Annals of intensive care · 2026
Discrepancies between declared and real practices of continuous renal replacement therapy for septic acute kidney injury in French intensive care units.
СтатьяНазвание и аннотация: Перевод в очереди
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Stephan Loïz, Prevel Renaud, Sazio Charline, Ilciukas-Miquel Hugo, Auvet Adrien, Bodot Simon, Chelha Riad, Coirier Valentin, Fabre Xavier, Garin Aude, Garraud Jimmy, Gisbert-Mora Chloé, Grillet Guillaume, Hayon Jan, Labro Guylaine, Lambour Alexis, Lancrey-Javal Théophile, Le Basnier Eliott, Mikulski Marc, Nicolas Jonathan, Olry Kévin, Plouvier Fabienne, Seguin Thierry, Tientcheu Audrey, Valette Marc, Guisset Olivier, Gruson Didier, Boyer Alexandre, Orieux Arthur
Аннотация
BACKGROUND: Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is frequent in the intensive care unit (ICU). While the timing of initiation has been extensively studied, discontinuation remains poorly defined. Current guidelines provide only vague recommendations, and CRRT liberation is mainly guided by clinical judgment.
METHODS: We aimed to compare declared and real CRRT weaning practices among intensivists in septic AKI.We conducted one study with two complementary investigations. Phase 1 was a nationwide survey distributed to 230 French ICUs that explored physician experience, weaning criteria, fluid balance management, urine output thresholds, and urinary biomarker use. A total of 243 intensivists from 87 ICUs responded. Phase 2 was a multicentre retrospective cohort study describing real-world management across 22 ICUs of patients with septic AKI who initiated and were subsequently weaned from CRRT. Weaning was defined as the first discontinuation of CRRT with the intent to stop, regardless of later resumption. We collected clinical, hemodynamic, renal, and fluid data over the 5 days before Day 0, the weaning day.
RESULTS: In survey phase, 93% of respondents cited urine output as the main criterion for discontinuation, with a mean reported threshold of 612 ± 328 mL/day; 74% reassessed daily, and only 3% reported using a protocol. In the retrospective cohort phase (n = 116), markedly lower urine outputs were observed at weaning (median 275 mL [30-967] on D0, 122 mL [17-562] on D-1). On weaning day, 52% of patients were still on norepinephrine (median dose 0.22 μg/kg/min, bitartrate), 72% had a positive cumulative fluid balance (median +5 L), and diuretics were prescribed in 25% of patients. In unadjusted comparisons, patients with successful weaning (63%) had higher urine output at discontinuation and more frequent diuretic use, whereas vasopressor support and fluid balance substantially overlapped between groups. In multivariable analysis, only persistent anuria as the indication for CRRT initiation remained independently associated with weaning failure.
CONCLUSIONS: This combined analysis highlights a discrepancy between reported weaning practices and observed bedside management at the centre level. Despite declared reliance on urine output, hemodynamic stability, and decongestion, CRRT is often discontinued under oliguria, residual vasopressor use, and persistent fluid overload. The absence of standardized protocols underscores the need for validated composite readiness criteria that integrate urine output, vasopressor dependency, fluid status, and, possibly, urinary biomarkers.
METHODS: We aimed to compare declared and real CRRT weaning practices among intensivists in septic AKI.We conducted one study with two complementary investigations. Phase 1 was a nationwide survey distributed to 230 French ICUs that explored physician experience, weaning criteria, fluid balance management, urine output thresholds, and urinary biomarker use. A total of 243 intensivists from 87 ICUs responded. Phase 2 was a multicentre retrospective cohort study describing real-world management across 22 ICUs of patients with septic AKI who initiated and were subsequently weaned from CRRT. Weaning was defined as the first discontinuation of CRRT with the intent to stop, regardless of later resumption. We collected clinical, hemodynamic, renal, and fluid data over the 5 days before Day 0, the weaning day.
RESULTS: In survey phase, 93% of respondents cited urine output as the main criterion for discontinuation, with a mean reported threshold of 612 ± 328 mL/day; 74% reassessed daily, and only 3% reported using a protocol. In the retrospective cohort phase (n = 116), markedly lower urine outputs were observed at weaning (median 275 mL [30-967] on D0, 122 mL [17-562] on D-1). On weaning day, 52% of patients were still on norepinephrine (median dose 0.22 μg/kg/min, bitartrate), 72% had a positive cumulative fluid balance (median +5 L), and diuretics were prescribed in 25% of patients. In unadjusted comparisons, patients with successful weaning (63%) had higher urine output at discontinuation and more frequent diuretic use, whereas vasopressor support and fluid balance substantially overlapped between groups. In multivariable analysis, only persistent anuria as the indication for CRRT initiation remained independently associated with weaning failure.
CONCLUSIONS: This combined analysis highlights a discrepancy between reported weaning practices and observed bedside management at the centre level. Despite declared reliance on urine output, hemodynamic stability, and decongestion, CRRT is often discontinued under oliguria, residual vasopressor use, and persistent fluid overload. The absence of standardized protocols underscores the need for validated composite readiness criteria that integrate urine output, vasopressor dependency, fluid status, and, possibly, urinary biomarkers.