Debate at Kidney Week: Intensivist vs Nephrologist for Renal Replacement Therapy (RRT) in the ICU

By David White

A lively, but friendly, debate over RRT in the ICU took place late yesterday in a “Timely Debate” session before a standing-room only crowd. The format positioned Sean M. Bagshaw, MD, representing the role of the intensivist in the ICU, debating Paul M. Palevsky, MD, FASN, representing the role of the nephrologist. Dr. Bagshaw, who is an Associate Professor of Critical Care Medicine at the University of Alberta, took a decidedly humorous approach declaring himself “the most unpopular person at Kidney Week.” Not to be outdone, Dr. Palevsky, who is a renowned nephrologist and Chief of the Renal Section of the VA Pittsburgh Healthcare System, humorously countered that the reason he believes nephrologist should oversee RRT in the ICU was because “Well…duh. We’re nephrologists, that’s what we do!”

As the session progressed, a more serious and collaborative dialogue emerged. Dr. Bagshaw outlined his view, as an intensivist, of the ideal role of the nephrologist in the ICU as:

  1. Consultation for patients with kidney-specific diagnostic or management dilemmas
  2. Consultation for transition from CRRT to IRRT (where applicable)
  3. Consultation for transition of patients recovering from severe AKI or still RRT dependent to ward for ongoing care


Dr. Palevsky choose to redefine the question of “who should be the lead on RRT in the ICU” to a different query: “the question is therefore not simply who should control CRRT in the ICU, but what is the value that a nephrologist brings to the care of critically ill patients with AKI?” He explained that AKI is not a disease and that there are many forms of AKI and part of the nephrology skill set is to differentiate between the different “phenotypes” of AKI. Knowing when to wait to start RRT was another value of the nephrologist’s role he maintained and that established “indications” for RRT are nuanced such as volume overload, metabolic acidosis, hyperkalemia, and uremic symptoms.

After an exhaustive and persuasive presentation on the value of the nephrologist in the ICU, Dr. Palevsky expressed his views on what it means to “own” RRT in the ICU:

  • Availability
  1. The critically ill patient cannot be cared for on a 9-5 schedule
  • Collegiality
  1. Care of the critically ill patient is a team effort
  2. It serves no purpose to have battles over care
  • Expertise
  1. As nephrologists, we need to understand the world (and the world-view) of the intensivist
  • Continuous quality improvement
  1. This is a fundamental component of our care of ESRD patients
  2. We need to apply CQI to our care of AKI patients to optimize care and outcomes


After the session, ASN President Mark D. Okusa, MD, FASN, spoke with Kidney News Online, saying “We need to put the patient at the center of this discussion because, to care for these patients optimally, requires collaboration between the nephrologist and the intensivist when a patient with AKI is in the ICU.”

The presentation, which will be available on Kidney Week on Demand (available to full-paid annual meeting registrants in January 2019), extensively outlines the multi-faceted value and experience nephrologists bring to the treatment of AKI in the RRT. Consider downloading his presentation to help you better assert the value of nephrology in the ICU.

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Author:
David White
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A lively, but friendly, debate over RRT in the ICU took place late yesterday in a “Timely Debate” session before a standing-room only crowd. The format positioned Sean M. Bagshaw, MD, representing the role of the intensivist in the ICU, debating Paul M. Palevsky, MD, FASN, representing the role of the nephrologist. Dr. Bagshaw, who is an Associate Professor of Critical Care Medicine at the University of Alberta, took a decidedly humorous approach declaring himself “the most unpopular person at Kidney Week.” Not to be outdone, Dr. Palevsky, who is a renowned nephrologist and Chief of the Renal Section of the VA Pittsburgh Healthcare System, humorously countered that the reason he believes nephrologist should oversee RRT in the ICU was because “Well…duh. We’re nephrologists, that’s what we do!”

As the session progressed, a more serious and collaborative dialogue emerged. Dr. Bagshaw outlined his view, as an intensivist, of the ideal role of the nephrologist in the ICU as:

  1. Consultation for patients with kidney-specific diagnostic or management dilemmas
  2. Consultation for transition from CRRT to IRRT (where applicable)
  3. Consultation for transition of patients recovering from severe AKI or still RRT dependent to ward for ongoing care


Dr. Palevsky choose to redefine the question of “who should be the lead on RRT in the ICU” to a different query: “the question is therefore not simply who should control CRRT in the ICU, but what is the value that a nephrologist brings to the care of critically ill patients with AKI?” He explained that AKI is not a disease and that there are many forms of AKI and part of the nephrology skill set is to differentiate between the different “phenotypes” of AKI. Knowing when to wait to start RRT was another value of the nephrologist’s role he maintained and that established “indications” for RRT are nuanced such as volume overload, metabolic acidosis, hyperkalemia, and uremic symptoms.

After an exhaustive and persuasive presentation on the value of the nephrologist in the ICU, Dr. Palevsky expressed his views on what it means to “own” RRT in the ICU:

  • Availability
  1. The critically ill patient cannot be cared for on a 9-5 schedule
  • Collegiality
  1. Care of the critically ill patient is a team effort
  2. It serves no purpose to have battles over care
  • Expertise
  1. As nephrologists, we need to understand the world (and the world-view) of the intensivist
  • Continuous quality improvement
  1. This is a fundamental component of our care of ESRD patients
  2. We need to apply CQI to our care of AKI patients to optimize care and outcomes


After the session, ASN President Mark D. Okusa, MD, FASN, spoke with Kidney News Online, saying “We need to put the patient at the center of this discussion because, to care for these patients optimally, requires collaboration between the nephrologist and the intensivist when a patient with AKI is in the ICU.”

The presentation, which will be available on Kidney Week on Demand (available to full-paid annual meeting registrants in January 2019), extensively outlines the multi-faceted value and experience nephrologists bring to the treatment of AKI in the RRT. Consider downloading his presentation to help you better assert the value of nephrology in the ICU.

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Date:
Friday, October 26, 2018