Survey of U.S. Critical Care Practitioners on Net Ultrafiltration Prescription and Practice Among Critically Ill Patients Receiving Kidney Replacement Therapy

Abstract

Introduction The current prescription and practice of net ultrafiltration among critically ill patients receiving kidney replacement therapy in the U.S. are unclear. Aim of the study To assess the attitudes of U.S. critical care practitioners on net ultrafiltration (UFNET) prescription and practice among critically ill patients with acute kidney injury treated with kidney replacement therapy. Methods A secondary analysis was conducted of a multinational survey of intensivists, nephrologists, advanced practice providers, and ICU and dialysis nurses practising in the U.S. Results Of 1,569 respondents, 465 (29.6%) practitioners were from the U.S. Mainly were nurses and advanced practice providers (58%) and intensivists (38.2%). The median duration of practice was 8.7 (IQR, 4.2-19.4) years. Practitioners reported using continuous kidney replacement therapy (as the first modality in 60% (IQR 20%-90%) for UFNET. It was found that there was a significant variation in assessment of prescribed-to-delivered dose of UFNET, use of continuous kidney replacement therapy for UFNET, methods used to achieve UFNET, and assessment of net fluid balance during continuous kidney replacement therapy. There was also variation in interventions performed for managing hemodynamic instability, perceived barriers to UFNET, belief that early and protocol-based fluid removal is beneficial, and willingness to enroll patients in a clinical trial. Conclusions There was considerable practice variation in UFNET among critical care practitioners in the U.S., reflecting the need to generate evidence-based practice guidelines for UFNET.

Restrictive versus Liberal Rate of Extracorporeal Volume Removal Evaluation in Acute Kidney Injury (RELIEVE-AKI): a pilot clinical trial protocol

“…We chose a UF NET rate of 0.5–1.5 mL/kg/hour in the restrictive arm because these UF NET rates are inclusive of the rates studied in the middle UF NET rate group in observational studies 11 13. We chose 2.0–5.0 mL/kg/hour in the liberal arm because these UF NET rates are also within the UF NET rate ranges studied in observational studies11 13 and surveys 6–9…”

“…Second, we debated including a usual care arm in our trial. However, there are few published protocols for UF NET , and surveys show considerable variation in clinical practice 6–9. This makes it difficult to define what represents usual care for UF NET .…”

“…International consensus guidelines recommend initiating extracorporeal fluid removal when a life-threatening fluid overload occurs 3–5. However, there is uncertainty about the optimal net fluid removal rate, and there is a global variation in clinical practice 6–9. In addition, complications such as intradialytic hypotension, hypertension and cardiac arrhythmias frequently occur during fluid removal 6 10…”

“…Although it may be unethical to randomise patients to UF NET versus no UF NET , clinical trials comparing alternative approaches to UF NET can be performed. Indeed, in surveys, more than two-thirds of clinicians had the equipoise to enrol patients in a clinical trial of protocol-based UF NET 6 7 9…”

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis

“…Additionally, observational studies have reported significant heterogeneity in RRT practice patterns within North America ( 15 , 16 ). Regarding FB management using ultrafiltration, an international survey has revealed significant practice variation ( 4 ), also regionally in North America ( 17 ) and Europe ( 18 ). Finally, surveys in the United Kingdom ( 19 ) and Australia and New Zealand (ANZ) ( 20 ) have demonstrated varying practices within nations.…”