Review of Hospital Admissions for Urgent Dialysis Initiation among Patients with Stage 5 CKD

Background: Patients with advanced CKD may present to the emergency department with unplanned and urgent indications to start dialysis. Lack of patient preparedness and an urgent start to dialysis are associated with higher morbidity. Methods: This QI project utilizes EMR for chart review of adult patients who were admitted to our institution from January 2023 to December 2023, and who required hemodialysis initiation. We particularly focused on the review of the CKD stage 5 patients that were followed in the CKD clinic. Results: There was a total of 146 patients who were admitted for urgent dialysis initiation. 74 patients (51%) had CKD stage 5. Among this cohort, 59 of these patients were followed in our CKD clinic. 42 patients (71%) did not have any vascular access, 11 patients (19%) had mature AVF/ AVG, and 6 patients (10%) either had non-mature or non-functioning AVF/AVG. The average length of hospital stay was 22.5 days. 11 patients (18%) required medical ICU admission for emergent dialysis start. A review of the CKD clinic visits reveals that in 67% of the patients, dialysis education with Kidney Smart (Davita) was offered, however, only half attended and expressed their modality of choice. 21% of the patients had short (<6 months) dialysis planning time due to their advanced presentation and lost to follow-up, and 12% were not interested in GOC discussion, kidney education, and dialysis planning. Other factors that were identified include language barrier, lack of social support, untimely Nephrology and Vascular surgery referral, late initiation of GOC discussion, and unpredictable timing of kidney function decline and symptoms. Conclusion: Among CKD5 patients, suboptimal dialysis planning leads to urgent and unplanned admission for HD initiation. These patients receive a higher intensity of care, have longer hospital stays, and have higher medical costs. Factors are multifactorial including lack of patient education, untimely Nephrology and Vascular referral, and late initiation of GOC discussion, among others. Optimal dialysis planning should focus on early patient education and GOC discussion and improving pre-dialysis care that involves a multidisciplinary team, timely referral, frequent follow-up, and access to different members of the care team. A risk prediction tool (KFRE) and a dialysis planning list (EPIC smart phrase) may be of utility.