Discrepancies between present guidelines and clinical practice in renal replacement therapy in critically ill patients with acute kidney injury: A Dutch survey

Objective: Acute kidney injury is a common complication of critical illness with high morbidity and mortality. There is no consensus on its optimal management, including renal replacement therapy (RRT). The aim of this survey was to ascertain RRT management in Dutch intensive care units (ICUs), and to evaluate compliance to present guidelines. Intervention: Questionnaires concerning hospital demographics and RRT management were sent to all ICUs practicing RRT. Results: ICU physicians and nurses were in charge of RRT in 75% of the ICUs and continuous veno-venous haemofiltration was the preferred modality. A large variability was noted particularly for timing of RRT, but also for dose prescription, anticoagulation strategies and non-renal indications. Only 30% of respondents prescribed the recommended dose of 35 mL/kg/h. The most commonly used anticoagulant was unfractionated heparin. One third of the participating ICUs practiced regional citrate anticoagulation, while 61% were considering implementing it shortly. Danaparoid was the preferred anticoagulation strategy (60%) in patients with heparin-induced thrombocytopenia. The majority of responders (81%) agreed with non-renal indications, including refractory septic shock (48%). Conclusions: The Dutch practice of RRT is remarkably variable and only partly in line with present guidelines. The high prevalence of regional citrate anticoagulation is in sharp contrast with worldwide practice.