Trends in In-Hospital Cardiopulmonary Resuscitation and Survival in Adults Receiving Maintenance Dialysis

Abstract

resuscitation (CPR) practices and outcomes can help to support advance care planning in patients receiving maintenance dialysis. OBJECTIVE To characterize patterns and outcomes of in-hospital CPR in US adults receiving maintenance dialysis. DESIGN, SETTING, AND PARTICIPANTS This national retrospective cohort study studied 663 734 Medicare beneficiaries 18 years or older from a comprehensive national registry for end-stage renal disease who initiated maintenance dialysis from January 1, 2000, through December 31, 2010. EXPOSURES Receipt of in-hospital CPR from 91 days after dialysis initiation through the time of death, first kidney transplantation, or end of follow-up on December 31, 2011. MAIN OUTCOMES AND MEASURES Incidence of CPR and survival after the first episode of CPR recorded in Medicare claims during follow-up. RESULTSThe annual incidence of CPR for the overall cohort was 1.4 events per 1000 in-hospital days (95% CI, 1.3-1.4). A total of 21.9% CPR recipients (95% CI, 21.4%-22.3%) survived to hospital discharge, with a median postdischarge survival of 5.0 months (interquartile range, 0.7-16.8 months). Among patients who died in the hospital, 14.9% (95% CI, 14.8%-15.1%) received CPR during their terminal admission. From 2000 to 2011, there was an increase in the incidence of CPR (1.0 events per 1000 in-hospital days; 95% CI, 0.9-1.1; to 1.6 events per 1000 in-hospital days; 95% CI, 1.6-1.7; P for trend <.001), the proportion of CPR recipients who survived to discharge (15.2%; 95% CI, 11.1%-20.5%; to 28%; 95% CI, 26.7%-29.4%; P for trend <.001), and the proportion of in-hospital deaths preceded by CPR (9.5%; 95% CI, 8.4%-10.8%; to 19.8%; 95% CI, 19.2%-20.4%; P for trend <.001), with no substantial change in duration of postdischarge survival.CONCLUSIONS AND RELEVANCE Among a national cohort of patients receiving maintenance dialysis, the incidence of CPR was higher and long-term survival worse than reported for other populations.

Trends in Receipt of Intensive Procedures at the End of Life Among Patients Treated With Maintenance Dialysis

“…Nevertheless, it is not possible to tell from our results whether an upward trend in use of intensive procedures among decedents with ESRD has occurred as part of a broader trend toward more widespread use of these procedures more generally in this population. 13, 14 Finally, our study findings may not necessarily apply to racial/ethnic groups that were excluded from this study, such as American Indians, Alaska Natives, Asians, Native Hawaiians, Pacific Islanders or those of other race.…”

“…13, 20–22 However, most studies describing patterns of end-of-life care for patients with kidney disease have either focused exclusively on older adults or did not present age-stratified results. 12, 15 While life expectancy is shortest and the prevalence of frailty highest for older patients with ESRD, differences in life expectancy compared with the general population are most marked for younger dialysis patients and their prevalence of frailty is much higher than for the general population.…”

Do patient‐reported measures of symptoms and health status predict mortality in hemodialysis? An assessment of POS‐S Renal and EQ‐5D

“…Although the mortality risk found in this study may or may not be modifiable in individual cases, the use of PROMs may help multidisciplinary teams to identify dialysis patients in need of additional support such as symptom control and advance care planning. Open discussions regarding the potential appropriateness of resuscitation in individual cases are especially pertinent given the recently reported poor outcomes associated with cardiopulmonary resuscitation in dialysis . The value of estimating prognosis in CKD has been highlighted by the executive summary of the Kidney Disease Improving Global Outcomes (KDIGO) controversies conference on supportive care in CKD .…”

Long-Term Outcomes in Critically Ill Septic Patients Who Survived Cardiopulmonary Resuscitation*

“…However, we included demographic data, baseline comorbidities, and acute organ support measures in the propensity score analysis to represent disease burden at discharge in both cohorts. Second, as for other national CPR registries (22)(23)(24), we lacked details of CPR procedures, such as initial heart rhythm during cardiac arrest, timing and duration of CPR, and neurologic or physical status beyond successful CPR. In addition, as patients with do-notresuscitate (DNR) orders would not receive CPR, the prevalence of post-CPR sepsis survivors may have been underestimated.…”