OPTIMAL Selection for and Timing to Start Renal Replacement in Critically Ill Older Patients with Acute Kidney Injury (OPTIMAL-AKI): A Prospective Observational Cohort Study
CCCF ePoster library. Wald R. Oct 31, 2016; 150878; 1
Ron Wald
Ron Wald
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Topic: Retrospective or Prospective Cohort Study

OPTIMAL Selection for and Timing to Start Renal Replacement in Critically Ill Older Patients with Acute Kidney Injury (OPTIMAL-AKI): A Prospective Observational Cohort Study

Bagshaw, Sean M1; Adhikari, Neill2; Burns, Karen3; Friedrich, Jan3; Barton, James4; Bouchard, Josee5; Cailhier,Jean-François 6; Dodek, Peter7; Griesdale, Donald8; Herridge, Margaret9; Lapinsky, Stephen 10; Lamontagne, Francois 11; McIntrye, Lauralyn 12; Muscedere, John 13; Soth, Mark 14; Stelfox, Henry T. 15; Lebovic, Gerald 3; Wald, Ron 3
1. University of Alberta Hospital (Edmonton), 2. Sunnybrook Medical Center (Toronto), 3. St. Michael’s Hospital (Toronto), 4. Royal University Hospital (Saskatoon), 5. Sacré-Coeur de Montréal (Montreal), 6. Centre hospitalier universitaire de Montréal (Montreal), 7. St. Paul’s Hospital (Vancouver), 8. Vancouver General Hospital (Vancouver), 9. University Health Network (Toronto), 10. Mt. Sinai Hospital (Toronto), 11. Centre hospitalier universitaire de Sherbrooke (Sherbrooke), 12. Ottawa-Civic/Ottawa-General Hospitals (Ottawa), 13. Kingston General Hospital (Kingston), 14. St. Joseph’s Hospital (Hamilton), 15. Foothills Medical Center (Calgary)

Grant acknowledgements:
Canadian Frailty Network


Introduction: Older critically ill patients represent approximately half of all patients who receive advanced life support with acute renal replacement therapy (RRT) in intensive care unit (ICU) settings. Yet, we have limited information on the optimal circumstances for starting or withholding RRT in older patients with AKI.
Objective: To evaluate whether there are important differences in survival, receipt of life-sustaining therapies, commitment to ongoing support, and changes in goals of care amongst those who do receive or those who do not receive RRT among older critically ill patients with AKI.
Methods: Prospective observational cohort study performed at 16 academic-affiliated centers from Canada between September 25, 2013 and July 24, 2015. Participants were eligible for inclusion if they fulfilled all of: 1) aged >= 65 years, 2) admitted to ICU, and 3) had evidence of severe AKI defined by presence of KDIGO Stage 3 AKI; and were excluded for any of: 1) received urgent RRT for drug overdose and/or dialyzable toxin and 2) known pre-hospital end-stage kidney disease requiring chronic RRT. Primary exposure was receipt of RRT. Primary outcome was 90-day mortality. Secondary outcomes included reasons for not receiving RRT and changes to goals-of-care (GOC).
Results: In total, 499 patients were enrolled. Mean (SD) age was 75.2 years (7.2), 204 (41%) were female, and mean (SD) Charlson comorbidity score (CCI) was 3.0 (2.3). Median (IQR) Clinical Frailty Score (CFS) was 4.0 (3.0-5.0), 95 (20%) had cognitive impairment and 192 (39%) and 53 (11%) had been hospitalized or admitted to ICU in the preceding 6 months. In the ICU, mean (SD) APACHE II score was 28.0 (8.8) and 318 (66%) and 313 (65) received mechanical ventilation and vasoactive support, respectively. KDIGO stage 3 AKI occurred in 409 (82%) with a mean (SD) peak creatinine of 393 µmol/L (263). Of the cohort, only 361 (72%) of patients would have been offered RRT if indicated; and 229 (46%) received RRT. Indications for RRT included oligo-anuria (n=169, 74%), fluid overload (n=81, 35%) and acidemia (n=75, 33%). Reason for not starting RRT were: kidney recovery (n=180, 67%), not aligned with goals-of-care (GOC) (n=66, 25%), limitation-of-medical-therapy (LOMT) (n=29, 11%), and death prior to starting RRT (n=26, 10%). Only 18 patients (7%) were not offered RRT due to the medical team’s perception of no benefit. Factors independently associated with not receiving RRT included: age, CFS score, peak serum creatinine at admission, vasoactive support and APACHE II score. Mortality was 45% (n=113) for those receiving RRT and 56% (n=141) for those not receiving RRT (OR 0.91; 95% CI, 0.64-1.31). Among those who would be offered RRT, mortality was 60% (n=104) and 40% (n=69) for those receiving and not receiving RRT (OR 1.04; 95% CI, 0.68-1.60), respectively. In total, 201 patients (42%) had a change in GOC in ICU. GOC changes occurred in 41% (n=92) compared with 43% (N=113) among those who received and did not receive RRT (OR 0.93; 95% CI, 0.65-1.33).
Conclusions: The majority of older adults in the ICU with AKI would be offered RRT and approximately half received RRT. Clinical need, as well as underlying frailty and severity of illness, influence decision-making regarding RRT.


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