Elsevier

Journal of Critical Care

Volume 46, August 2018, Pages 44-49
Journal of Critical Care

Renal
Current practice of diagnosis and management of acute kidney injury in intensive care unit in resource limited settings

https://doi.org/10.1016/j.jcrc.2018.04.007Get rights and content

Highlights

  • The largest survey study for AKI practice in ASIAN and resource limited settings

  • Nephrologists play major role on AKI management and RRT initiation.

  • Intermittent hemodialysis is the preferred mode of RRT over continuous RRT and peritoneal dialysis.

Abstract

Purpose

In a resource limited settings, there is sparse information about the management of acute kidney injury (AKI) based on systemic data collection. This survey aimed to described the current management of AKI in intensive care units (ICUs) across Thailand.

Materials and methods

Questionnaires were distributed to 160 physicians involved in the intensive care between January and December 2014 across Thailand. Distribution was done through an online survey platform or telephone interview.

Results

The response rate was 80.6% (129 physicians). AKI diagnosis was mostly made by using KDIGO criteria (36.7%). A common diagnostic investigation of AKI was urinalysis (86%). Nephrologists had a major role (86.4%) in deciding the initiation and selection of renal replacement therapy (RRT) modality. Intermittent hemodialysis is the preferable mode of RRT (72.0%), followed by continuous renal replacement therapy (CRRT, 12%), sustained low efficiency dialysis (10.0%) and peritoneal dialysis (6.0%). Catheter insertion was predominantly performed by nephrologist (51.1%) with ultrasound guidance. The right internal jugular vein was the most common site of insertion (70.4%). The most common indication for CRRT was hemodynamic instability.

Conclusions

Amid increasing concern of AKI in the ICU, our study provides the insight into the management of AKI in resource limited settings.

Introduction

Acute kidney injury (AKI) is an important and common problem in the intensive care unit (ICU). Worldwide prevalence of AKI in ICU ranges from 20%–70%, with a rate of renal replacement therapy (RRT) of 10% [[1], [2], [3]]. Regardless of clinical setting, AKI has been linked to increased morbidity and mortality.

After the introduction of Risk, Injury, Failure, Loss and End (RIFLE) criteria [4,5], Acute Kidney Injury Network (AKIN) criteria [6] and the latest, Kidney Disease Improving Global Outcomes (KDIGO) criteria [7], the definition and staging of AKI has become more standardized. Even though, these criteria are widely adopted in resource sufficient settings. Little is known about their use in resource limited settings [8].

Furthermore, there is still no adequate systemic data collection on which diagnostic investigations were devised in this specific setting. AKI greatly increases cost of medical care, therefore, gaining information regarding the diagnostic methods most commonly used will help provide a practical insight to better understand our practice of AKI management in resource limited settings.

Optimal management of AKI, especially RRT initiation in patients with advanced AKI stages will much decrease morbidity and mortality [9,10]. Many national surveys of current practice of RRT management were previously conducted in many countries such as Australia and New Zealand [11], UK [12], Europe [13], Japan [14] and Malaysia [15]. However, there are a few reports from resource limited settings.

This survey aimed to systematically collect data to reflect the current clinical management of AKI in hospitals across Thailand.

Section snippets

Survey and participants

To conduct this prospective study, we identified roughly 400 physicians who participated in the annual Thai nephrology conference and/or who were members of the Thai Nephrology Society between January and December 2014. We randomly selected 160 physicians who were involved in ICU practices and invited them to participate in our study by answering a questionnaire administered through online Survey Monkey or telephone interview.

Survey design

The 48 questions in the survey were mainly divided into the diagnosis

Results

The survey was distributed to 160 physicians involved in the critical care practices. One hundred and twenty-nine across 82 hospitals responded. We achieved a response rate 80.6% and cover 40% of Thailand hospitals with an ICU facility. Physicians were composed of nephrologists (69.0%), internists (22.0%), intensivists (7.8%), general practitioners (0.8%), and others (6.3%). The median age of survey participants was 36 (IQR 33–42) years. All levels of hospitals were included in our survey:

Discussion

Interestingly, the survey practice of AKI in resource limited countries may reveal different socioeconomic, environmental, and processes of care than in resource sufficient countries and may help to identify the important barriers. This, in turn, will help in the improvement AKI management which ultimately lead to better clinical outcomes. Our survey achieved in high response rate. Diagnosis of AKI was mostly defined by KDIGO criteria, and AKI assessment was mostly done through urinalysis

Conclusions

With increasing concern about current practice of AKI management in ICU, our study showed both the similarities and differences of AKI practice between resource limited settings and resource sufficient settings. It is noteworthy to emphasize that in Thailand, nephrologists play a major role in AKI management and that IHD is a main RRT modality. Our survey results may help provide insights into the current standard of care of AKI in resource limited settings and ultimately aims to guide the

Competing interests

The authors declare that they have no competing interests.

Acknowledgements

This study is a part of a project supported and funded by the Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross. We thank the staff, fellows, nurses and research coordinators at the Excellence Center for Critical Care Nephrology.

References (32)

  • J.A. Lopes et al.

    The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review

    Clin Kidney J

    (2013)
  • R. Bellomo et al.

    Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group

    Crit Care

    (2004)
  • R.L. Mehta et al.

    Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

    Crit Care

    (2007)
  • KDIGO clinical practice guideline for acute kidney injury

    Kidney Int

    (2012)
  • R.W. Schrier et al.

    Acute renal failure: definitions, diagnosis, pathogenesis, and therapy

    J Clin Invest

    (2004)
  • J. Himmelfarb

    Continuous renal replacement therapy in the treatment of acute renal failure: critical assessment is required

    Clin J Am Soc Nephrol

    (2007)
  • Cited by (11)

    • Diagnostic Challenges of Acute Kidney Injury in Asia

      2020, Seminars in Nephrology
      Citation Excerpt :

      Their application in LRS, similar to most parts of Asia, is even more challenging (Fig. 3). Our group conducted a retrospective survey by distributing online questionnaires to 160 physicians practicing critical care medicine across Thailand between January and December 2014.58 Of 129 respondents, 68.9% were nephrologists, 22.0% were internists, and 7.8% were intensivists.

    • RRT Selection for AKI Patients With Critical Illness

      2020, Seminars in Nephrology
      Citation Excerpt :

      However, nonclinical factors such as socioeconomic status and health care system have a significant impact on modality selection, and diverse circumstances impacting care decisions frequently are found in Asia. For instance, a questionnaire study from Thailand described RRT modality selection as follows: IRRT is the preferable mode of RRT (72.0%), followed by CRRT (12%), sustained low-efficiency dialysis (10.0%), and PD (6.0%).8 On the other hand, a survey from China reported different patterns of RRT modality selection as follows: CRRT (53.9%), IRRT (38.0%), CRRT complemented by IRRT (6.2%), CRRT complemented by PD (0.8%), and PD (1.1%).9

    View all citing articles on Scopus
    View full text