncertain, and the continuation of aggressive treatment requires careful consideration.
Clinical Pearls: ◻ The primary focus should be on the patient’s goals and quality of life. This includes discussions about the benefits and burdens of CRRT in the context of the patient’s overall prognosis and wishes. ◻ Clear and compassionate communication with families is essential to help them understand the role of CRRT, its potential outcomes, and the patient’s wishes. ◻ For patients who are unlikely to benefit from CRRT, transitioning to comfort-focused care may be appropriate. This involves discontinuing CRRT and focusing on symptom relief and quality of life.
