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Timing of dialysis initiation in AKI in ICU: international survey.

Thakar CV, Rousseau J, Leonard AC - Crit Care (2012)

Bottom Line: The proportion of subjects choosing absolute creatinine level to be more influential than relative increment, went from 60% to 54% to 43% as predicted mortality increased (p < 0.0001).Severely ill patients were more likely to be subjected to early dialysis initiation, but its utility is not clear.Rank-order analysis indicates dialysis initiation is still influenced by "imminent" indications rather than a "proactive" decision based on the severity of AKI or azotemia.

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ABSTRACT

Introduction: Initiating dialysis in acute kidney injury (AKI) in an intensive care unit (ICU) remains a subjective clinical decision. We examined factors and practice patterns that influence early initiation of dialysis in ICU patients with acute kidney injury.

Methods: An online survey presented nephrologists (international) with three case scenarios with unstated predicted mortality rates of < 10%, 10 - 30% and > 30%. For each case the respondents were asked 4 questions about influences on the decision whether or not to initiate dialysis within 24 hours: Q1, likelihood of initiating dialysis; Q2, threshold of BUN levels (< 50, 50 - 75, 76 - 100, > 100 mg/dl) considered relevant to this decision; Q3, magnitude of creatinine elevation (two to three-fold increase; greater than threefold increase; absolute level > 5 mg/dl regardless of change) considered relevant; Q4, a rank order of the influence of five parameters (BUN level, change of creatinine from baseline, oxygen saturation, potassium level, and urine output), 1 being the most influential and 5 being the least influential.

Results: One hundred seventy-two nephrologists (73% in practice for > 5 years; 70% from the U.S.A.) responded to the survey. The proportion of subjects likely to initiate early dialysis increased (76% to 94%), as did the predicted mortality (p < 0.001). The proportion of subjects considering early dialysis at a BUN level ≤ 75 increased from 17% to 30 to 40% as the predicted mortality of the cases increased (p < 0.0001). The proportion of subjects choosing absolute creatinine level to be more influential than relative increment, went from 60% to 54% to 43% as predicted mortality increased (p < 0.0001). Rank-order analysis indicated that influence of oxygen saturation and potassium level on dialysis decision showed a significant change with severity of illness, but BUN level and creatinine elevation remained less influential, and did not change with severity.

Conclusions: Severely ill patients were more likely to be subjected to early dialysis initiation, but its utility is not clear. Rank-order analysis indicates dialysis initiation is still influenced by "imminent" indications rather than a "proactive" decision based on the severity of AKI or azotemia.

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Rank order of biochemical parameters that influence dialysis decision. Data are from all 172 respondents.
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Figure 2: Rank order of biochemical parameters that influence dialysis decision. Data are from all 172 respondents.

Mentions: The results of the rankings of the influence of the five biochemical parameters are shown in Figure 2 (1 is most influential and 5 is least). Generally, oxygen saturation and potassium levels remained predominantly influential parameters in initiating dialysis across all scenarios. In Table 2, we show the average rank order based on the responses for each of the biochemical parameters, for each of the three cases. The mean ranking for oxygen saturation went down (became more influential) and potassium level went up (became less influential) as predicted mortality increased (paired t tests P < 0.0001 for each). In other words, potassium levels had the most influence on the dialysis decision in the case with lowest severity of illness, whereas oxygen level was most influential in the case with highest severity of illness. Mean rankings for urine output, BUN level, and creatinine elevation did not significantly differ across the least severe and the most severe cases.


Timing of dialysis initiation in AKI in ICU: international survey.

Thakar CV, Rousseau J, Leonard AC - Crit Care (2012)

Rank order of biochemical parameters that influence dialysis decision. Data are from all 172 respondents.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3672626&req=5

Figure 2: Rank order of biochemical parameters that influence dialysis decision. Data are from all 172 respondents.
Mentions: The results of the rankings of the influence of the five biochemical parameters are shown in Figure 2 (1 is most influential and 5 is least). Generally, oxygen saturation and potassium levels remained predominantly influential parameters in initiating dialysis across all scenarios. In Table 2, we show the average rank order based on the responses for each of the biochemical parameters, for each of the three cases. The mean ranking for oxygen saturation went down (became more influential) and potassium level went up (became less influential) as predicted mortality increased (paired t tests P < 0.0001 for each). In other words, potassium levels had the most influence on the dialysis decision in the case with lowest severity of illness, whereas oxygen level was most influential in the case with highest severity of illness. Mean rankings for urine output, BUN level, and creatinine elevation did not significantly differ across the least severe and the most severe cases.

Bottom Line: The proportion of subjects choosing absolute creatinine level to be more influential than relative increment, went from 60% to 54% to 43% as predicted mortality increased (p < 0.0001).Severely ill patients were more likely to be subjected to early dialysis initiation, but its utility is not clear.Rank-order analysis indicates dialysis initiation is still influenced by "imminent" indications rather than a "proactive" decision based on the severity of AKI or azotemia.

View Article: PubMed Central - HTML - PubMed

ABSTRACT

Introduction: Initiating dialysis in acute kidney injury (AKI) in an intensive care unit (ICU) remains a subjective clinical decision. We examined factors and practice patterns that influence early initiation of dialysis in ICU patients with acute kidney injury.

Methods: An online survey presented nephrologists (international) with three case scenarios with unstated predicted mortality rates of < 10%, 10 - 30% and > 30%. For each case the respondents were asked 4 questions about influences on the decision whether or not to initiate dialysis within 24 hours: Q1, likelihood of initiating dialysis; Q2, threshold of BUN levels (< 50, 50 - 75, 76 - 100, > 100 mg/dl) considered relevant to this decision; Q3, magnitude of creatinine elevation (two to three-fold increase; greater than threefold increase; absolute level > 5 mg/dl regardless of change) considered relevant; Q4, a rank order of the influence of five parameters (BUN level, change of creatinine from baseline, oxygen saturation, potassium level, and urine output), 1 being the most influential and 5 being the least influential.

Results: One hundred seventy-two nephrologists (73% in practice for > 5 years; 70% from the U.S.A.) responded to the survey. The proportion of subjects likely to initiate early dialysis increased (76% to 94%), as did the predicted mortality (p < 0.001). The proportion of subjects considering early dialysis at a BUN level ≤ 75 increased from 17% to 30 to 40% as the predicted mortality of the cases increased (p < 0.0001). The proportion of subjects choosing absolute creatinine level to be more influential than relative increment, went from 60% to 54% to 43% as predicted mortality increased (p < 0.0001). Rank-order analysis indicated that influence of oxygen saturation and potassium level on dialysis decision showed a significant change with severity of illness, but BUN level and creatinine elevation remained less influential, and did not change with severity.

Conclusions: Severely ill patients were more likely to be subjected to early dialysis initiation, but its utility is not clear. Rank-order analysis indicates dialysis initiation is still influenced by "imminent" indications rather than a "proactive" decision based on the severity of AKI or azotemia.

Show MeSH
Related in: MedlinePlus