Renal Replacement Therapy for Acute Kidney Injury in French Intensive Care Units: A Nationwide Survey of Practices

Abstract

<b><i>Background:</i></b> The frequency of acute kidney injury (AKI) can be as high as 50% in the intensive care unit (ICU). Despite the publication of national guidelines in France in 2015 for the use of RRT, there are no data describing the implementation of these recommendations in real-life. <b><i>Methods:</i></b> We performed a nationwide survey of practices from November 15, 2019, to January 24, 2020, in France. An electronic questionnaire based on the items recommended in the national guidelines was sent using an online survey platform, to the chiefs of all ICUs in France. The questionnaire comprised a section for the Department Chief about local organization and facilities, and a second section destined for individual physicians about their personal practices. <b><i>Results:</i></b> We contacted the Department Chief in 356 eligible ICUs, of whom 88 (24.7%) responded regarding their ICU organization. From these 88 ICUs, 232/285 physicians (82%) completed the questionnaire regarding individual practices. The practices reported by respondent physicians were as follows: intermittent RRT was first-line choice in >75% in a patient with single organ (kidney) failure at the acute phase, whereas continuous RRT was predominant (>75%) in patients with septic shock or multi-organ failure. Blood and dialysate flow for intermittent RRT were 200–300 mL/min and 400–600 mL/min, respectively. The dose of dialysis for continuous RRT was 25–35 mL/kg/h (65%). Insertion of the dialysis catheter was mainly performed by the resident under echographic guidance, in the right internal jugular vein. The most commonly used catheter lock was citrate (53%). The most frequently cited criterion for weaning from RRT was diuresis, followed by a drop in urinary markers (urea and creatinine). <b><i>Conclusion:</i></b> This study shows a satisfactory level of reported compliance with French guidelines and recent scientific evidence among ICU physicians regarding initiation of RRT for AKI in the ICU.

Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Argument for CKRT

“…101 So while there may be a reasonable rationale for the adoption of PIKRT/SLED, its utilization for initiation, maintenance, and de-escalation of KRT in critically ill patients remains limited and warrants further investigation. 9,51,82,104…”

“…101 So while there may be a reasonable rationale for the adoption of PIKRT/ SLED, its utilization for initiation, maintenance, and deescalation of KRT in critically ill patients remains limited and warrants further investigation. 9,51,82,104 In conclusion, the choice of KRT modality in the ICU should be driven by more pragmatism and less dogma. This comes with the acknowledgment that no single KRT modality is ideally suited for the entire spectrum of patients receiving care in the ICU.…”

“…2,8 CKRT has become deeply entrenched worldwide, especially in high-income countries, and in particular for critically ill patients with hemodynamic instability or multiorgan dysfunction. 1,2,9 With growing trends in the incidence of AKI, sepsis, and multiorgan dysfunction and the evolving functionality of newer CKRT platforms, the utilization of CKRT is likely to expand further. [10][11][12] Evolution of CKRT CKRT was developed more than 40 years ago in response to the challenges of trying to provide conventional intermittent hemodialysis (HD) to critically ill patients with hemodynamic compromise.…”

“…2,8 CKRT has become deeply entrenched worldwide, especially in high-income countries, and in particular for critically ill patients with hemodynamic instability or multiorgan dysfunction. 1,2,9 With growing trends in the incidence of AKI, sepsis, and multiorgan dysfunction and the evolving functionality of newer CKRT platforms, the utilization of CKRT is likely to expand further. 10–12…”