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The intent of ADQI is to provide an objective, dispassionate distillation
of the literature and description of the current state of practice of
dialysis and related therapies. The purpose is to develop a consensus
of opinion, with evidence where possible, on best practice and to articulate
a research agenda to focus on important unanswered questions. This approach
is a blend of "expert panel" and "evidence appraisal" and was chosen
in order to achieve the best of both methods. We recognize that the
expert panel in absence of the literature can lead to statements at
odds with high quality research and that evidence appraisal without
expert input to question the framework can lead to erroneous interpretation
(1). Furthermore, this combined approach has led to important practice
guidelines with wide acceptance and adoption into clinical practice
OBJECTIVES OF ADQI
The final objectives for ADQI are the following:
To obtain such these results, a first step was required and the first
ADQI conference was organized (New York on August 28-30, 2000) specifically
focusing on CRRT. The objectives for this first phase were:
- Standardize and possibly optimize the process of dialysis for the
critically ill patient
- Develop consensus recommendations for best practice
- Establish evidence based statements and possibly guidelines where
- Identify questions for future research and consider study design
- To describe the current clinical applications of CRRT (therapeutic
options, current practice, and evidence).
- To identify and prioritize issues within each CRRT topic requiring
standardization and to define current state of consensus.
- To propose a strategy to address unresolved issues (consensus development,
further research).(Fig 1)
Figure 1: *When conflicting studies were found, a full evaluation and
appraisal was recommended. Individual workgroups did not attempt to synthesize
and combine data from individual studies (meta-analysis) nor were attempts
made to adjudicate between individual studies on the basis of quality.
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RATIONALE FOR ADQI
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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 defined Acute Dialysis Quality Initiative
(ADQI). ADQI aims at establishing an evidence-based appraisal and set
of consensus recommendations to standardize care and direct further
CRRT is being used at ever increasing rates worldwide. Today, approximately
one quarter of all patients with acute renal failure are 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 centers. 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-centered clinical
trials in supportive care in the ICU (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
August 28-30, 2000. The conference focused on the application of continuous
renal replacement therapy (CRRT) in the critically ill patient with
acute renal failure.
While the primary aims of this conference was were to establish the
methodology for the consensus process, to describe current clinical
practice and to identify important clinical and research questions,
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 change 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 was constituted by a balanced group of scientists
of both branches.
THE FIRST ADQI CONFERENCE
PHOTO ALBUM FROM THE FIRST ADQI CONFERENCE IN NEW YORK
The Renal Research Institute of New York is the Organiser
of the First ADQI Conference and its Major Sponsor.
Chaired by John Kellum, Claudio Ronco and Ravindra Mehta as directors
of the ADQI conference, the group featured 7 intensivists (Drs Murray,
Stewart, Corwin, Bellomo, Skippen, Schetz and Angus) and 7 nephrologists
(Drs Paganini, Leblanc, Bunchman, Levin, Depner Palevsky and Davenport)
(figure 2). In the group a few members
from the industry (Drs Tetta, Lazarus and Clark) and two representatives
from the American National Institute of Health (Drs Star and Kimmel)
were included. Since the meeting took place in the US, the American
Society of Nephrology (represented by Dr. Palevsky) and the Society
of Critical Care Medicine (represented by Dr. Angus) 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. The Conference
in New York was hosted by the Renal Research Institute that we must
congratulate for the efficient organization and the excellent logistics.
Specific objectives for this conference were:
To establish a methodology for the development of a series of evidence
based recommendations on dialytic intervention in the ICU.
This methodological analysis included:
the systematic search for evidence in different areas based on review
and evaluation of the available literature;
the establishment of clinical and physiologic outcomes as well as measure
parameters to be utilized for comparison of different treatments;
the description of the current practice and the rationale for the use
of current techniques;
the analysis of areas in which evidence is lacking and future research
is required to obtain new valuable information.
To focus first on CRRT and define the topics that will require development
of evidence based guidelines. Summary statements were drafted by seven
different working groups to describe the current state of the art for
each topic. The covered topics were as follows:
Solute Control (Treatment Dose)
Operational characteristics (Convection/Diffusion)
Anticoagulation / Access
ADQI founding group
Clik the pictures
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ADQI CONFERENCE METHODOLOGY
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PRECONFERENCE ACTIVITY • CONFERENCE ACTIVITIES PART 1 • CONFERENCE ACTIVITIES PART 2 • POST-CONFERENCE ACTIVITY AND FUTURE PLANS
Given the multidisciplinary aspects of CRRT, a multidisciplinary group
(nephrologists and intensivists) was assembled. This group was organized
into smaller workgroups. Each workgroup was assigned a particular topic
area. Topics are shown in table one and were selected on the basis of
the following criteria:
Prevalence of the clinical problem
Variation in clinical practice
Potential influence on outcome
Potential for development of EBM guidelines
Availability of scientific evidence
Studies were identified via MEDLINE search, bibliographies of review
articles and participants' files. Searches were limited to English language
articles. However, articles written in other languages were used when
identified and presented by members of the group. Evidence was classified
according to levels per EBM methodology. Qualitative commentary was
provided when deemed necessary by the group. However, there was no critical
appraisal of individual studies during this phase. Outcomes were grouped
into the following major categories: physiologic (eg. blood pressure,
BUN, etc.), clinical (short-term morbidity/ mortality, long-term morbidity/mortality,
renal recovery, functional class/quality of life) and economic. Different
types of outcomes were considered separately for each area. Animal research
was not considered evidence except that it contributed to commentary.
Each work group was composed of three members, one who served as the
group facilitator. Summary statements were developed through a series
of breakout sessions where individual work group members were required
to identify key issues for which guidelines are needed and to classify
current state of consensus and identify supporting evidence for each
issue. Workgroup members were then required to present their findings
to the entire group, revising each statement as needed until a final
version was agreed upon. The responsibilities for presenting the findings
of the work group to the rest of the participants was shared by each
member on a rotating basis. Group facilitators revised work group findings
as needed after each plenary session. Directives for future research
were achieved by asking the participants to: a. identify deficiencies
in the literature, b. determine if more evidence is necessary, and c.
if more evidence is necessary, articulate general research questions.
When possible, pertinent study design issues were also considered. Conference
activities were divided into three steps: pre-conference, conference
and post-conference. In the pre-conference step, the methodology was
developed, work groups were assembled and assigned to specific topics
(Table 1). Each group identified a list of key questions, conducted
a systematic literature search and generated a bibliography of key studies.
During this stage, the scope of the conference was also defined and
some topics were excluded from this phase (Table 1). During the next
step, the conference itself, the methodology was approved by the group
and the conference was divided into breakout sessions where work groups
addressed the issues in their assigned topic area, and plenary sessions
where their findings were presented, debated and refined. During the
first plenary session, the key questions were discussed and debated.
Revised versions (some added, some deleted and others rewritten) of
each question were then presented at the second plenary. At this point
evidence was assembled for each question and summary statements was
were drafted. These statements were further refined in subsequent plenary
sessions until final versions were agreed upon. A writing committee
assembled the individual reports from the work groups. Each report was
edited to conform to a uniform style and for length. The final reports
were posted on the internet (www.ADQI.net) and mailed to each participant
for comment and revision. Finally, international consultants were identified
and reports were sent to them for comment. Once final reports were completed,
the writing committee summarized the individual reports into a final
conference document. In detail, the following steps can be summarized
to identify the first ADQI conference:
Each participant was part of a working group to cover a single topic.
Each member was required to perform the tasks listed below. Participants
were encouraged to communicate with other group members via Email or
other means in order to streamline their efforts and work collectively.
Participants were also encouraged to communicate with other experts
both locally and internationally.
1. Define a list of questions within the topic
For each topic, a list of questions was generated. For example under
membranes: "Which membranes should be used for CRRT?", "should bio-compatible
membranes be used for CRRT", "how often should filters be changed during
2. Perform a systematic literature search
Each participant was provided with a list of references from the directors.
Participants were required to perform their own literature search to
find any additional articles. Search strategy and terms had to be specified
and participants had to be prepared to defend any exclusion criteria.
In general, the trend was to be as broad and inclusive as possible.
3. Compile a bibliography
One complete set of references was brought to the meeting by the group
members. A bibliography was compiled prior to the meeting, and this
was organized in a single format used by JAMA (this is only to keep
the references in a single format).
4. Assess the current status of consensus
It was determined for local institutions and regions what questions
were already fairly settled vs. ones that were not. It was also determined
what questions will be likely to be answerable with current literature
vs. ones that have insufficient evidence. Each question was rated as
either: a. consensus already exists, b. data exists but controversy
and variability of practice is still present, c. insufficient evidence
is available. Note: we did not try to judge the quality of the evidence
at this stage.
CONFERENCE ACTIVITIES PART 1
The entire group was asked to consider methodology for the ADQI process.
Specific tasks included the following:
The incorporation of Evidence-based Medicine principles into the literature
review process. Definition of levels of evidence and terms to be used.
Definition of what the literature sources should be and how far back
the literature should be reviewed.
Determination of what clinical, physiologic, and health economic outcomes
should be considered evidence of effectiveness in clinical trials in
Definition of how, physiologic outcomes (e.g. arterial blood pressure)
should be rated in relation to clinical outcomes (e.g. survival, need
for long-term dialysis) and health economic outcomes (e.g. total costs,
length of hospitalization) in evidentiary tables used for further ADQI
Debate on the role of evidence from animal research in RRT.
Draft and review forms to be used for review of literature and data
Definition of how peer review should be done and who will be the peer
Discussion on how "best clinical practice" will be established in the
absence of evidence.
Determination of how consensus will be achieved on directions for future
Draft methodology statement.
Discuss who will be sponsoring bodies for overall effort and how we
will approach this issue
CONFERENCE ACTIVITIES PART 2
Breakout sessions were used for each group to catalog 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 present a draft set of statements that summarize the questions
for their topic and the state of the current literature. The specific
tasks for each group were:
Create a list of individuals to serve as consultants (for each topic)
for the final consensus
Develop the final list of questions and identify key evidence that should
be reviewed. (Each topic required a few the key references associated
Work groups rated the current status of the literature based on the
ratings above (a. b. or c. from above).
A summary statement listing what is needed to proceed further for each
question and the current state of the literature was drafted. The spokesperson
presented the draft summary statements and presented findings from any
Note, at this stage, we did not attempt to develop NEW consensus; that
will be covered in the second stage of the ADQI process. Instead, summary
statements listed questions, described current practices and noted the
presence or absence consensus already existing.
The entire group evaluated the statements and suggested revisions.
Final statements were drafted "on line" with all members present. A
2/3 majority vote was required to approve all statements. Indeed, unanimous
agreement existed for most.
POST-CONFERENCE ACTIVITY AND FUTURE PLANS
A writing committee will include the conference directors and 1-2 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
http://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.
In conclusion, ADQI is a moving process that will produce evidence - based
statements on different issues concerning acute dialysis. The first step
was to try to reach consensus on Continuous Renal replacement Therapies,
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 cooperation of anybody all who may be interested
in helping and becoming temporary or permanent members of the commission
for the development of the ADQI tasks.
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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 Renal Care, Kimal, Medica, Nextrom
Med Tech and Renaltech.
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Kellum JA, Ramakrishnan N, Angus D. Appraising and Using Evidence in
Critical Care. In, Grenvik A, Shoemaker PK, Ayers S, Holbrook (eds).
Textbook of Critical Care, W.B. Saunders Co, Philadelphia, 1999; Chapter
193; pp 2059-2069.
Chestnut RM. Implications of the guidelines for the management of severe
head injury for the practicing neurosurgeon. Surg Neurol 1998; 50:187-93.
National Kidney Foundation : KDOQI: www.kdoqi.org