Introduction:
All patients receiving kidney replacement therapy (KRT) should have a documented cardiopulmonary resuscitation (CPR) decision. However, the literature on CPR outcomes in this cohort has not yet been formally assessed. Addressing this disparity could improve and support individualised, patient-centred decision making. We conducted a systematic review of survival and neurological outcomes of CPR in patients undergoing KRT.
Methods:
A comprehensive literature search identified studies including in hospital or in dialysis unit CPR in adults (>18 years) receiving chronic KRT (i.e., haemodialysis, peritoneal dialysis, and kidney transplantation). Cardiac arrests or CPR occurring outside of a hospital or dialysis unit setting were excluded. Due to population heterogeneity, lack of standardised outcomes and inconsistent use of control groups, a narrative review was conducted.
Results:
After screening 1,301 studies, eleven studies were included. No study included kidney transplant recipients.
Six studies investigated CPR during inpatient admission (n=125,125), five were conducted in North America and one in Taiwan. Mean age ranged from 64-76 years. Comorbidities included ischaemic heart disease (17-51%), cardiac failure (23-73%) and chronic respiratory disease (5-37%).
Five studies (all North American) investigated CPR in the outpatient setting (n= 1,661), defined as remote dialysis facilities without access to external automated defibrillation and facilities within acute hospitals.
Two studies reported the aetiology of cardiac arrest, 34-51% arrests were cardiac in origin. Three of the four studies reporting initial cardiac rhythm suggested most patients were in a ‘non-shockable’ rhythm (66-81%).
Inpatient rates of return of spontaneous circulation (ROSC) were 69-72%, and survival to discharge 18-30%. 30-day and 1-year survival were not reported. Median length of survival post-discharge was 3–11 months.
Outpatient rates of ROSC were 49-76%, survival to discharge 24-75%, 30-day survival 16-75% and 1-year survival 8-15% (Figure 1).
Generally, certainty of evidence was ‘low’ for survival outcomes, except for survival to discharge for the inpatient cohort (‘high’).
A single inpatient study reported 17% of survivors experienced ‘good’ neurological outcome, and three inpatient studies reported 36-44% were discharged to their own home.
Conclusions:
Between a fifth and a third of patients undergoing dialysis who experience inpatient CPR survive to discharge, 36-44% of these survivors will be discharged to their own home. Outcomes are similar to those of the general population.
The literature base is centred on North America and does not represent other high-, middle- or low-income countries. Kidney transplant recipients are not represented and reliable survival or neurological outcome data following outpatient CPR is lacking.
A more holistic measure of neurological function with acknowledgement of personal, societal and cultural expectation would increase applicability to the individual. Further work should assess outcomes and experiences of advanced resuscitation decisions more globally. Specific cardiac arrest aetiology (e.g., intra-dialysis, intra-operative or traumatic cardiac arrest) should be explored, these factors may account for variance in survival outcomes.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.