1 Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy, 2 Department of Intensive Care, University of Pittsburgh, Pittsburgh and 3 Department of Nephrology, USC at San Diego, San Diego, USA
Abstract
A new star is born. Its name is ADQI which stands for Acute Dialysis Quality Initiative. In the firmament of guidelines and directions for appropriate management of renal diseases, little has been done so far concerning acute renal failure and its treatment. For this reason we felt that a process seeking consensus and evidence-based statements in the field of acute renal failure was needed.
Introduction
An increasing number of patients develop acute renal failure each year, and mortality is still higher than 50% despite new treatment strategies. In recent years, there have been considerable advances in our understanding and technical capabilities, but consensus over the optimal way to deliver care does not exist. Consequently, we decided to initiate a process which will include a series of conferences and interactions with a large number of reviewers and experts. This process, termed Acute Dialysis Quality Initiative (ADQI), aims at establishing an evidence-based appraisal and set of consensus recommendations to standardize care and direct further research.
Continuous renal replacement therapy (CRRT) is being used at ever increasing rates worldwide. Today, approximately one quarter of all patients with acute renal failure is treated with CRRT. Despite the increasing use, there are presently no published standards for the application of this therapy and practice patterns vary widely between individual centres. Results from recent clinical trials on selection of dialysis membranes and dialysis dose, provide strong, yet conflicting evidence to guide therapy. Other areas of uncertainty have not been sufficiently addressed by clinical studies and directives for future research are needed. Finally, the success of multi-centred clinical trials in supportive care in the ICU (e.g. transfusion thresholds and ventilator management) have intensified and renewed interest in the study of supportive care methods as a major target for future research. These developments have set the stage for the first ADQI conference held in New York on 2830 August 2000. The conference focused on the application of CRRT in the critically ill patient with acute renal failure.
While the primary aim of this conference was to establish the methodology for the consensus process, the final objectives of ADQI are the development of evidence-based practice guidelines and directions for future research.
Since among the several controversial points concerning CRRT there is the question of who should be in charge of patient's care and what should be the specific contribution of intensive care and renal physicians, the founding group of ADQI in New York included a balanced group of clinicians and scientists of both these branches of medicine.
Chaired by John Kellum, Claudio Ronco and Ravindra Mehta as directors of the ADQI conference, the group featured seven intensivists (Drs Angus, Murray, Stewart, Corwin, Bellomo, Wensley, Schetz) and seven nephrologists (Drs Palevsky, Paganini, Leblanc, Bunchman, Levin, Depner and Davenport) (Figure 1). The group also included members from industry (Drs Tetta, Lazarus and Clark) and two representatives from the American National Institute of Health (Drs Star and Kimmel). Since the meeting took place in the US, the American Society of Nephrology and the Society of Critical Care Medicine endorsed the scientific event. Nevertheless, for the future we are very much looking forward to receiving further sponsorships and endorsement from other scientific societies in Europe and Asia and possibly to organize focused conferences of ADQI on different specific issues in various countries.
|
Specific objectives for this conference were:
Conference methodology
The overall conference methodology is summarized in Figure 2.
|
Conference activity part 1
The entire group was asked to consider methodology for the ADQI process. Specific tasks included the following.
Conference activities part 2
Breakout sessions were used for each group to catalogue and review the literature in each area and define areas of established consensus as well as areas where consensus is lacking. Each group reviewed pre-conference work and presented a draft set of statements that summarized the questions for their topic and the state of the current literature. The specific tasks for each group are listed below.
Post-conference activity and future plans
A writing committee will include the conference directors and one or two other members nominated by the group to compile the findings of the conference. This document will be completed as soon as all the necessary revisions will be made from the original drafts and will be posted on the internet (www.ADQI.net) for comment by the remainder of the participants. The period for comment will be limited in time and revisions will be made accordingly. The final product will be submitted as a manuscript for publication immediately following this process.
Conclusion
ADQI is an ongoing process that will compile evidence-based statements on different issues concerning acute dialysis. The first step was to try to reach consensus on CRRT, an area where major controversies are still present. The next step will be the development of consensus statements that should provide the basis for recommendations to be used in clinical practice. Our effort aims at obtaining a common ground where acute dialysis should be discussed and hopefully optimized. At the present time there is very little agreement on how much, when and how dialysis should be provided. We hope to move a little further with the co-operation of anyone who may be interested in helping and becoming temporary or permanent member of the commission for the development of the ADQI tasks.
Editor's note
Please see also Editorial Comment by A. M. Davison, p. 1535.
Acknowledgments
The ADQI directors would like to express their gratitude to Renal Research Institute for the organizational and scientific support to the first ADQI conference. The generous support of the sponsors should also be acknowledged. In particular we would like to thank: Baxter, Bellco, B. Braun, Fresenius Medical Care, Gambro, Kimal, Medica, Nextrom Med Tech and Renaltech.
Notes
Correspondence and offprint requests to: C. Ronco, Renal Research Institute, Division of Nephrology and Hypertension, 207 East 94th Street, New York, NY 10128, USA.