Improving delivery and quality of renal replacement therapy in the ICU

Acute kidney injury (AKI) affects more than half of critically ill patients, and 10-15% require acute renal replacement therapy (RRT). Despite comparable outcomes among appropriately delivered RRT modalities, substantial practice variation persists due to differences in organizational structures, resources availability, and implementation of evidence-bases care. This review summarizes recent advances in quality improvement for acute RRT, including quality frameworks, key performance indicators (KPIs), and implementation science.

The Acute Disease Quality Initiative (ADQI) established a framework for evaluating acute RRT quality across structure, process, and outcome domains and developed consensus-based KPIs for continuous RRT (CRRT). Key CRRT quality measures include program leadership, education and training, filter life, treatment downtime, access alarms, dose-intensity, ultrafiltration, adverse events, RRT discontinuation, and ICU mortality. Institutional QI initiatives demonstrate that multidisciplinary collaboration, standardized protocols, electronic medical record integration, and continuous audit and feedback can improve treatment delivery, adherence to evidence-based practices, and resource utilization. Contemporary registries are generating data to validate KPIs, characterize practice variation, and establish performance benchmarks.

Quality improvement is essential for optimizing acute RRT delivery. Integrating standardized quality measurement with implementation science provides a practical framework to reduce practice variation, improve RRT delivery, and enhance patient outcomes.