Renal replacement therapy in the ICU: The Australian experience

The structure of health care drives medical practice in a powerful way, shaping choices of therapy and approaches, and influencing scientific evidence. The Australian experience with continuous renal replacement therapy (CRRT) confirms the importance of structure, A public health system like that of Australia's contains the following variables: well-developed intensive care tradition and expertise, a dominant ''closed'' intensive care unit (ICU) model, well-developed training of intensive care nurses with established one-to-one nurse-patient ratios, salaried medical practitioners, overworked general dialysis units with inadequate nursing resources, and lack of fee-for-service incentive for nephrologists to see ICU patients with acute renal failure, The likely outcome of such a system is for CRRT to be run by intensive care staff, As shown by a recent regional survey, this approach, although somewhat unique, is dominant and appears to work well with excellent clinical results and constant clinical research output. (C) 1997 by the National Kidney Foundation, Inc.