Continuous Renal Replacement Therapy Practices in ICU

A Multinational Global Cross-Sectional Survey

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METHODOLOGY Search Engine and Search Strategy Utilising the combination of appropriate Medical Subject Headings (MeSH) terms and keywords, a comprehensive search was conducted in online databases such as PubMed/MEDLINE, Google Scholar, and Scopus. MeSH terms included “Continuous Renal Replacement Therapy,” “Acute Kidney Injury,” and related terms. The search strategy incorporated all relevant synonyms and spellings. The language was restricted to English. No restrictions were applied regarding species. In addition to electronic database searches, manual searches were performed to identify relevant articles. This included scanning reference lists of relevant studies, contacting experts in the field, and exploring grey literature sources. Grey literature was sought through Google searches and other relevant platforms. The literature search was used to formulate the questions of the survey in the format of knowledge, attitude and practice(KAP).

Inclusion Criteria Studies were included if they met the following criteria:
● Addressed CRRT practices in critical care settings.
● Focused on acute kidney injury management.
● Conducted in low to middle-income countries.

Exclusion Criteria Studies were excluded if they did not meet the inclusion as mentioned above criteria or if they were duplicates, reviews, editorials, or conference abstracts without full-text availability.

Screening Process Title and Abstract Screening: Initial screening of retrieved articles was conducted based on titles and abstracts to identify potentially relevant studies.
Full-Text Screening: Full texts of potentially relevant articles were retrieved and assessed for eligibility based on the inclusion and exclusion criteria by two independent reviewers. A total of 200 articles were reviewed during the literature review process. Articles were excluded based on relevance to the research question, duplication, and lack of access to full text. Out of the 200 articles reviewed, 150 were excluded, resulting in a final sample of 50 for analysis.

Study Design An online observational cross-sectional survey based on Google Forms will be used to evaluate Continuous Renal Replacement Therapy (CRRT) practices and Acute Kidney Injury (AKI) management in Critical Care Units.

Setting The survey will explore practices of CRRT in Critical Care Units across the globe . Detailed descriptions of locations, relevant dates, recruitment periods, exposure, follow-up, and data collection timelines will be provided.

Participants Healthcare professionals directly engaged in CRRT practices and AKI management constituted the study participants. Convenience sampling will be utilized to ensure representation from various countries and healthcare settings.Eligibility criteria for participants included healthcare professionals directly involved in Continuous Renal Replacement Therapy (CRRT) practices and Acute Kidney Injury (AKI) management. Paediatric ICUs will be excluded from the study. The survey instrument was developed based on a synthesis of findings from the literature review and underwent rigorous validation. Convenience sampling was employed to ensure representation from various countries and healthcare settings.

Variables All pertinent outcomes, including indications for initiating renal replacement therapy (RRT), modalities of RRT utilization, and clinical outcomes, are clearly defined based on established criteria derived from the literature and clinical guidelines. Exposures such as modality preferences, technological integration, and documentation practices for CRRT sessions are also explicitly outlined. Predictors influencing the choice of RRT modality, such as patient characteristics and clinical conditions, are identified and defined. Additionally, potential confounders such as severity of illness, comorbidities, and resource availability were carefully accounted for in the analysis. Effect modifiers, if identified, such as institutional protocols or cultural factors, were clearly delineated to understand their impact on CRRT practices. Diagnostic criteria for AKI, as well as criteria for classifying its severity, are explicitly stated to ensure uniformity and accuracy in diagnosing and categorizing AKI cases across participating sites. These criteria included serum creatinine levels, urine output, and clinical signs of renal dysfunction, adhering to established guidelines such as RIFLE, AKIN, or KDIGO classifications.(9–12)

Data Sources/Measurement Data on various aspects related to Continuous Renal Replacement Therapy (CRRT) practices and Acute Kidney Injury (AKI) management in Critical Care settings across different countries would be collected. This would include demographic information such as country of practice, educational degree, type of healthcare facility, setup, number of ICU beds, and type of ICU. Additionally, data would be collected on the setup and modalities of CRRT available in the ICU, preferences for RRT modalities, initiation criteria, maintenance practices, termination criteria, AKI management approaches, barriers faced in implementing CRRT, level of institutional support, participation in research studies, cultural considerations, and regulatory compliance measures.

The methods of assessment for each variable of interest were meticulously detailed to ensure consistency and reliability across sites. For instance, information regarding CRRT practices, AKI management protocols, and institutional guidelines is collected through the survey instrument. Any comparability issues regarding assessment methods, particularly in cases where different CRRT modalities or management protocols were employed across sites, will be addressed through standardized data collection procedures and detailed documentation of variations in practice. Efforts will be made to harmonize data collection methods and ensure that data from different sources are comparable and valid for analysis.

Bias Efforts were undertaken to mitigate potential sources of bias throughout the study process. Selection bias will be minimized by employing a diverse sample of healthcare professionals across various Critical Care Units and geographic regions. Information bias will be mitigated through rigorous validation of the survey instrument and standardized data collection procedures. Additionally, confounding bias will be addressed through appropriate statistical methods, such as multivariable regression analysis, to control for potential confounders and effect modifiers.

Study Size
Quantitative Variables
Quantitative variables, such as patient demographics, clinical parameters, and CRRT-related outcomes, were handled in the analysis carefully considering their distributions and clinical relevance.
Continuous variables will be summarized using appropriate measures of central tendency and dispersion, and subgroup analyses will be conducted to explore potential heterogeneity in treatment effects across different patient populations.
Data were collected through an online survey platform, with targeted outreach to healthcare professionals in diverse geographical locations. Ethical principles were strictly adhered to, ensuring informed consent from all participants. Confidentiality of participant information was rigorously maintained throughout the study. Quantitative data obtained from the survey were analysed using appropriate statistical methods, providing valuable insights into global CRRT practices and AKI management.

Thank you for participating in this survey. Your insights will contribute to a better understanding of global practices in Continuous Renal Replacement Therapy (CRRT) and Acute Kidney Injury (AKI) management in Critical Care settings.

Your responses will be kept confidential.

REFERENCES
1. Kellum JA, Hoste EAJ. Acute kidney injury: epidemiology and assessment. Scand J Clin Lab Invest Suppl. 2008;241:6–11.
2. Bagshaw SM, George C, Bellomo R, ANZICS Database Management Committee. Early acute kidney injury and sepsis: a multicentre evaluation. Crit Care. 2008 Apr 10;12(2):R47.
3. Digvijay K, Neri M, Fan W, Ricci Z, Ronco C. International Survey on the Management of Acute Kidney Injury and Continuous Renal Replacement Therapies: Year 2018. Blood Purif. 2019;47(1-3):113–9.
4. Soni SS, Nagarik AP, Adikey GK, Raman A. Using continuous renal replacement therapy to manage patients of shock and acute renal failure. J Emerg Trauma Shock. 2009 Jan;2(1):19–22.
5. Yılmaz Aydın F, Aydın E, Kadiroglu AK. Comparison of the Treatment Efficacy of Continuous Renal Replacement Therapy and Intermittent Hemodialysis in Patients With Acute Kidney İnjury Admitted to the Intensive Care Unit. Cureus. 2022 Jan;14(1):e21707.
6. Kramer P, Schrader J, Bohnsack W, Grieben G, Gröne HJ, Scheler F. Continuous arteriovenous haemofiltration. A new kidney replacement therapy. Proc Eur Dial Transplant Assoc. 1981;18:743–9.
7. Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet. 2000 Jul 1;356(9223):26–30.
8. Sodhi K, Phillips A, Mishra RC, Tyagi N, Dixit SB, Chaudhary D, et al. Renal Replacement Therapy Practices in India: A Nationwide Survey. Indian J Crit Care Med. 2020 Sep;24(9):823–31.
9. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004 Aug;8(4):R204–12.
10. Lopes JA, Jorge S. The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review. Clin Kidney J. 2013 Feb;6(1):8–14.
11. Lin CY, Chen YC. Acute kidney injury classification: AKIN and RIFLE criteria in critical patients. Pediatr Crit Care Med. 2012 Apr 4;1(2):40–5.
12. Kellum JA, Lameire N, Aspelin P, Barsoum RS, Burdmann EA, Goldstein SL, et al. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney international supplements. 2012;2(1):1–138.

Demographics

2. Specialty Of Training:
3. Years of Experience in RRT:
4. Type of Healthcare Facility:
5. The number of ICU Beds:
6. Type of ICU Structure:
7. Type of ICU Specialty:
8. Number of Dialysis Machines Capable of CRRT in ICU

Knowledge

1. Most Common Mode of RRT for Acutely Ill AKI Patients
2. Which of the following is a contraindication for CRRT?
3. Indications of starting RRT in a sepsis patient
4. Bicarbonate Therapy in AKI Secondary to Septic Shock: I would administer bicarbonate
5. Preferred Vascular Access for RRT in ICU
6. How often should the filter in CRRT be changed according to standard guidelines?
7. CRRT is preferable over intermittent haemodialysis in critically ill patients because:
8. Predominant CRRT Technique Used in ICU
9. Preferred RRT for Septic AKI on Pressor Agents
10. Preferred RRT for Septic AKI When Intubated, Ventilated, and Not on Pressors
11. Most common Anticoagulant Used for CRRT Patients
12. Determination of Initial CRRT Dose is done by
13. Primary Source of Nutrition in CRRT Patients with Stabilized Condition:
14. How Is the Adequacy of RRT Dose Monitored?
15. Most preferred Level of Training/Education for Healthcare Professionals Involved in CRRT:

Attitude

1. Approach to Initiating RRT for AKI
2. My approach to opting for IHD in my ICU
3. My approach to starting RRT in a septic patient
4. Timing of CRRT in Septic Shock with Multiorgan Failure:
5. Timing of CRRT in Multiorgan Failure Without Shock:
6. Perceived Barriers to CRRT Use in ICU:
7. Who Should Manage CRRT-Related Decisions in the ICU?
8. How important is regular refresher training on CRRT practices for ICU staff?
9. Do you believe that CRRT improves patient outcomes in the ICU?
10. How confident are you in initiating CRRT on an ICU patient?

Practice

1. Is Bedside Renal Replacement Therapy (RRT) Available in Your ICU?
2. Who Decides to Start CRRT in Your ICU?
3. Is Nephrology Approval Required to Start RRT?
4. Technical Assistance Available for Dialysis in ICU
5. Who Manages RRT Setup, Delivery, and Discontinuation?
6. In my hospital, I initiate dialysis if
7. When Do You Consider Peritoneal Dialysis (PD) for Renal Replacement in ICU?
8. Patient Characteristics Influencing Choice Between CRRT, SLED, IHD, and PD
9. I would Start RRT in a Sepsis Patient with Progressive Oliguria if
10. I would start RRT in a Sepsis Patient with Progressive Acidosis if
11. I would start RRT in a Sepsis Patient with Fluid Overload if
12. Starting RRT for Hyperkalemia in an AKI Patient with Polytrauma: I would start RRT if
13. In order to Assess CRRT Efficacy I would do appropriate blood tests:
14. Frequency of Patient Monitoring During CRRT:
15. Frequency of CRRT Circuit Change:
16. Reasons for Changing the CRRT Circuit:
17. What Action Would You Take with CRRT During a CT Scan or Surgery?
18. After How Long Following CRRT Discontinuation for scan/ surgery Would You Discard the Circuit?
19. Protein Intake for a Stable CRRT Patient
20. Criteria for Terminating CRRT:
21. Preferred Criteria for Discontinuing RRT:
22. In my practice, I monitor the adequacy of RRT Dose by: