Intensive Care Medicine

, Volume 33, Issue 9, pp 1563–1570 | Cite as

Continuous renal replacement therapy: A worldwide practice survey

The Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators
  • Shigehiko Uchino
  • Rinaldo BellomoEmail author
  • Hiroshi Morimatsu
  • Stanislao Morgera
  • Miet Schetz
  • Ian Tan
  • Catherine Bouman
  • Ettiene Macedo
  • Noel Gibney
  • Ashita Tolwani
  • Heleen Oudemans-van Straaten
  • Claudio Ronco
  • John A. Kellum



Little information is available regarding current practice in continuous renal replacement therapy (CRRT) for the treatment of acute renal failure (ARF) and the possible clinical effect of practice variation.


Prospective observational study.


A total of 54 intensive care units (ICUs) in 23 countries.

Patients and participants

A cohort of 1006 ICU patients treated with CRRT for ARF.


Collection of demographic, clinical and outcome data.

Measurements and results

All patients except one were treated with venovenous circuits, most commonly as venovenous hemofiltration (52.8%). Approximately one-third received CRRT without anticoagulation (33.1%). Among patients who received anticoagulation, unfractionated heparin (UFH) was the most common choice (42.9%), followed by sodium citrate (9.9%), nafamostat mesilate (6.1%), and low-molecular-weight heparin (LMWH; 4.4%). Hypotension related to CRRT occurred in 19% of patients and arrhythmias in 4.3%. Bleeding complications occurred in 3.3% of patients. Treatment with LMWH was associated with a higher incidence of bleeding complications (11.4%) compared to UFH (2.3%, p = 0.0083) and citrate (2.0%, p = 0.029). The median dose of CRRT was 20.4 ml/kg/h. Only 11.7% of patients received a dose of > 35 ml/kg/h. Most (85.5%) survivors recovered to dialysis independence at hospital discharge. Hospital mortality was 63.8%. Multivariable analysis showed that no CRRT-related variables (mode, filter material, drug for anticoagulation, and prescribed dose) predicted hospital mortality.


This study supports the notion that, worldwide, CRRT practice is quite variable and not aligned with best evidence.


Acute renal failure Critical illness Continuous renal replacement therapy Epidemiology Heparin Low-molecular-weight heparin 

Supplementary material

134_2007_754_MOESM1_ESM.doc (75 kb)
Electronic Supplementary Material (DOC 75K)
134_2007_754_MOESM2_ESM.doc (54 kb)
Electronic Supplementary Material (DOC 55K)


  1. 1.
    Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Ronco C, Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators (2005) Acute renal failure in critically ill patients. A multinational, multicenter study. JAMA 294:813–818PubMedCrossRefGoogle Scholar
  2. 2.
    Davenport A, Will EJ, Davidson AM (1993) Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med 21:328–338PubMedCrossRefGoogle Scholar
  3. 3.
    Uchino S, Bellomo R, Ronco C (2001) Intermittent versus continuous renal replacement therapy in the ICU: impact on electrolyte and acid–base balance. Intensive Care Med 27:1037–1043PubMedCrossRefGoogle Scholar
  4. 4.
    Bellomo R, Farmer M, Bhonagiri S, Porceddu S, Ariens M, M'Pisi D, Ronco C (1999) Changing acute renal failure treatment from intermittent hemodialysis to continuous hemofiltration: impact on azotemic control. Int J Artif Organs 22:145–150PubMedGoogle Scholar
  5. 5.
    Kruczynski K, Irvine-Bird K, Toffelmire EB, Morton AR (1993) A comparison of continuous arteriovenous hemofiltration and intermittent hemodialysis in acute renal failure patients in the intensive care unit. ASAIO 39:M778–781CrossRefGoogle Scholar
  6. 6.
    Rialp G, Roglan A, Betbese AJ, Perez-Marquez M, Ballus J, Lopez-Velarde G, Santos JA, Bak E, Net A (1996) Prognostic indexes and mortality in critically ill patients with acute renal failure treated with different dialytic techniques. Ren Fail 18:667–675PubMedGoogle Scholar
  7. 7.
    Swartz RD, Messana JM, Orzol S, Port FK (1999) Comparing continuous hemofiltration with hemodialysis in patients with severe acute renal failure. Am J Kidney Dis 34:424–432PubMedGoogle Scholar
  8. 8.
    Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P, La Greca G (2000) Effects of different doses in continuous veno–venous haemofiltration on outcomes of acute renal failure: a prospective randomized trial. Lancet 356:26–30PubMedCrossRefGoogle Scholar
  9. 9.
    Hakim RM, Wingard RL, Parker RA (1994) Effect of the dialysis membrane in the treatment of patients with acute renal failure. N Engl J Med 331:1338–1342PubMedCrossRefGoogle Scholar
  10. 10.
    Reeves JH, Cumming AR, Gallagher L, O'Brien JL, Santamaria JD (1999) A controlled trial of low-molecular-weight heparin (dalteparin) versus unfractionated heparin as anticoagulant during continuous venovenous hemodialysis with filtration. Crit Care Med 27:2224–2228PubMedCrossRefGoogle Scholar
  11. 11.
    Langenecker SA, Felfernig M, Werba A, Mueller CM, Chiari A, Zimpfer M (1994) Anticoagulation with prostacyclin and heparin during continuous venovenous hemofiltration. Crit Care Med 22:1774–1781PubMedCrossRefGoogle Scholar
  12. 12.
    Vargas Hein O, von Heymann C, Lipps M, Ziemer S, Ronco C, Neumayer HH, Morgera S, Welte M, Kox WJ, Spies C (2001) Hirudin versus heparin for anticoagulation in continuous renal replacement therapy. Intensive Care Med 27:673–679PubMedCrossRefGoogle Scholar
  13. 13.
    Kellum JA, Mehta RL, Angus DC, Palevsky P, Ronco C, ADQI Workgroup (2002) The first international consensus conference on continuous renal replacement therapy. Kidney Int 62:1855–1863PubMedCrossRefGoogle Scholar
  14. 14.
    Bellomo R, Honore PM, Matson J, Ronco C, Winchester J (2005) Extracorporeal blood treatment (EBT) methods in SIRS/Sepsis. Int J Artif Organs 28:450–458PubMedGoogle Scholar
  15. 15.
    Uchino S, Doig GS, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Nacedo E, Gibney N, Tolwani A, Ronco C, Kellum JA, Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators (2004) Diuretics and mortality in acute renal failure. Crit Care Med 32:1669–1677PubMedCrossRefGoogle Scholar
  16. 16.
    Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Doig GS, Oudemans van Straaten H, Ronco C, Kellum JA, Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators (2005) External validation of severity scoring systems for acute renal failure using a multinational database. Crit Care Med 33:1961–1967PubMedCrossRefGoogle Scholar
  17. 17.
    Uchino S, Cole L, Morimatsu H, Bellomo R (2002) Clearance of vancomycin during high volume hemofiltration: impact of pre-dilution. Intensive Care Med 28:1664–1667PubMedCrossRefGoogle Scholar
  18. 18.
    Himmelfarb J, Tolkoff Rubin N, Chandran P, Parker RA, Wingard RL, Hakim R (1998) A multicenter comparison of dialysis membranes in the treatment of acute renal failure requiring dialysis. J Am Soc Nephrol 9:257–266PubMedGoogle Scholar
  19. 19.
    Jaber BL, Lau J, Schmid CH, Karsou SA, Levey AS, Pereira BJ (2002) Effect of biocompatibility of hemodialysis membranes on mortality in acute renal failure: a meta-analysis. Clin Nephrol 57:274–282PubMedGoogle Scholar
  20. 20.
    Subramanian S, Venkataraman R, Kellum JA (2002) Influence of dialysis membranes on outcomes in acute renal failure: a meta-analysis. Kidney Int 62:1819–1823PubMedCrossRefGoogle Scholar
  21. 21.
    Jorres A, Gahl GM, Dobis C, Polenakovic MH, Cakalaroski K, Rutkowski B, Kisielnicka E, Krieter DH, Rumpf KW, Guenther C, Gaus W, Hoegel J (1999) Haemodialysis-membrane biocompatibility and mortality of patients with dialysis-dependent acute renal failure: a prospective randomised multicentre trial. International Multicentre Study Group. Lancet 354:1337–13341PubMedCrossRefGoogle Scholar
  22. 22.
    Kramer BK, Pickert A, Hohmann C, Liebich HM, Muller GA, Hablitzel M, Risler T (1992) In vivo clearance and elimination of nine marker substances during hemofiltration with different membranes. Int J Artif Organs 15:408–412PubMedGoogle Scholar
  23. 23.
    Bouman CS, van Olden RW, Stoutenbeek CP (1998) Cytokine filtration and adsorption during pre- and postdilution hemofiltration in four different membranes. Blood Purif 16:261–268PubMedCrossRefGoogle Scholar
  24. 24.
    Rogiers P, Zhang H, Pauwels D, Vincent JL (2003) Comparison of polyacrylonitrile (AN69) and polysulphone membrane during hemofiltration in canine endotoxic shock. Crit Care Med 31:1219–1225PubMedCrossRefGoogle Scholar
  25. 25.
    Gastaldello K, Melot C, Kahn RJ, Vanherweghem JL, Vincent JL, Tielemans C (2000) Comparison of cellulose diacetate and polysulfone membranes in the outcome of acute renal failure. A prospective randomized study. Nephrol Dial Transplant 15:224–230PubMedCrossRefGoogle Scholar
  26. 26.
    Morabito S, Guzzo I, Solazzo A, Muzi L, Luciani R, Pierucci A (2003) Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding. J Nephrol 16:566–571PubMedGoogle Scholar
  27. 27.
    Uchino S, Fealy N, Baldwin I, Morimatsu H, Bellomo R (2004) Continuous venovenous hemofiltration without anticoagulation. ASAIO J 50:76–80PubMedCrossRefGoogle Scholar
  28. 28.
    Hein OV, von Heymann C, Diehl T, Ziemer S, Ronco C, Morgera S, Siebert G, Kox WJ, Neumayer HH, Spies C (2004) Intermittent hirudin versus continuous heparin for anticoagulation in continuous renal replacement therapy. Ren Fail 26:297–303PubMedCrossRefGoogle Scholar
  29. 29.
    Monchi M, Berghmans D, Ledoux D, Canivet JL, Dubois B, Damas P (2004) Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med 30:260–265PubMedCrossRefGoogle Scholar
  30. 30.
    Kutsogiannis DJ, Gibney RT, Stollery D, Gao J (2005) Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 67:2361–2367PubMedCrossRefGoogle Scholar
  31. 31.
    Silvester W, Bellomo R, Cole L (2001) Epidemiology, management, and outcome of severe acute renal failure of critical illness in Australia. Crit Care Med 29:1910–1915PubMedCrossRefGoogle Scholar
  32. 32.
    Mehta RL, McDonald B, Gabbai FB, Pahl M, Pascual MT, Farkas A, Kaplan RM; Collaborative Group for Treatment of ARF in the ICU (2001) A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 60:1154–1163PubMedCrossRefGoogle Scholar
  33. 33.
    Saudan P, Niederberger M, De Seigneux S, Romand J, Pugin J, Perneger T, Martin PY (2006) Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int 70:1312–1317PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Shigehiko Uchino
    • 1
  • Rinaldo Bellomo
    • 2
    Email author
  • Hiroshi Morimatsu
    • 2
  • Stanislao Morgera
    • 3
  • Miet Schetz
    • 4
  • Ian Tan
    • 5
  • Catherine Bouman
    • 6
  • Ettiene Macedo
    • 7
  • Noel Gibney
    • 8
  • Ashita Tolwani
    • 9
  • Heleen Oudemans-van Straaten
    • 10
  • Claudio Ronco
    • 11
  • John A. Kellum
    • 12
  1. 1.Intensive Care Unit, Department of AnesthesiologyJikei University School of MedicineTokyoJapan
  2. 2.Department of Intensive Care and Department of MedicineAustin HospitalMelbourneAustralia
  3. 3.Department of NephrologyUniversity hospital CharitéBerlinGermany
  4. 4.Dienst Intensieve GeneeskundeUniversitair Ziekenhuis GasthuisbergLeuvenBelgium
  5. 5.Dept of Intensive Care MedicineSingapore General HospitalSingaporeSingapore
  6. 6.Adult Intensive Care UnitAcademic Medical CenterAmsterdamThe Netherlands
  7. 7.Nephrology DivisionUniversity of São Paulo School of MedicineSão PauloBrazil
  8. 8.Division of Critical Care MedicineUniversity of AlbertaEdmontonCanada
  9. 9.Department of Medicine, Division of NephrologyThe University of AlabamaBirminghamUSA
  10. 10.Intensive Care UnitOnze Lieve Vrouwe GasthuisAmsterdamThe Netherlands
  11. 11.Nephrology – Intensive CareSt. Bortolo HospitalVicenzaItaly
  12. 12.Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghUSA

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