Kidney Week

Abstract: TH-PO303

Evaluating Dialysis Decision-Making in Hepatorenal Syndrome

Session Information

• Hemodialysis and Frequent Dialysis - 1
  October 24, 2024 | Location: Exhibit Hall, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Dialysis

• 801 Dialysis: Hemodialysis and Frequent Dialysis

Authors

• Bailoor, Kunal, University of Michigan, Ann Arbor, Michigan, United States

Kunal Bailoor, MD

• Tapper, Elliot, University of Michigan, Ann Arbor, Michigan, United States

Elliot Tapper, MD

• Wright Nunes, Julie A., University of Michigan, Ann Arbor, Michigan, United States

Julie A. Wright Nunes, MD, MPH

Background

Hepatorenal syndrome has been traditionally felt to have universally high in-hospital mortality without transplantation. However, the underlying data is uncertain. The question of whether to recommend initiation of hemodialysis for patients with HRS who are not considered candidates for liver transplant is therefore both clinically and emotionally difficult.

Methods

We conducted a vignette-based survey of clinicians across 3 internal medicine sub-specialties (nephrology, critical care, and palliative care) who are involved in decision making regarding dialysis initiation for critically ill patients with hepatorenal syndrome. Our vignette included a case of a critically ill patient with hepatorenal syndrome requiring multiple vasopressors who was not felt to be a candidate for liver transplantation.

Results

53 clinicians (19 nephrology, 21 critical care, 9 palliative care, 4 trainees) responded; the majority of clinicians (77%) did not recommend hemodialysis. High distress around this decision was reported (Figure 1); this was measured with a validated scale. There were varying degrees of comfort with dialysis-decision making (Figure 2), with nephrologists reporting the lowest comfort (2.6 on 4 point Likert scale) and critical care physicians reporting the highest (2.9/4). Nephrologists reported the highest increase in distress when colleagues disagreed with their decision; all clinicians reported increases in distress with family disagreement.

Conclusion

Decision making about dialysis initiation in the critically ill patient with hepatorenal syndrome provokes distress in all clinicians involved, though distress and comfort with decision making varies among specialties. Further research into what underlies these differences and how best to support clinicians is needed.