Acute kidney injury (AKI) remains one of the most frequent and clinically significant complications among critically ill patients, affecting nearly half of those admitted to intensive care units (ICUs). AKI is associated with prolonged hospitalization, increased healthcare costs, long-term kidney dysfunction, and higher mortality. Over the past decade, advances in critical care nephrology and the publication of Kidney Disease: Improving Global Outcomes (KDIGO) guidelines have strengthened the evidence supporting structured preventive approaches aimed at reducing the incidence and severity of AKI. However, whether these evidence-based strategies are consistently implemented in routine clinical practice have remained uncertain.
The AKI-PURIFY survey was designed to explore this gap between evidence and real-world implementation. Conducted between February and April 2024 and endorsed by the European Society of Intensive Care Medicine (ESICM), the survey collected responses from 703 healthcare professionals involved in ICU care across multiple countries and healthcare settings. Participants included intensivists, nephrologists, ICU consultants, fellows, nurses, and advanced practitioners working in general, medical, cardiac, neurocritical, pediatric, and post-surgical ICUs.
The survey focused on four major domains: AKI diagnostic strategies, implementation of KDIGO preventive measures, renal replacement therapy (RRT) practices, and organizational or educational barriers affecting care delivery. The results revealed substantial variability in all domains, highlighting the persistence of a significant implementation gap in AKI prevention worldwide.
One of the most important findings was the relatively low uptake of structured KDIGO preventive strategies. Although strong randomized evidence now supports the use of kidney-protective bundles in high-risk patients, only approximately one-third of all respondents reported routine implementation. Even among clinicians who answered the specific question regarding KDIGO strategies, fewer than half stated that these preventive measures were regularly applied. This finding is particularly relevant because recent trials, including biomarker-guided approaches, such as BigpAK-2, demonstrated that structured preventive strategies can significantly reduce moderate-to-severe AKI without increasing adverse events.
The survey also identified marked heterogeneity in diagnostic approaches. Traditional urinalysis was more frequently used in lower-income settings and pediatric ICUs, while adoption of advanced AKI biomarkers remained limited overall. Nephrologists and clinicians with greater ICU experience reported higher utilization of diagnostic tools, suggesting that both expertise and training influence clinical practice. Despite increasing interest in biomarker-guided prevention, the survey showed that implementation remains constrained by factors such as cost, local availability, workflow integration, and uncertainty regarding cost-effectiveness.
Importantly, educational and organizational barriers emerged as major determinants of implementation. Clinicians reporting inadequate training were significantly less likely to adopt both urinalysis and KDIGO preventive strategies. Similarly, higher organizational barrier scores—including the absence of ICU audit systems and difficulties in fluid balance management—were independently associated with lower implementation rates. These findings underline that publication of guidelines alone is insufficient to achieve meaningful changes in bedside practice. Sustainable improvement requires structured education, institutional support, audit-and-feedback systems, and interdisciplinary collaboration between intensivists and nephrologists.
The survey further highlighted disparities across healthcare systems. Respondents from lower-middle and low-income countries reported higher rates of inadequate training and greater organizational barriers compared with colleagues in high-income settings. These gradients suggest that inequities in infrastructure, workforce training, and resource availability may contribute to the unequal adoption of evidence-based AKI care globally.
The AKI-PURIFY survey therefore offers important insights into the current state of AKI prevention and management in ICUs worldwide. While advances in evidence generation continue to shape the field, translating evidence into routine practice remains a major challenge. Addressing this implementation gap will require coordinated, context-sensitive strategies that integrate education, quality improvement, organizational support, and scalable diagnostic pathways. Ultimately, improving global AKI outcomes depends not only on scientific progress but also on ensuring equitable and sustainable implementation of guideline-recommended care across diverse healthcare environments.
Reference
DOI: https://doi.org/10.1016/j.jointm.2026.04.005
About the University
The University of Trento is a leading Italian public research university recognized for excellence in education, scientific innovation, and international collaboration. Founded in 1962, the university promotes interdisciplinary research across medicine, engineering, social sciences, and technology, with a strong commitment to advancing translational and evidence-based healthcare. Through its Centre for Medical Sciences (CISMed), the University of Trento supports high-impact clinical and critical care research aimed at improving patient outcomes and global health practices.
Website: https://www.unitn.it/it
About Silvia De Rosa, Associate Professor in Anesthesiology, University of Trento
Dr. Silvia De Rosa is an Associate Professor in Anesthesiology at the Centre for Medical Sciences (CISMed), University of Trento, and a consultant anesthesiologist and intensivist at Santa Chiara Hospital in Trento, Italy. Her research focuses on acute kidney injury (AKI), extracorporeal organ support, critical care nephrology, sepsis, and intensive care medicine. She has authored more than 160 peer-reviewed international publications and has an h-index of 30. Dr. De Rosa collaborates with several leading international critical care and nephrology networks and has contributed to multiple consensus statements and multicenter studies in AKI prevention and renal replacement therapy.
Funding information
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
