Skip to main content

Advertisement

SpringerLink
Log in

Continuous renal replacement therapy: A worldwide practice survey

The Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Objective

Little information is available regarding current practice in continuous renal replacement therapy (CRRT) for the treatment of acute renal failure (ARF) and the possible clinical effect of practice variation.

Design

Prospective observational study.

Setting

A total of 54 intensive care units (ICUs) in 23 countries.

Patients and participants

A cohort of 1006 ICU patients treated with CRRT for ARF.

Interventions

Collection of demographic, clinical and outcome data.

Measurements and results

All patients except one were treated with venovenous circuits, most commonly as venovenous hemofiltration (52.8%). Approximately one-third received CRRT without anticoagulation (33.1%). Among patients who received anticoagulation, unfractionated heparin (UFH) was the most common choice (42.9%), followed by sodium citrate (9.9%), nafamostat mesilate (6.1%), and low-molecular-weight heparin (LMWH; 4.4%). Hypotension related to CRRT occurred in 19% of patients and arrhythmias in 4.3%. Bleeding complications occurred in 3.3% of patients. Treatment with LMWH was associated with a higher incidence of bleeding complications (11.4%) compared to UFH (2.3%, p = 0.0083) and citrate (2.0%, p = 0.029). The median dose of CRRT was 20.4 ml/kg/h. Only 11.7% of patients received a dose of > 35 ml/kg/h. Most (85.5%) survivors recovered to dialysis independence at hospital discharge. Hospital mortality was 63.8%. Multivariable analysis showed that no CRRT-related variables (mode, filter material, drug for anticoagulation, and prescribed dose) predicted hospital mortality.

Conclusions

This study supports the notion that, worldwide, CRRT practice is quite variable and not aligned with best evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Ronco C, Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators (2005) Acute renal failure in critically ill patients. A multinational, multicenter study. JAMA 294:813–818

    Article  PubMed  CAS  Google Scholar 

  2. Davenport A, Will EJ, Davidson AM (1993) Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med 21:328–338

    Article  PubMed  CAS  Google Scholar 

  3. Uchino S, Bellomo R, Ronco C (2001) Intermittent versus continuous renal replacement therapy in the ICU: impact on electrolyte and acid–base balance. Intensive Care Med 27:1037–1043

    Article  PubMed  CAS  Google Scholar 

  4. Bellomo R, Farmer M, Bhonagiri S, Porceddu S, Ariens M, M'Pisi D, Ronco C (1999) Changing acute renal failure treatment from intermittent hemodialysis to continuous hemofiltration: impact on azotemic control. Int J Artif Organs 22:145–150

    PubMed  CAS  Google Scholar 

  5. Kruczynski K, Irvine-Bird K, Toffelmire EB, Morton AR (1993) A comparison of continuous arteriovenous hemofiltration and intermittent hemodialysis in acute renal failure patients in the intensive care unit. ASAIO 39:M778–781

    Article  CAS  Google Scholar 

  6. Rialp G, Roglan A, Betbese AJ, Perez-Marquez M, Ballus J, Lopez-Velarde G, Santos JA, Bak E, Net A (1996) Prognostic indexes and mortality in critically ill patients with acute renal failure treated with different dialytic techniques. Ren Fail 18:667–675

    PubMed  CAS  Google Scholar 

  7. Swartz RD, Messana JM, Orzol S, Port FK (1999) Comparing continuous hemofiltration with hemodialysis in patients with severe acute renal failure. Am J Kidney Dis 34:424–432

    PubMed  CAS  Google Scholar 

  8. Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P, La Greca G (2000) Effects of different doses in continuous veno–venous haemofiltration on outcomes of acute renal failure: a prospective randomized trial. Lancet 356:26–30

    Article  PubMed  CAS  Google Scholar 

  9. Hakim RM, Wingard RL, Parker RA (1994) Effect of the dialysis membrane in the treatment of patients with acute renal failure. N Engl J Med 331:1338–1342

    Article  PubMed  CAS  Google Scholar 

  10. Reeves JH, Cumming AR, Gallagher L, O'Brien JL, Santamaria JD (1999) A controlled trial of low-molecular-weight heparin (dalteparin) versus unfractionated heparin as anticoagulant during continuous venovenous hemodialysis with filtration. Crit Care Med 27:2224–2228

    Article  PubMed  CAS  Google Scholar 

  11. Langenecker SA, Felfernig M, Werba A, Mueller CM, Chiari A, Zimpfer M (1994) Anticoagulation with prostacyclin and heparin during continuous venovenous hemofiltration. Crit Care Med 22:1774–1781

    Article  PubMed  CAS  Google Scholar 

  12. Vargas Hein O, von Heymann C, Lipps M, Ziemer S, Ronco C, Neumayer HH, Morgera S, Welte M, Kox WJ, Spies C (2001) Hirudin versus heparin for anticoagulation in continuous renal replacement therapy. Intensive Care Med 27:673–679

    Article  PubMed  CAS  Google Scholar 

  13. Kellum JA, Mehta RL, Angus DC, Palevsky P, Ronco C, ADQI Workgroup (2002) The first international consensus conference on continuous renal replacement therapy. Kidney Int 62:1855–1863

    Article  PubMed  Google Scholar 

  14. Bellomo R, Honore PM, Matson J, Ronco C, Winchester J (2005) Extracorporeal blood treatment (EBT) methods in SIRS/Sepsis. Int J Artif Organs 28:450–458

    PubMed  CAS  Google Scholar 

  15. Uchino S, Doig GS, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Nacedo E, Gibney N, Tolwani A, Ronco C, Kellum JA, Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators (2004) Diuretics and mortality in acute renal failure. Crit Care Med 32:1669–1677

    Article  PubMed  Google Scholar 

  16. Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Doig GS, Oudemans van Straaten H, Ronco C, Kellum JA, Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators (2005) External validation of severity scoring systems for acute renal failure using a multinational database. Crit Care Med 33:1961–1967

    Article  PubMed  Google Scholar 

  17. Uchino S, Cole L, Morimatsu H, Bellomo R (2002) Clearance of vancomycin during high volume hemofiltration: impact of pre-dilution. Intensive Care Med 28:1664–1667

    Article  PubMed  Google Scholar 

  18. Himmelfarb J, Tolkoff Rubin N, Chandran P, Parker RA, Wingard RL, Hakim R (1998) A multicenter comparison of dialysis membranes in the treatment of acute renal failure requiring dialysis. J Am Soc Nephrol 9:257–266

    PubMed  CAS  Google Scholar 

  19. Jaber BL, Lau J, Schmid CH, Karsou SA, Levey AS, Pereira BJ (2002) Effect of biocompatibility of hemodialysis membranes on mortality in acute renal failure: a meta-analysis. Clin Nephrol 57:274–282

    PubMed  CAS  Google Scholar 

  20. Subramanian S, Venkataraman R, Kellum JA (2002) Influence of dialysis membranes on outcomes in acute renal failure: a meta-analysis. Kidney Int 62:1819–1823

    Article  PubMed  CAS  Google Scholar 

  21. Jorres A, Gahl GM, Dobis C, Polenakovic MH, Cakalaroski K, Rutkowski B, Kisielnicka E, Krieter DH, Rumpf KW, Guenther C, Gaus W, Hoegel J (1999) Haemodialysis-membrane biocompatibility and mortality of patients with dialysis-dependent acute renal failure: a prospective randomised multicentre trial. International Multicentre Study Group. Lancet 354:1337–13341

    Article  PubMed  CAS  Google Scholar 

  22. Kramer BK, Pickert A, Hohmann C, Liebich HM, Muller GA, Hablitzel M, Risler T (1992) In vivo clearance and elimination of nine marker substances during hemofiltration with different membranes. Int J Artif Organs 15:408–412

    PubMed  CAS  Google Scholar 

  23. Bouman CS, van Olden RW, Stoutenbeek CP (1998) Cytokine filtration and adsorption during pre- and postdilution hemofiltration in four different membranes. Blood Purif 16:261–268

    Article  PubMed  CAS  Google Scholar 

  24. Rogiers P, Zhang H, Pauwels D, Vincent JL (2003) Comparison of polyacrylonitrile (AN69) and polysulphone membrane during hemofiltration in canine endotoxic shock. Crit Care Med 31:1219–1225

    Article  PubMed  CAS  Google Scholar 

  25. Gastaldello K, Melot C, Kahn RJ, Vanherweghem JL, Vincent JL, Tielemans C (2000) Comparison of cellulose diacetate and polysulfone membranes in the outcome of acute renal failure. A prospective randomized study. Nephrol Dial Transplant 15:224–230

    Article  PubMed  CAS  Google Scholar 

  26. Morabito S, Guzzo I, Solazzo A, Muzi L, Luciani R, Pierucci A (2003) Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding. J Nephrol 16:566–571

    PubMed  Google Scholar 

  27. Uchino S, Fealy N, Baldwin I, Morimatsu H, Bellomo R (2004) Continuous venovenous hemofiltration without anticoagulation. ASAIO J 50:76–80

    Article  PubMed  CAS  Google Scholar 

  28. Hein OV, von Heymann C, Diehl T, Ziemer S, Ronco C, Morgera S, Siebert G, Kox WJ, Neumayer HH, Spies C (2004) Intermittent hirudin versus continuous heparin for anticoagulation in continuous renal replacement therapy. Ren Fail 26:297–303

    Article  PubMed  CAS  Google Scholar 

  29. Monchi M, Berghmans D, Ledoux D, Canivet JL, Dubois B, Damas P (2004) Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med 30:260–265

    Article  PubMed  Google Scholar 

  30. Kutsogiannis DJ, Gibney RT, Stollery D, Gao J (2005) Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 67:2361–2367

    Article  PubMed  CAS  Google Scholar 

  31. Silvester W, Bellomo R, Cole L (2001) Epidemiology, management, and outcome of severe acute renal failure of critical illness in Australia. Crit Care Med 29:1910–1915

    Article  PubMed  CAS  Google Scholar 

  32. Mehta RL, McDonald B, Gabbai FB, Pahl M, Pascual MT, Farkas A, Kaplan RM; Collaborative Group for Treatment of ARF in the ICU (2001) A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 60:1154–1163

    Article  PubMed  CAS  Google Scholar 

  33. Saudan P, Niederberger M, De Seigneux S, Romand J, Pugin J, Perneger T, Martin PY (2006) Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int 70:1312–1317

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan

    Shigehiko Uchino

  2. Department of Intensive Care and Department of Medicine, Austin Hospital, Melbourne, Australia

    Rinaldo Bellomo & Hiroshi Morimatsu

  3. Department of Nephrology, University hospital Charité, Berlin, Germany

    Stanislao Morgera

  4. Dienst Intensieve Geneeskunde, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium

    Miet Schetz

  5. Dept of Intensive Care Medicine, Singapore General Hospital, Outram Road, Singapore, Singapore

    Ian Tan

  6. Adult Intensive Care Unit, Academic Medical Center, Amsterdam, The Netherlands

    Catherine Bouman

  7. Nephrology Division, University of São Paulo School of Medicine, São Paulo, Brazil

    Ettiene Macedo

  8. Division of Critical Care Medicine, University of Alberta, Edmonton, Canada

    Noel Gibney

  9. Department of Medicine, Division of Nephrology, The University of Alabama, Birmingham, AL, USA

    Ashita Tolwani

  10. Intensive Care Unit, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands

    Heleen Oudemans-van Straaten

  11. Nephrology – Intensive Care, St. Bortolo Hospital, Vicenza, Italy

    Claudio Ronco

  12. Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    John A. Kellum

Authors
  1. Shigehiko Uchino
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rinaldo Bellomo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hiroshi Morimatsu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Stanislao Morgera
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Miet Schetz
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ian Tan
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Catherine Bouman
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ettiene Macedo
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Noel Gibney
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ashita Tolwani
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Heleen Oudemans-van Straaten
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Claudio Ronco
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. John A. Kellum
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rinaldo Bellomo.

Additional information

This article is discussed in the editorial available at: http://dx.doi.org/10.1007/s00134-007-0755-3.

This study was supported by the Austin Hospital Anaesthesia and Intensive Care Trust Fund.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Cite this article

Uchino, S., Bellomo, R., Morimatsu, H. et al. Continuous renal replacement therapy: A worldwide practice survey. Intensive Care Med 33, 1563–1570 (2007). https://doi.org/10.1007/s00134-007-0754-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-007-0754-4

Keywords

Search

Navigation