Critical Care Nephrology in the ICU: A New Specialization?

Tejas P. Desai, MD


May 03, 2017

The Critical Role of the Nephrologist in the ICU

All too often, I hear from many people in and around nephrology that the field has stagnated. Many of the scientific breakthroughs in nephrology happened years ago, and today's perception is one of motionless existence.

Although we can debate the merits of this perception, what many don't see is that the nature of nephrology itself is in the midst of a transformation. Today, there is an increased focus on incorporating procedures into daily nephrology practice and combining facets of hospital medicine with the more traditional aspects of nephrology.

More opportunities exist for superspecialization in glomerular diseases and chronic dialysis. Whether it is "nephrology proceduralists," "nephrology hospitalists," or glomerular disease or dialysis specialists, these changes are slowly invalidating the perception that nephrology is an idle field within modern medicine. Indeed, the focus of this viewpoint is on an article written by Askenazi and colleagues[1] about another new change to our field: critical care nephrology.

Critical care nephrology may not be new to you, because many nephrologists already care for patients in intensive care units (ICUs). Perhaps what is new is the increasing acceptance of critical care nephrology as a distinct specialization in which the general nephrologist plays perhaps the most important role.

In their article, Askenazi and colleagues expeditiously note that the number of patients, severity of disease, and burden of acute kidney injury in the ICU are increasing. Critically ill patients require a different and unique type of kidney care that specialized nephrologists can best offer. Indeed, a dedicated team of healthcare providers is needed for all aspects of critical care, and the critical care nephrologist has a number of important roles within that team that she or he is well positioned to provide. The authors divide these roles into three areas: leadership, clinical care, and education.

Leadership. Every healthcare team needs leadership. Whether that comes from one or a group of individuals, leadership needs to have a vision for progress, be attentive to details, and orient the team toward predefined goals.

The specialized nephrologist is best suited to meet these demands and more in the critical care nephrology team. These nephrologists have the knowledge and experience to design protocols and procedures and are intimately familiar with executing quality improvement programs in all aspects of kidney care.

The authors deftly highlight these requirements and more as essential for the effective functioning of the critical care nephrology team. They note how general nephrologists currently perform or invaluably assist in these critical tasks outside of the ICU, specifically in both outpatient and inpatient dialysis units. Those skills are equally, if not more, valuable within the ICU when more aggressive and specialized kidney care is warranted.

Clinical Care. Critical care nephrologists are aptly suited for delivering dialytic and nondialytic treatment options for patients with acute kidney injury (AKI) and equally adept at transitioning between these two realms as a patient's condition changes.

Familiarity with acid/base homeostasis, electrolyte derangements, volume assessments, AKI biomarkers, and the effects of CRRT make critical care nephrologists essential teammates and terrific sources of knowledge.

The reasons are many, but include an in-depth and evolving knowledge of renal pathophysiology in AKI, early recognition of AKI on the basis of subtle clinical or biochemical clues, knowledge and experience with the effects and limitations of continuous renal replacement therapy (CRRT), and accurate prognostication of one's kidney health during and after the period of critical illness. Each of these reasons provides added value to the critical care nephrologist's role with the ICU team.

Education Successful practice of nephrology requires a level of physiologic understanding that may be matched by only a few medical disciplines. This level of understanding places nephrologists in an enviable role of teacher to many in the critical care nephrology team. Familiarity with acid/base homeostasis, electrolyte derangements, volume assessments, AKI biomarkers, and the effects of CRRT on the aforementioned make critical care nephrologists essential teammates and terrific sources of knowledge. The authors confirm what many of us already knew: Being a repository of on-demand knowledge is a vital component of the critical care team.

I encourage anyone who perceives nephrology as comfortably resting on its historical triumphs to read Askenazi and colleagues' article. Scientific breakthroughs, though common, are not the only measure of a field's dynamism. Perhaps out of necessity or a unique level of broad-mindedness, the field of nephrology is pursuing a commendable hybridization that, I believe, will improve the services that we will provide to our patients and colleagues.

Follow Tejas P. Desai, MD, on Twitter: @nephondemand
Follow Medscape Nephrology on Twitter for more Nephrology news @MedscapeKidney


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