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Publications

Journal Article Epublish

PubMed: 42221803 DOI: 10.1016/j.aicoj.2026.100077

Discrepancies between declared and real practices of continuous renal replacement therapy for septic acute kidney injury in French intensive care units.

Ann Intensive Care 16:100077

Authors: Loïz Stephan, Renaud Prevel, Charline Sazio, Hugo Ilciukas-Miquel, Adrien Auvet, Simon Bodot, Riad Chelha, Valentin Coirier, Xavier Fabre, Aude Garin, Jimmy Garraud, Chloé Gisbert-Mora, Guillaume Grillet, Jan Hayon, Guylaine Labro, Alexis Lambour, Théophile Lancrey-Javal, Eliott Le Basnier, Marc Mikulski, Jonathan Nicolas, Kévin Olry, Fabienne Plouvier, Thierry Seguin, Audrey Tientcheu, Marc Valette, Olivier Guisset, Didier Gruson, Alexandre Boyer, Arthur Orieux

Affiliations

  • Service de Médecine Intensive Réanimation, CHU de Bordeaux, France.
  • Univ Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm U1045, F-33000 Bordeaux, France.
  • Service de Réanimation - CH de Dax, Dax, France.
  • Service de Réanimation - CH de Pau, Pau, France.
  • Service de Réanimation - Hôpital Claude Galien, Quincy-Sous-Sénart, France.
  • Service de Médecine Intensive Réanimation - CHU de Rennes, Rennes, France.
  • Service de Réanimation - CH de Roanne, Roanne, France.
  • Service de Médecine Intensive Réanimation - CH de Dreux, France.
  • Service de Médecine Intensive Réanimation - CHU de Clermont-Ferrand, Clermont-Ferrand, France.
  • Service de Réanimation - CH Côte Basque, Bayonne, France.
  • Service de Réanimation Polyvalente - GHBS site du Scorff, Lorient, France.
  • Service de Médecine Intensive Réanimation - CHI Poissy Saint-Germain-en-Laye, Poissy, France.
  • Service de Médecine Intensive Réanimation, GHR Mulhouse et Sud Alsace, Mulhouse, France.
  • Service de Médecine Intensive Réanimation - CHU de Amiens, Amiens, France.
  • Service de Médecine Intensive Réanimation - CHU de Nantes, Nantes, France.
  • Service de Réanimation - CH Le Mans, Le Mans, France.
  • Service de Réanimation - CHT Gaston-Bourret, Nouméa, France.
  • Service de Médecine Intensive Réanimation - CHU Rouen, Rouen, France.
  • Service de Réanimation - CH Émile Durkheim, Épinal, France.
  • Service de Réanimation - CH Agen Nérac, Agen, France.
  • Service de Réanimation - CHU de Toulouse, Toulouse, France.
  • Service de Médecine Intensive Réanimation - CHU de Saint Étienne, Saint Étienne, France.
  • Service de Réanimation - CHU de Guadeloupe, Les Abymes, France.
  • Univ Bordeaux, Biology of Cardiovascular Diseases, Inserm UMR 1034, F-33000 Bordeaux, France.

Abstract

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.

MeSH

Continuous Renal Replacement Therapy, Kidney, Biomarkers, Diuretics, Therapeutics, Intensive Care Units, Renal Replacement Therapy, Hemodynamics, Acute Kidney Injury, Weaning