Introduction
Continuous kidney replacement therapy (CKRT) is commonly used to treat critically ill children. Recent work by the WE-ROCK collaborative reports that longer CKRT duration and lower urine output at CKRT initiation are associated with lower likelihood of successful liberation from CKRT [1, 2]. However, approaches to CKRT liberation and factors important in this decision-making process are inadequately described. Using a multinational collaborative, we sought to characterize providers’ approaches to CKRT liberation.
Methods
An electronic survey was distributed to WE-ROCK collaborative members (N=319) from March-June 2024. Questions evaluated decision-making factors used to determine both a patient’s CKRT liberation readiness and success (Supplemental Item 1). Factor importance was rated using a 5-point Likert scale with 4 and 5 representing “moderately” and “very” important. Responses are reported as medians [interquartile range]. Responses were compared between nephrologists and intensivists using Wilcoxon rank sum or Fisher exact tests as appropriate (GraphPad, San Diego, CA).
Results
A total of 229 respondents (36% nephrology, 64% intensive care) completed the survey. Most (85%) practiced in the United States, with 11 total countries represented (Table 1). Only 24% of respondents had a standardized approach to CKRT liberation. Of those, 65% used a diuretic bolus, and 57% used a combination of loop and thiazide diuretics. Nephrologists were four times more likely than intensivists to give the diuretic bolus after stopping CKRT versus before or at the time of stopping (P<0.001).
Table 1.
Participant-Reported Demographics and Practice Settings
| Responses, n (%) | 229 |
|---|---|
| Pediatric specialty (n=235) | |
| Nephrology | 83 (36.2) |
| Pediatric Intensivist | 108 (47.2) |
| Cardiac Intensivist | 38 (16.6) |
| Neonatologist | 6 (2.6) |
| Role (n=228) | |
| Attending | 179 (78.2) |
| Fellow | 30 (13.1) |
| Advanced Practice Provider | 19 (8.3) |
| Year of Practice (n=228) | |
| 1 to 5 | 101 (44.3) |
| 6 to 10 | 49 (21.5) |
| 11 to 20 | 55 (24.1) |
| >20 | 23 (10.1) |
| CKRT Patient Days in 2023 (n=47) | |
| <100 | 1 (2.1) |
| 100-500 | 14 (29.8) |
| 500-750 | 16 (34.0) |
| >750 | 16 (34.0) |
| Countries (n=217) | |
| United States | 185 (85.3) |
| Canada | 11 (5.1) |
| Europe (Austria, Italy, Spain, United Kingdom) | 14 (6.5) |
| Asia (Turkey, Japan, Thailand) | 5 (2.3) |
| Australia | 1 (0.5) |
| South America (Ecuador) | 1 (0.5) |
When evaluating readiness for CKRT liberation, nephrologists placed higher value than intensivists on spontaneous urine output without diuretics (5 [4, 5] vs. 3 [3, 4], P<0.001), number of vasoactive medications (4, [3, 4] vs. 3 [2, 4], P<0.001), and expected total fluid intake (5 [4, 5] vs. 4 [4, 5], P<0.001). When determining liberation success, nephrologists placed a higher value on spontaneous urine output (5 [4, 5] vs. 4 [3, 5], P<0.001). The highest-rated factor in determining liberation success was urine output in response to diuretics, with 94% of respondents ranking it “moderately” or “very” important followed by cumulative fluid balance (89%). The highest-rated factor in readiness for liberation expected fluid intake and cumulative fluid balance (86%). (Figure 1). Years of practice did not change responses among intensivists; there were not enough nephrologists to assess how years of practice changed responses.
Figure 1.
Clinical Decision-Making Factors Valued by Respondents for A) Decision to attempt liberation from CKRT and B) liberation success from CKRT. Representation of clinical decision-making factors ranked with moderate or high importance (Likert 4 or 5) by respondents, with percentage displayed in parenthesis and grouped into high importance (>80%), moderate importance (50-80%) and less important (<50%).
Discussion
We found that nephrologists and intensivists generally agree on factors important for decision-making in CKRT liberation. Few providers have a standard approach, a finding that echoes current literature [3]. Fluid balance emerged as the top consideration in determining readiness for CKRT liberation. While respondents placed high value on urine output, there remains a lack of standardized output thresholds to guide CKRT liberation decisions. This likely contributes to variability in the design and interpretation of CKRT liberation studies [3-5].
A strength of this survey is the diversity of participant specialties and levels of training, capturing many types of providers that make decisions in pediatric CKRT. The distribution method through WE-ROCK providers and colleagues may have introduced a sampling bias toward those at large academic centers, as well as limits our ability to determine a response rate. Future research should focus on integrating these existing practice patterns with CKRT liberation data to define objective markers and clinically relevant thresholds.
Supplementary Material
Acknowledgements:
We would like to thank all who completed the survey. Participants included: Sameer Thadani, Danielle E. Soranno, Eliza Blanchette, Alexander J Kula, Jeanne Frisby-Zedan, Loachamin Caiza Franklin, Uthaiwan Khongkhanin, Brendan Crawford, Claudia A. Mosquera Vasquez, Pattareeya Yottasan, Kyle A Merrill, Kera Luckritz, Rebecca M Lombel, Caroline V Jackson, Matthew Biehl, Shina Menon, Shanthi sree Balani, Brynna L Van Wyk, Jessica Williams, Gauri Kulkarni, Aesha Maniar, Jordan Symons, Aadil Kakajiwala, Scott Sutherland, Naile Tufan, Katherine L. Kurzinski, Shrea Goswami, Melissa A. Muff-Luett, H. Stella Shin, Tennille N. Webb, Weiwen Vivian Shih, Melvin Chan, Matthew Pinto, Matthew P. Malone, Katja M Gist , Merve Erdem, Denise C Hasson, Taiki Haga, Natalja L. Stanski, Meghan M. Chlebowski, Maria J Santiago, Sylvia Belda, Arun Ghose, Francesco Guzzi, María Amalia Ballesta Yagüe, Sarah N. Fernández Lafever, Kelley A. Groves, Samer Abu-Sultaneh, Rebecca Bertrandt, James G. Williams, James Schneider, Elizabeth Wei, Rashid Alobaidi, Sharon P Dial , Manuel Nieto, Natalie Anton, Lane T Lanier, Lama Elbahlawan, Matthew F. Barhight, Rajit K. Basu, Mahil Rao, Maria Murphy, Cara L. Slagle , Stephen M. Gorga, Justinn M Tanem, Laura Meeker, Stacey Sears, Cassandra Coleman, María García-Besteiro, Timothy P. Welch, S Rhodes Proctor Short , Claire M. Hennigan, Robert A Niebler, Jennifer L van Helmond, Kyle Lieppman. We would also like to thank all other participants who did not provide their names.
Funding/Support:
This study was funded in part by T32GM008425 from the National Institute of General Medical Sciences (E.R.). M.S is supported in part by K23HL168362. The funding sources for this study had no role in the design, conduct, collection, management, analysis, and interpretation of the data, nor the preparation, review, or decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of General Medical Sciences or the National Institutes of Health.
Statements and Declarations:
All authors declare no real or perceived conflicts of interest that could affect the study design, collection, analysis, or interpretation of data, writing of the report, or the decision to submit for publication. For full disclosure, we provide here an additional list of other author’s commitments and funding sources that are not directly related to this study: Evan Rajadhyaksha receives funding from the National Institutes of Health (NIGMS). Dana receives funding from the National Institutes of Health (NIDDK). Shina Menon is a consultant for Medtronic, Inc and Nuwellis, Inc and receives funding from the Gerber Foundation. Katja M. Gist is a consultant for Bioporto Diagnostics and Potrero Medical and receives funding from the Gerber Foundation. Michelle C. Starr receives funding from the National Institutes of Health (NIDDK and NHLBI).
Footnotes
Prior Presentation of Study Data: An earlier analysis of these data was presented in abstract form at the Pediatric Academic Societies Annual Meeting.
Data Availability:
De-identified summary data are available through the WE-ROCK collaborative. The statistical analysis plan will be made available upon request. The survey instrument is available upon request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
De-identified summary data are available through the WE-ROCK collaborative. The statistical analysis plan will be made available upon request. The survey instrument is available upon request.