To dialyze or not: the patient with metastatic cancer and AKI in the intensive care unit

Abstract

AKI severe enough to necessitate renal replacement therapy occurs in approximately 5% of patients admitted to the intensive care unit (ICU) and is associated with in-hospital mortality in excess of 50%. Complicating factors, such as cancer, can increase in-hospital mortality to 85%. Intensivists often expect that consulted nephrologists will provide dialysis when asked to do so, without considering whether it is likely to benefit the patient and therefore is medically and ethically appropriate. In this Attending Rounds, on the basis of the evidence and recommendations in Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, a clinical practice guideline, a case of anuric AKI in the ICU is presented and analyzed. Woven into the discussion are insights from the clinical and ethics literature on this topic, along with the experience of the author. This Attending Rounds presents an approach to deciding when it is not appropriate to dialyze patients with AKI in the ICU.