Real-world management of dialysis-requiring acute kidney injury in Italy: a national survey of nephrology centers

Background Dialysis-requiring acute kidney injury (AKI-D) is a frequent and severe in-hospital complication associated with high mortality, long-term kidney sequelae, and substantial resource use. National data on AKI-D impact and service organization in Italy are limited. Methods We conducted a nationwide, web-based, 20-item survey endorsed by the Italian Society of Nephrology. We assessed care settings (dialysis units and other wards, including intensive care units [ICUs]), kidney replacement therapy (KRT) modalities in ICUs, staffing models, monitoring and anticoagulation strategies, and nephrologists' perspectives on barriers and priorities for improvement. Results Fifty-nine centers responded; analyses focused on 57 adult centers. AKI-D represented similar to 20% to >60% of dialysis-unit activity. KRT was frequently delivered outside nephrology wards, most often in cardiac intensive care units (94%) and emergency departments (50.8%). In ICUs, nephrologists primarily prescribed KRT in 73.7% of centers; continuous KRT (CKRT) was available in 94.7%, and regional citrate anticoagulation was first-line in 82.5%. Dialysis dose was reassessed daily in 55.2% of centers. Routine antibiotic therapeutic drug monitoring during CKRT was available in 30.3%, and in 22.8% dedicated post-AKI outpatient clinics. Most indicators were similar between center types; however, structured antibiotic therapeutic drug monitoring during CKRT was more frequently available in University and Hub centers than in Spokes (43.5 vs 31.6 vs 7.1%, respectively, P = .031). Respondents highlighted heterogeneous protocols, limited dedicated staffing, and gaps in multidisciplinary coordination. Conclusions AKI-D care in Italy is widespread but organizationally heterogeneous across settings, responsibilities, and key operational practices. Standardized pathways, training, and measurable monitoring tools are key priorities for improvement.