Centre de recherche du CHUM, Montreal, Quebec, Canada.
Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Clin J Am Soc Nephrol. 2023 Jun 1;18(6):705-715. doi: 10.2215/CJN.0000000000000157. Epub 2023 Mar 28.
In critically ill patients receiving KRT, high ultrafiltration rates and persistent fluid accumulation are associated with adverse outcomes. The purpose of this international survey was to evaluate current practices and evidence gaps related to fluid removal with KRT in critically ill patients.
This was a multinational, web-based survey distributed by seven networks comprising nephrologists and intensivists. Physicians involved in the care of critically ill patients were invited to complete a 39-question survey about fluid management practices on KRT. The survey was distributed from September 2021 to December 2021.
There were 757 respondents from 96 countries (response rate of 65%). Most respondents practiced adult medicine (89%) and worked in an academic center (69%). The majority (91%) reported aiming for a 0.5- to 2-L negative fluid balance per day when fluid removal is indicated, although there was important variability in what respondents considered a safe maximal target. Intensivists were more likely than nephrologists to use adjunct volume status assessment methods ( i.e. , ultrasound, hemodynamic markers, and intra-abdominal pressure), while nephrologists were more likely to deploy cointerventions aimed at improving tolerance to fluid removal ( i.e. , osmotic agents and low-temperature dialysate). There was a broad consensus that rapid decongestion should be prioritized when fluid accumulation is present, but the prevention of hypotension was also reported as a competing priority. A majority (77%) agreed that performing trials that compare fluid management strategies would be ethical and clinically relevant.
We have identified multiple areas of variability in current practice of fluid management for patients receiving KRT. Most nephrologists and intensivists agreed that several knowledge gaps related to fluid removal strategies should be investigated in future randomized controlled trials.
在接受肾脏替代治疗（KRT）的危重症患者中，超滤率高和持续液体蓄积与不良结局相关。本次国际调查的目的是评估与危重症患者 KRT 中液体清除相关的当前实践和证据差距。
这是一项多中心、基于网络的调查，由包括肾脏病医生和重症医生在内的七个网络进行分发。参与危重症患者治疗的医生被邀请完成一项关于 KRT 液体管理实践的 39 个问题的调查。该调查于 2021 年 9 月至 2021 年 12 月期间分发。
来自 96 个国家的 757 名受访者（应答率为 65%）参与了调查。大多数受访者从事成人医学工作（89%），并在学术中心工作（69%）。当需要清除液体时，大多数受访者（91%）报告的目标是每天实现 0.5-2L 的负平衡，但他们认为安全的最大目标存在很大差异。与肾脏病医生相比，重症医生更有可能使用附加的容量状态评估方法（即超声、血流动力学标志物和腹腔内压），而肾脏病医生更有可能采取联合干预措施以提高对液体清除的耐受性（即渗透性药物和低温透析液）。人们广泛认为，当存在液体蓄积时应优先快速消肿，但也报告了防止低血压是一个竞争优先事项。大多数（77%）人同意，进行比较液体管理策略的试验将具有伦理和临床相关性。
我们已经确定了当前接受 KRT 治疗的患者液体管理实践中的多个变异性领域。大多数肾脏病医生和重症医生都认为，应该在未来的随机对照试验中研究与液体清除策略相关的几个知识差距。
