International survey on weaning from acute kidney replacement therapy in ICU patients

Dear colleague,

This anonymous survey explores how clinicans discontinue acute kidney replacement therapy (KRT) in adult ICU patients with acute kidney injury (AKI). We are fully aware of survey fatigue, and for this reason we designed this questionnaire to be as straightforward, focused, and time-efficient as possible. It should take about 8 to 10 minutes to complete. Your answers, based on your usual practice in the ICU you know best, will provide valuable insights into an important and still insufficiently explored area of critical care practice.

For this survey:
“Acute KRT” refers to KRT used in ICU for acute kidney injury, not chronic maintenance dialysis.
“A weaning attempt” means intentional discontinuation of acute KRT to assess whether native kidney function is sufficient, it refers to stopping acute KRT altogether, not to a transition from CRRT to IRRT
“Successful weaning” means no restart of acute KRT during the time period that you consider clinically relevant.

-Khalil Chaïbi MD., PhD. Departement of Bioinformatics, Harvard Medical School, Boston, USA; Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists

- Matthieu Legrand MD., PhD. Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA; Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists

- Stephane Gaudry MD., PhD. Intensive Care Unit, Avicenne Hospital, Bobigny, France; Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists

For any questions: khalil_chaibi@hms.harvard.edu

Q1 Country of practice

Q2 Primary specialty

Q3 Current position

Q4 Years in clinical practice in your current specialty (enter numbers only)

Q5 What best describes the hospital where you mainly practice?

Q5bis Type of ICU

Q6 Approximate number of ICU patients treated with acute KRT per month in your unit (enter numbers only)

Q7 Which KRT modalities are available in your ICU ?

Intermittent hemodialysis

Continuous KRT

Hybrid therapy (PIRRT, SLED, EDD)

Peritoneal dialysis

Q8 Who usually makes the decision to discontinue acute KRT ?

Q9 Is there a written local protocol for weaning of acute KRT ?

Q10 Which parameters do you routinely consider before attempting complete discontinuation of acute KRT ?

Urine output

Response to diuretics

Serum creatinine trend

Urinary urea excretion

Urinary creatinine excretion

Serum urea or azotemia

Potassium

Acid-base status

Fluid balance or fluid overload

Need for ongoing net ultrafiltration

Hemodynamic stability or vasopressor requirement

Respiratory status or pulmonary edema

Biomarkers (such as cystatin C or NGAL)

Time elapsed since KRT initiation

Other

Q11 Among the parameters you routinely consider, which ones most strongly influence your decision to attempt discontinuation of acute KRT? (Select up to 3 answers)

Urine output

Response to diuretics

Serum creatinine trend

Urinary urea excretion

Urinary creatinine excretion

Serum urea or azotemia

Potassium

Acid-base status

Fluid balance or fluid overload

Need for ongoing net ultrafiltration

Hemodynamic stability or vasopressor requirement

Respiratory status or pulmonary edema

Biomarkers (such as cystatin C or NGAL)

Time elapsed since KRT initiation

Other

Q12 In a patient not receiving diuretics, what minimum urine output usually makes you consider a weaning attempt? (in ml/24h)

Q12bis In a patient receving diurectics, what minimum urine output usually makes you consider a KRT weaning attempt ? (in ml/24h)

Q13 Independently of urine output, can persistent positive fluid balance lead you to continue KRT rather than attempt weaning ?

Q14 Do you ever use a structured diurectic challenge or a furosemide stress-type approach specifically to assess the likelihood of successful discontinuation of acute KRT?

Q15 Which operational strategy do you most commonly use when attempting complete discontinuation of KRT ?

Q16 In your everyday clinical practice, which definition best matches "successful weaning" ?

Q17 For a clinical trial or observational study, which definition would you prefer as the primary endpoint for succesful weaning ?

Q18 If acute KRT is restarted solely for fluid management after a weaning attempt, would you generally consider the initial weaning attempt a failure?

Q19 Compared with unnecessary continuation of KRT, premature discontinuation is in your view

Q20 In your view, what are the main harms of continuing KRT unnecessarily? (select up to 3 answers)

Catheter-related infection

Catheter-related thrombosis

Bleeding related to anticoagulation

Intradialytic hypotension

Electrolyte depletion, including hypophosphatemia

Drug or antibiotic removal

Delayed renal recovery

Workload or cost

Q21 After a weaning attempt, what most commonly triggers KRT restart in your practice? (select up to 3 answers)

Persistent oliguria or anuria

Fluid overload

Hyperkalemia

Metabolic acidosis

Rising urea or azotemia

Rising creatinine alone

Need for net ultrafiltration exceeding urine output

Hemodynamic deterioration

Overall clinical judgment based on several abnormalities rather than a single trigger

Q22 In your practice, after KRT discontinuation in a clinically stable patient with no immediate indication for KRT restart (in your judgment) when is the dialysis catheter most often removed?

Q23 What most often influences your decision to keep the dialysis catheter in place after discontinuation of acute KRT? (select up to 2 answers)

Risk of early acute KRT restart

Need to preserve vascular access

Pending procedure or bleeding risk

Local organizational practice

Nephrology input or shared decision-making