How do you manage acute kidney injury (AKI) in a palliative care patient?

Managing Acute Kidney Injury in Palliative Care Patients

In palliative care patients with AKI, prioritize symptom management and shared decision-making over aggressive interventions, with conservative management (active medical management without dialysis) being the preferred approach unless life-threatening complications develop that align with the patient's goals of care. 1

Initial Assessment and Goals of Care Discussion

Immediately establish goals of care through shared decision-making with the patient, family, and multidisciplinary team, using simple lay language and avoiding technical terms like "RRT"—instead use "kidney machine" or "life support." 1

• Assess whether the patient's overall prognosis and functional status make aggressive AKI treatment consistent with their values and preferences 1
• Determine if the patient has advance directives specifically addressing dialysis, and respect these directives 2
• Recognize that palliative care should be based on need rather than survival estimation, and can be provided alongside disease-modifying treatments 1

Conservative Management Approach (Preferred for Most Palliative Patients)

Conservative management without dialysis should be the default approach for palliative AKI patients, as it avoids the high symptom burden and invasive nature of dialysis while focusing on comfort. 1, 3

Symptom Management

• Stop all nephrotoxic medications unless absolutely essential, including NSAIDs, ACE inhibitors, ARBs, and aminoglycosides 4
• Hold diuretics when AKI is diagnosed to prevent worsening kidney injury 4
• Manage volume overload with careful diuretic use only when causing distressing symptoms like dyspnea 1
• Target glucose control to 110-149 mg/dL in critically ill patients 1

Fluid Management

• Use isotonic crystalloids cautiously for volume resuscitation only if clear hypovolemia exists, targeting euvolemia 4, 5
• Avoid aggressive fluid resuscitation in patients with cardiac dysfunction or signs of volume overload 6
• Monitor for fluid overload >10-15% body weight, which worsens outcomes 5

Nutritional Support

• Provide 20-30 kcal/kg/day total energy intake, preferably via enteral route 1, 4
• Administer 0.8-1.0 g/kg/day protein in noncatabolic AKI patients without dialysis 1, 4

When to Consider Renal Replacement Therapy

RRT should only be initiated in palliative patients if life-threatening complications develop AND the intervention aligns with the patient's stated goals of care. 1

Emergent Indications (Only if Consistent with Goals)

• Severe hyperkalemia with ECG changes unresponsive to medical management 4
• Severe metabolic acidosis with impaired respiratory compensation 4
• Pulmonary edema unresponsive to diuretics causing severe dyspnea 4
• Uremic complications (pericarditis, encephalopathy, bleeding) 4

Modality Selection if RRT Pursued

• Use continuous RRT (CRRT) in hemodynamically unstable patients requiring vasopressors, as it is more physiologically appropriate 1
• Consider intermittent hemodialysis in stable patients for faster correction of hyperkalemia 4
• Individualize dialysis prescription focusing on symptom relief rather than standard adequacy targets 3

Communication and Coordination

Regular communication with patients and families should occur at frequent intervals, acknowledging that patients may be traumatized and require repeated explanations in lay language. 1

• Involve palliative care consultation early—ideally at AKI diagnosis or ICU admission—rather than waiting until the terminal phase 1
• Coordinate care among nephrology, palliative care, and primary teams to ensure consistent messaging 1
• Reassess goals of care regularly as clinical status evolves 1

Critical Pitfalls to Avoid

• Never initiate dialysis simply to "do something" when it conflicts with established goals of care 1
• Avoid the misconception that all AKI requires aggressive fluid resuscitation—context and volume status are critical 5
• Do not delay palliative care consultation until the terminal phase—early integration improves quality of life and reduces unnecessary procedures 1
• Never use dopamine, diuretics (except for volume overload), or N-acetylcysteine as AKI treatments, as they lack efficacy 1, 4

Special Considerations for End-of-Life Care

If the patient is actively dying or has chosen comfort-focused care, discontinue RRT when it becomes inconsistent with shared care goals. 1

• Recognize that withdrawal from dialysis is an appropriate option when burdens outweigh benefits 1
• Provide comprehensive symptom management during the dying process, including management of dyspnea, pain, and delirium 3
• Consider hospice referral, though recognize that current Medicare hospice benefit does not cover patients continuing dialysis 1

Monitoring and Follow-Up

• Monitor biochemistry (urea, creatinine, electrolytes) every 48 hours or more frequently if clinically indicated 4
• Assess for distressing symptoms requiring intervention rather than focusing on laboratory values 3
• Discontinue monitoring that does not inform comfort-focused interventions 2