Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Net Ultrafiltration Prescription and Practice Among Critically Ill Patients Receiving Renal Replacement Therapy

A Multinational Survey of Critical Care Practitioners

Murugan, Raghavan MD, MS, FRCP, FCCM1,2; Ostermann, Marlies MD, PhD3; Peng, Zhiyong MD, PhD4; Kitamura, Koichi MD5; Fujitani, Shigeki MD, PhD6; Romagnoli, Stefano MD, PhD7,8; Di Lullo, Luca MD, PhD9; Srisawat, Nattachai MD, MS10; Todi, Subhash MD, MRCP11; Ramakrishnan, Nagarajan MD, MMM, FCCM, FISCCM12; Hoste, Eric MD, PhD13; Puttarajappa, Chethan M. MD, MS14; Bagshaw, Sean M. MD, MSc15; Weisbord, Steven MD, MSc1,14,16; Palevsky, Paul M. MD1,14,16; Kellum, John A. MD, MCCM1,2; Bellomo, Rinaldo MD, PhD17; Ronco, Claudio MD, PhD18

doi: 10.1097/CCM.0000000000004092
Online Clinical Investigation: PDF Only

Objectives: To assess the attitudes of practitioners with respect to net ultrafiltration prescription and practice among critically ill patients with acute kidney injury treated with renal replacement therapy.

Design: Multinational internet-assisted survey.

Setting: Critical care practitioners involved with 14 societies in 80 countries.

Subjects: Intensivists, nephrologists, advanced practice providers, ICU and dialysis nurses.

Intervention: A cross-sectional survey.

Measurement and Main Results: Of 2,567 practitioners who initiated the survey, 1,569 (61.1%) completed the survey. Most practitioners were intensivists (72.7%) with a median duration of 13.2 years of practice (interquartile range, 7.2–22.0 yr). Two third of practitioners (71.0%; regional range, 55.0–95.5%) reported using continuous renal replacement therapy with a net ultrafiltration rate prescription of median 80.0 mL/hr (interquartile range, 49.0–111.0 mL/hr) for hemodynamically unstable and a maximal rate of 299.0 mL/hr (interquartile range, 200.0–365.0 mL/hr) for hemodynamically stable patients, with regional variation. Only a third of practitioners (31.5%; range, 13.7–47.8%) assessed hourly net fluid balance during continuous renal replacement therapy. Hemodynamic instability was reported in 20% (range, 20–38%) of patients and practitioners decreased the rate of fluid removal (70.3%); started or increased the dose of a vasopressor (51.5%); completely stopped fluid removal (35.8%); and administered a fluid bolus (31.6%), with significant regional variation. Compared with physicians, nurses were most likely to report patient intolerance to net ultrafiltration (73.4% vs 81.3%; p = 0.002), frequent interruptions (40.4% vs 54.5%; p < 0.001), and unavailability of trained staff (11.9% vs 15.6%; p = 0.04), whereas physicians reported unavailability of dialysis machines (14.3% vs 6.1%; p < 0.001) and costs associated with treatment as barriers (12.1% vs 3.0%; p < 0.001) with significant regional variation.

Conclusions: Our study provides new knowledge about the presence and extent of international practice variation in net ultrafiltration. We also identified barriers and specific targets for quality improvement initiatives. Our data reflect the need for evidence-based practice guidelines for net ultrafiltration.

1The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

2The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

3Department of Critical Care, King’s College London, Guy’s & St Thomas’ Hospital, London, United Kingdom.

4Department of Critical Care Medicine, Wuhan University Zhongnan Hospital, Wuhan, Hubei Province, China.

5Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan.

6Emergency and Critical Care Medicine Department, St. Marianna University, Kawasaki-city, Kanagawa, Japan.

7Department of Health Science, University of Florence, Florence, Italy.

8Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.

9Department of Nephrology and Dialysis, L. Parodi-Delfino Hospital, Colleferro, Italy.

10Excellence Center for Critical Care Nephrology, Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand.

11Department of Critical Care, AMRI Hospitals, Kolkata, West Bengal, India.

12Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India.

13Department of Intensive Care Medicine, Ghent University, Ghent, Belgium.

14Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.

15Department of Critical Care Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, AB, Canada.

16Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.

17Department of Intensive Care Medicine, Austin Hospital, The University of Melbourne, Melbourne, VIC, Australia.

18Department of Medicine, University of Padova, International Renal Research Institute of Vicenza and Department of Clinical Nephrology, San Bortolo Hospital, Vicenza, Italy.

Dr. Murugan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, and involved in drafting of the article, statistical analysis, and study supervision. Drs. Murugan, Ostermann, Peng, Puttarajappa, Weisbord, Palevsky, Kellum, and Bellomo were involved in study concept and design. Drs. Murugan, Ostermann, Peng, Kitamura, Romagnoli, Di Lullo, Srisawat, Todi, Bellomo, and Ronco were involved in acquisition of data. Drs. Murugan, Ostermann, Weisbord, Palevsky, Kellum, Bellomo, and Ronco were involved in analysis and interpretation of data. Drs. Murugan, Ostermann, Peng, and Kitamura were involved in administrative, technical, or material support. All authors were involved in critical revision of the article for important intellectual content.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Murugan received grant funding from the National Institute of Diabetes and Digestive and Kidney Diseases and Bioporto and funding from AM Pharma and La Jolla unrelated to this study. Dr. Romagnoli received funding from Baxter, MSD, and Masimo. Dr. Hoste’s institution received funding from AM Pharma and Sopachem. Dr. Bagshaw received funding from Baxter. Dr. Weisbord received funding from Saghmos Therapeutics. Drs. Weisbord and Palevsky disclosed government work. Dr. Palevsky’s institution received funding from Dascena, and he received funding from Baxter, Novartis, and GE Healthcare. Dr. Kellum received funding from Baxter (grant and consulting) and NxStage (consulting). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail:

Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.