Accepted Article
Journal name: Nephrology Manuscript Type: Original Article Manuscript reference number: NEP-2014-0063.R1 Manuscript Title: A national survey of renal replacement therapy prescribing practice for acute kidney injury in Malaysian intensive care units Accept Date: 01-May-2014 COMMENTS FROM THE JOURNAL CONCERNING THE PRODUCTION OF THE PAPER: Summary at a Glance A review of renal replacement therapy for acute kidney injury in Malayasian Intensive Care Units. CRRT utilising CVVH was the first choice modlality. Initiation of RRT wasundertaken by the Intensivists.
A national survey of renal replacement therapy prescribing practice for acute kidney injury in Malaysian intensive care units1
Janattul-Ain Jamal1,2, Mohd-Basri Mat-Nor3, Fariz-Safhan Mohamad-Nor4, Andrew A. Udy5, Jeffrey Lipman1,6, Jason A. Roberts1,6,7 1
Burns, Trauma and Critical Care Research Centre, School of Medicine, The
University of Queensland, Brisbane, Queensland, Australia 2
Department of Pharmacy, Hospital Tengku Ampuan Afzan, Kuantan, Pahang,
Malaysia 3
Department of Anaesthesiology and Intensive Care, Kulliyah of Medicine,
International Islamic University of Malaysia, Kuantan, Pahang, Malaysia 4
Department of Nephrology, Hospital Tengku Ampuan Afzan, Kuantan, Pahang,
Malaysia
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/nep.12274 This article is protected by copyright. All rights reserved.
Department of Hyperbaric and Intensive Care Medicine, The Alfred Hospital,
Accepted Article
5
Commercial Road, Prahran, Melbourne, Australia 6
Department of Intensive Care Medicine, The Royal Brisbane and Women’s Hospital,
Brisbane, Queensland, Australia 7
Department of Pharmacy, The Royal Brisbane and Women’s Hospital, Brisbane,
Queensland, Australia
Short title: RRT prescribing practice survey
Keywords: survey, renal replacement therapy, intensive care
Address for correspondence: Prof. Jason A. Roberts; Burns Trauma and Critical Care Research Centre, Level 3 Ned Hanlon Building, Royal Brisbane and Women’s Hospital, Butterfield St, Brisbane Queensland Australia 4029; [email protected]; Ph +617 3646 4108; Fax: +617 3646 3542
Abstract
Objectives: To describe renal replacement therapy (RRT) prescribing practices in Malaysian intensive care units (ICU), and compare this with previously published data from other regions. Method: A survey was sent to physicians responsible for prescribing RRT in major ICUs throughout Malaysia. The questionnaire sought information on the physicians’ background, and detailed information regarding RRT settings. Results: Nineteen physicians from 24 sites throughout Malaysia responded to the survey (response rate 79.2%). Sixteen respondents were intensivists (84%), 2 were anaesthetists (11%) and one was a nephrologist (5%). The majority (58%) employed continuous venovenous haemofiltration (CVVH) as the treatment of choice for acute kidney injury (AKI) in critically ill patients. RRT prescription was predominantly practitioner-dependent (63%), while 37% reported use of a dedicated protocol. The This article is protected by copyright. All rights reserved.
Accepted Article
mean blood flow rate and effluent flow rate used for continuous RRT (CRRT) were 188.9 ± 28.9 ml/min and 30.6 ± 4.7 ml/kg/hour respectively. Replacement fluid solutions containing both lactate and bicarbonate were commonly used during CRRT, applied both pre- and post-dilution. Conclusion: CRRT was the first choice modality used to treat AKI in critically ill patients. CVVH was the most common CRRT technique utilised, while other RRT modalities were used less frequently. Overall, RRT practices were similar to those observed in other regions, although the modality and settings utilised were slightly different, likely due to local availability.
Introduction
Acute kidney injury (AKI) is a significant problem in critically ill patients. The reported incidence varies, but can be as high as 65% in some ICU populations, depending on the definition used.1,2 AKI is associated with mortality rates of
approximately 50%,2 and early management with renal replacement therapy (RRT) is considered an essential intervention. RRT modalities have evolved over time, in parallel with technological advances, to offer better patient tolerability and solute removal. However, ‘ideal’ RRT settings remain controversial, and delivery of a standard RRT prescription globally is unlikely. This is due, in part, to the high costs and need for specialised staff, which are unlikely to be sustainable in resource-limited settings.
RRT can be given intermittently, lasting approximately 4 hours per session, such as occurs with conventional intermittent haemodialysis (IHD). Prolonged intermittent RRT (PIRRT) adapted from both intermittent and continuous modalities, has a longer duration of treatment, lasting up to 18 hours.3 Continuous RRT (CRRT) is perhaps
most common in the ICU, and is given over 24 hours. Generally, the aims of This article is protected by copyright. All rights reserved.
Accepted Article
treatment are to control fluid volume, correct acid-base abnormalities, improve uraemia, promote renal recovery and improve mortality without causing complications.4 Solute removal during RRT occurs by convection and/or diffusion. Conventional dialysis uses diffusion for solute removal, whereas haemofiltration techniques employ convection. In some instances, both diffusion and convection are combined, as in haemodiafiltration.
Describing RRT practice in the ICU is important, as significant heterogeneity has been reported globally.5-13 A survey conducted among nephrologists in the United
States in 1995, demonstrated that IHD and CRRT were both widely used in ICU, while PIRRT was utilised infrequently.5 In contrast, a more recent survey of ICU
practitioners revealed increasing use of CRRT and PIRRT in the critically ill, in preference to IHD.8 In some countries, IHD is still used in the ICU although only for select critically ill patients who are haemodynamically stable, and approaching discharge to the ward.9 Variability in training and availability of resources between different ICUs may help to explain some of these inconsistencies in RRT prescription. Whilst some data exists from Western countries, limited data are currently available describing RRT prescribing in other regions. Advances in RRT technology are also likely to have influenced RRT practice among ICU clinicians in Malaysia, where the healthcare system is primarily government funded. In a small number of University facilities a co-payment is required from patients, although this is thought not to influence RRT decisions. In this respect it is important to provide baseline data on local practice, which can then serve as a starting point to assess the impact of alternative RRT methods in this setting.
The aims of this study were to describe RRT prescribing practices in Malaysian ICUs, and compare this with previously published data from other regions.
Methods
This study used a survey design and identified physicians who were responsible for RRT prescribing in major ICUs throughout Malaysia. Based on local ICU registry data,14 from a total of 51 facilities, 24 were classified as major ICUs. These were all
tertiary centers, with at least one ICU specialist, as well as an active in-house RRT This article is protected by copyright. All rights reserved.
Accepted Article
service. The reported number of admissions to these ICUs was more than 500 per year.14 Therefore, we expected that responses from physicians at these institutions would closely represent current RRT practices in ICU across Malaysia.
Expressions of interest for involvement in the study were initially sought from specialists attending a local ICU meeting in Malaysia. They were typically the director, or a senior ICU specialist from one of these centers. Subsequently a study questionnaire was developed based on previous literature,8,9 (Appendix 1), and was sent or emailed in August 2013 to those willing to participate. These were distributed to the physician responsible for RRT prescribing at each unit/institution.
The
questionnaire sought detailed information on institutional RRT prescribing and practice. In order to obtain sufficient responses, contact was made with nonresponders by email and/or phone. Respondents could return the questionnaire to the investigators via email or post.
Statistical analysis Results were analysed using Microsoft Excel (Microsoft Office 2011; Redmond, WA) and Prism (GraphPad version 6.0; San Diego, CA), and are presented as the percentage of respondents, mean (± standard deviation), or median (interquartile range), as appropriate. A Fisher’s exact test was used to compare categorical data. A P values
Journal name: Nephrology Manuscript Type: Original Article Manuscript reference number: NEP-2014-0063.R1 Manuscript Title: A national survey of renal replacement therapy prescribing practice for acute kidney injury in Malaysian intensive care units Accept Date: 01-May-2014 COMMENTS FROM THE JOURNAL CONCERNING THE PRODUCTION OF THE PAPER: Summary at a Glance A review of renal replacement therapy for acute kidney injury in Malayasian Intensive Care Units. CRRT utilising CVVH was the first choice modlality. Initiation of RRT wasundertaken by the Intensivists.
A national survey of renal replacement therapy prescribing practice for acute kidney injury in Malaysian intensive care units1
Janattul-Ain Jamal1,2, Mohd-Basri Mat-Nor3, Fariz-Safhan Mohamad-Nor4, Andrew A. Udy5, Jeffrey Lipman1,6, Jason A. Roberts1,6,7 1
Burns, Trauma and Critical Care Research Centre, School of Medicine, The
University of Queensland, Brisbane, Queensland, Australia 2
Department of Pharmacy, Hospital Tengku Ampuan Afzan, Kuantan, Pahang,
Malaysia 3
Department of Anaesthesiology and Intensive Care, Kulliyah of Medicine,
International Islamic University of Malaysia, Kuantan, Pahang, Malaysia 4
Department of Nephrology, Hospital Tengku Ampuan Afzan, Kuantan, Pahang,
Malaysia
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/nep.12274 This article is protected by copyright. All rights reserved.
Department of Hyperbaric and Intensive Care Medicine, The Alfred Hospital,
Accepted Article
5
Commercial Road, Prahran, Melbourne, Australia 6
Department of Intensive Care Medicine, The Royal Brisbane and Women’s Hospital,
Brisbane, Queensland, Australia 7
Department of Pharmacy, The Royal Brisbane and Women’s Hospital, Brisbane,
Queensland, Australia
Short title: RRT prescribing practice survey
Keywords: survey, renal replacement therapy, intensive care
Address for correspondence: Prof. Jason A. Roberts; Burns Trauma and Critical Care Research Centre, Level 3 Ned Hanlon Building, Royal Brisbane and Women’s Hospital, Butterfield St, Brisbane Queensland Australia 4029; [email protected]; Ph +617 3646 4108; Fax: +617 3646 3542
Abstract
Objectives: To describe renal replacement therapy (RRT) prescribing practices in Malaysian intensive care units (ICU), and compare this with previously published data from other regions. Method: A survey was sent to physicians responsible for prescribing RRT in major ICUs throughout Malaysia. The questionnaire sought information on the physicians’ background, and detailed information regarding RRT settings. Results: Nineteen physicians from 24 sites throughout Malaysia responded to the survey (response rate 79.2%). Sixteen respondents were intensivists (84%), 2 were anaesthetists (11%) and one was a nephrologist (5%). The majority (58%) employed continuous venovenous haemofiltration (CVVH) as the treatment of choice for acute kidney injury (AKI) in critically ill patients. RRT prescription was predominantly practitioner-dependent (63%), while 37% reported use of a dedicated protocol. The This article is protected by copyright. All rights reserved.
Accepted Article
mean blood flow rate and effluent flow rate used for continuous RRT (CRRT) were 188.9 ± 28.9 ml/min and 30.6 ± 4.7 ml/kg/hour respectively. Replacement fluid solutions containing both lactate and bicarbonate were commonly used during CRRT, applied both pre- and post-dilution. Conclusion: CRRT was the first choice modality used to treat AKI in critically ill patients. CVVH was the most common CRRT technique utilised, while other RRT modalities were used less frequently. Overall, RRT practices were similar to those observed in other regions, although the modality and settings utilised were slightly different, likely due to local availability.
Introduction
Acute kidney injury (AKI) is a significant problem in critically ill patients. The reported incidence varies, but can be as high as 65% in some ICU populations, depending on the definition used.1,2 AKI is associated with mortality rates of
approximately 50%,2 and early management with renal replacement therapy (RRT) is considered an essential intervention. RRT modalities have evolved over time, in parallel with technological advances, to offer better patient tolerability and solute removal. However, ‘ideal’ RRT settings remain controversial, and delivery of a standard RRT prescription globally is unlikely. This is due, in part, to the high costs and need for specialised staff, which are unlikely to be sustainable in resource-limited settings.
RRT can be given intermittently, lasting approximately 4 hours per session, such as occurs with conventional intermittent haemodialysis (IHD). Prolonged intermittent RRT (PIRRT) adapted from both intermittent and continuous modalities, has a longer duration of treatment, lasting up to 18 hours.3 Continuous RRT (CRRT) is perhaps
most common in the ICU, and is given over 24 hours. Generally, the aims of This article is protected by copyright. All rights reserved.
Accepted Article
treatment are to control fluid volume, correct acid-base abnormalities, improve uraemia, promote renal recovery and improve mortality without causing complications.4 Solute removal during RRT occurs by convection and/or diffusion. Conventional dialysis uses diffusion for solute removal, whereas haemofiltration techniques employ convection. In some instances, both diffusion and convection are combined, as in haemodiafiltration.
Describing RRT practice in the ICU is important, as significant heterogeneity has been reported globally.5-13 A survey conducted among nephrologists in the United
States in 1995, demonstrated that IHD and CRRT were both widely used in ICU, while PIRRT was utilised infrequently.5 In contrast, a more recent survey of ICU
practitioners revealed increasing use of CRRT and PIRRT in the critically ill, in preference to IHD.8 In some countries, IHD is still used in the ICU although only for select critically ill patients who are haemodynamically stable, and approaching discharge to the ward.9 Variability in training and availability of resources between different ICUs may help to explain some of these inconsistencies in RRT prescription. Whilst some data exists from Western countries, limited data are currently available describing RRT prescribing in other regions. Advances in RRT technology are also likely to have influenced RRT practice among ICU clinicians in Malaysia, where the healthcare system is primarily government funded. In a small number of University facilities a co-payment is required from patients, although this is thought not to influence RRT decisions. In this respect it is important to provide baseline data on local practice, which can then serve as a starting point to assess the impact of alternative RRT methods in this setting.
The aims of this study were to describe RRT prescribing practices in Malaysian ICUs, and compare this with previously published data from other regions.
Methods
This study used a survey design and identified physicians who were responsible for RRT prescribing in major ICUs throughout Malaysia. Based on local ICU registry data,14 from a total of 51 facilities, 24 were classified as major ICUs. These were all
tertiary centers, with at least one ICU specialist, as well as an active in-house RRT This article is protected by copyright. All rights reserved.
Accepted Article
service. The reported number of admissions to these ICUs was more than 500 per year.14 Therefore, we expected that responses from physicians at these institutions would closely represent current RRT practices in ICU across Malaysia.
Expressions of interest for involvement in the study were initially sought from specialists attending a local ICU meeting in Malaysia. They were typically the director, or a senior ICU specialist from one of these centers. Subsequently a study questionnaire was developed based on previous literature,8,9 (Appendix 1), and was sent or emailed in August 2013 to those willing to participate. These were distributed to the physician responsible for RRT prescribing at each unit/institution.
The
questionnaire sought detailed information on institutional RRT prescribing and practice. In order to obtain sufficient responses, contact was made with nonresponders by email and/or phone. Respondents could return the questionnaire to the investigators via email or post.
Statistical analysis Results were analysed using Microsoft Excel (Microsoft Office 2011; Redmond, WA) and Prism (GraphPad version 6.0; San Diego, CA), and are presented as the percentage of respondents, mean (± standard deviation), or median (interquartile range), as appropriate. A Fisher’s exact test was used to compare categorical data. A P values
