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Care of the critically ill patient with advanced chronic kidney disease or end-stage renal disease

Hotchkiss, John R.a,b,c,d; Palevsky, Paul M.b,d

Current Opinion in Critical Care: December 2012 - Volume 18 - Issue 6 - p 599–606
doi: 10.1097/MCC.0b013e32835a1c59
RENAL SYSTEM: Edited by Lakhmir S. Chawla

Purpose of review The number of individuals with chronic kidney disease (CKD) and end-stage renal disease (ESRD) is rising, and these individuals often require intensive care.

Recent findings Patients with CKD and ESRD require critical care more frequently than those without these conditions and have similar reasons for requiring critical care as the general population. However, the burden of comorbidities, overall severity of illness as assessed by standard scoring systems, and mortality are higher in patients with ESRD than in the non-ESRD critically ill. After adjustment for demographics, comorbidities, and physiologic variables, the increased mortality risk in patients with ESRD is attenuated. In comparison to patients with dialysis-requiring acute kidney injury (AKI), critically ill patients with ESRD have a more favorable prognosis. Severity of illness scoring systems such as Acute Physiology and Chronic Health Evaluation and Simplified Acute Physiology Score tend to overestimate the risk of death in critically ill ESRD patients. ICU admission does not appear to dramatically affect long-term mortality in those with ESRD who survive their initial acute illness as compared ESRD patients without critical illness.

Summary Despite the manifest physiologic derangements attending CKD/ESRD, a higher burden of comorbid conditions and a greater severity of illness on presentation account for much of the increased mortality. There is no justification for therapeutic nihilism in this population.

aCritical Care Medicine Service Line and Veteran's Engineering Resource Center, VA Pittsburgh Healthcare System

bRenal Section, Medical Specialty Service Line, VA Pittsburgh Healthcare System, University of Pittsburgh School of Medicine

cDepartment of Critical Care Medicine, University of Pittsburgh School of Medicine

dRenal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

Correspondence to Paul M. Palevsky, MD, Room 7E123 (111F-U), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA 15240, USA. Tel: +1 412 360 3932; fax: +1 412 360 6130; e-mail:

© 2012 Lippincott Williams & Wilkins, Inc.