Maintenance dialysis linked with increased incidence, worse survival of CPR

1. In this retrospective cohort study, which examined patients receiving maintenance dialysis for end-stage renal disease, 21.9% of patients who received cardiopulmonary resuscitation (CPR) survived to discharge.

2. There was a median post-discharge survival interval was 5.0 months, which is much lower than the previously reported median post-discharge survival of 3 years for other hospitalized patients.

Evidence Rating Level: 2 (Good)

Study Rundown: Cardiopulmonary resuscitation (CPR) can be a useful life-prolonging technique if used in an appropriately chosen patient population. For instance, studies have shown that older patients with more comorbidities have higher mortality after CPR. There is, however, limited data on CPR outcomes in patients on maintenance dialysis. This study aimed to characterize patterns and outcomes of in-hospital CPR in adults receiving maintenance dialysis. Overall, about 22% of patients receiving maintenance dialysis that received CPR survived to discharge. There was a median post discharge survival interval of about 5 months. Both rates of CPR and survival increased significantly over the study period.

While the rate of survival to discharge in this population was comparable to previously reported survival rates for other hospitalized patients, the median post-discharge survival was significantly lower. Strengths of this study include using a population-based cohort, hence increasing generalizability. However some limitations include use of Medicare claims data that may not have been validated. There was also a lack of analysis of patient data on factors that may impact survival post-CPR, such as cardiac arrest rhythm, treatments during resuscitation, or hospital-level characteristics.

Click to read the study, published today in JAMA Internal Medicine

Click to read an invited commentary in JAMA Internal Medicine

Relevant Reading: Survival and functional outcomes after cardiopulmonary resuscitation in the intensive care unit

In-Depth [retrospective cohort]: This study used data from the US Renal Data System (USRDS) registry, which details demographic and clinical patient information about end-stage renal disease (ESRD) throughout the USA. A total of 663,734 patients aged 18 years or older, who were on maintenance dialysis from January 2000 to December 2010, were included in the cohort. Using linked Medicare claims, all in-hospital CPR events that occurred beyond 90 days after initiation of dialysis were ascertained. Outcomes analyzed included CPR incidence, proportion of CPR recipients surviving to discharge, post-discharge survival and receipt of CPR before in-hospital death. Analyses were adjusted for sex, race, ESRD etiology, comorbidities, dialysis modality and year of dialysis initiation.

Of patients who received CPR, 21.9% survived to discharge (95% CI 21.4%-22.3%) with a median survival of 5 months (IQR 0.7-16.8 months). However, 14.9% (95% CI 14.8%-15.1%) of patients who died in-hospital received CPR. Over the study period, the incidence of CPR increased (1.0 events per 1000 hospital days to 1.6 events per 1000 hospital days; P <0.001) and the percentage of CPR recipients surviving to discharge increased (15.2% to 28.0%; P<0.001). There was an upward trend in post-discharge survival [2000: median 6.5 months (IQR 2.7-26.7 months), 2011: 5.9 months (IQR 1.7-17.9 months)]. These intervals of post-discharge survival are substantially worse than that which is reported for other patient populations.

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