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 displayedan increasing shift of cases from the renal ward to the intensivecare unit (ICU). Accordingly, two groups of physicians are nowhighly involved in the care of ARF patients: nephrologists andintensivists. Renal replacement therapy has also evolved a greatdeal over the last 20 years with the development and increasingapplication of continuous renal replacement therapy (CRRT).Several controversies have developed over which approach topatient care is most desirable and which form of renal replacementtherapy should be applied in preference within the ICU. Thereare also controversies on the best clinical practice for CRRTincluding indications, vascular access, anti-coagulation, membranesand filters, machines and finally, which specialist should bein overall charge of patient care. Taking advantage of two international meetings on renal replacementtherapy and critical care nephrology, we collected the answersto a wide-ranging questionnaire distributed among attendingpractitioners. We now report the responses of 345 physiciansfrom different centres in a wide variety of countries. The questionnaires were accurately prepared and distributedto the delegates of two international meetings carried out inthe US and Europe. The questionnaire was divided into severalsections concerning demographic and medical information, epidemiologyof ARF, practice of CRRT and current opinions about clinicaladvantages and problems related to CRRT. Out of the 375 collected questionnaires, only 345 were completeand could be utilized for the analysis. The respondents werefrom different continents with most in Europe and North America.Physicians were mostly nephrologists or intensivists and onlyfew of them had a combined background. The same was true forthe field of operation and medical specialty. Epidemiology ofARF highlights the shift towards more complicated cases occurringin a critically ill population. High variability was found in the practice of CRRT, althoughit seems that the multidisciplinary approach received a widerconsensus. Anti-coagulation and arterial vascular access stillrepresent a major concern for the treatment, while new machinesand membranes are considered major advances in the field. CRRTare frequently used even in the absence of acute renal failure(52% of the respondents) the prevalent use being for fluid control,congestive heart failure, acute respiratory distress syndrome(ARDS) and sepsis. Our survey describes in detail the problems encountered in theday-to-day practice of CRRT. The analysis outlines the fieldsin which further knowledge and education are definitely needed.A deeper understanding of the mechanisms and procedures involvedin continuous therapies is probably required both from the viewof the nurse and the physician. Several issues are still openand will be matter of controversy in the coming years. For thisreason, we hope that our survey will provide a stimulus fornew studies to seek evidence for different clinical decisions.A wider application of CRRT in the fields of sepsis and multipleorgan failure requires further experience and evidence for clinicalbenefit. In the mean time, several studies will focus on specificaspects such as cytokine removal and physiological responseto continuous versus intermittent therapies. We hope that littleby little these studies will contribute towards piecing togetherthe overall picture. Notes Correspondence and offprint requests to: Dr Claudio Ronco, Departmentof Nephrology, St Bortolo Hospital, I-36100 Vicenza, Italy.