Management of severe acute renal failure in critically ill patients: an international survey in 345 centres

The epidemiology of acute renal failure (ARF) has recently displayed an inc reasing shift of cases from the renal ward to the intensive care unit (ICU) . Accordingly, two groups of physicians are now highly involved in the care of ARF patients: nephrologists and intensivists. Renal replacement therapy has also evolved a great deal over the last 20 years with the development and increasing application of continuous renal replacement therapy (CRRT). Several controversies have developed over which approach to patient care is most desirable and which form of renal replacement therapy should be appli ed in preference within the ICU. There are also controversies on the best c linical practice for CRRT including indications, vascular access, anticoagu lation, membranes and filters, machines and finally, which specialist shoul d be in overall charge of patient care. Taking advantage of two international meetings on renal replacement therapy and critical care nephrology, we collected the answers to a wide-ranging q uestionnaire distributed among attending practitioners. We now report the r esponses of 345 physicians from different centres in a wide variety of coun tries. The questionnaires were accurately prepared and distributed to the d elegates of two international meetings carried out in the US and Europe. th e questionnaire was divided into several sections concerning demographic an d medical information, epidemiology of ARF, practice of CRRT and current op inions about clinical advantages and problems related to CRRT. Out of the 375 collected questionnaires, only 345 were complete and could b e utilized for the analysis. The respondents were from different continents with most in Europe and North America. Physicians were mostly nephrologist s or intensivists and only few of them had a combined background. The same was true for the field of operation and medical specialty. Epidemiology of ARF highlights the shift towards more complicated cases occurring in a crit ically ill population. High variability was found in the practice of CRRT, although it seems that the multidisciplinary approach received a wider consensus. Anti-coagulation and arterial vascular access still represent a major concern for the treat ment, while new machines and membranes are considered major advances in the field. CRRT are frequently used even in the absence of acute renal failure (52% of the respondents) the prevalent use being for fluid control, conges tive heart failure, acute respiratory distress syndrome (ARDS) and sepsis. Our survey describes in detail the problems encountered in the day-to-day p ractice of CRRT. The analysis outlines the fields in which further knowledg e and education are definitely needed. A deeper understanding of the mechan isms and procedures involved in continuous therapies is probably required b oth from the view of the nurse and the physician. Several issues are still open and will be matter of controversy in the coming years. For this reason , we hope that our survey will provide a stimulus for new studies to seek e vidence for different clinical decisions. A wider application of CRRT in th e fields of sepsis and multiple organ failure requires further experience a nd evidence for clinical benefit. In the mean time, several studies will fo cus on specific aspects such as cytokine removal and physiological response to continuous versus intermittent therapies. We hope that little by little these studies will contribute towards piecing together the overall picture .