Global heterogeneity and implementation gap in acute kidney injury prevention: Results from the AKI-PURIFY survey

Background Despite substantial advances in critical care nephrology, the real-world implementation of diagnostic tools and evidence-based preventive strategies for acute kidney injury (AKI) in critically ill patients remains poorly defined. Understanding the gap between guideline recommendations and bedside practice is essential to inform targeted quality-improvement initiatives. The AKI-PURIFY survey was designed to provide a contemporary international overview of AKI diagnosis and management in the ICU, with emphasis on implementation of the Kidney Disease: Improving Global Outcomes (KDIGO) preventive strategies and determinants with its adoption. We hypothesized that implementation of evidence-based preventive care varies across healthcare settings and is influenced by clinician training and organizational capacity. Methods AKI-PURIFY was a multicenter, international online survey endorsed by the European Society of Intensive Care Medicine (ESICM), conducted between February and April 2024. Healthcare professionals involved in intensive care unit (ICU) management of AKI were invited to participate. The survey explored diagnostic strategies, implementation of the KDIGO kidney prevention strategy, renal replacement therapy practices, and perceived organizational and educational barriers. Multivariable logistic regression analyses were conducted to identify factors independently associated with the use of diagnostic tools and the implementation of preventive strategies. Results A total of 703 respondents completed the survey. Routine implementation of the KDIGO kidney prevention strategy was reported by 36.3% of participants (47.0% among valid responses). Diagnostic practices varied across ICU and resource settings, and the use of AKI damage biomarkers remained low. In adjusted analyses, inadequate training (odds ratio [OR]=0.56, 95% confidence interval [CI]: 0.37 to 0.84, P =0.007) and higher organizational barrier scores (OR=0.78, 95% CI: 0.63 to 0.97, P =0.030) were independently associated with lower implementation. Clear income-level gradients were observed across diagnostic strategies, training adequacy, and organizational capacity. Conclusions Adoption of guideline-recommended AKI prevention strategies remains inconsistent worldwide and is influenced by modifiable educational and system-level factors. Addressing this gap will require coordinated, context-sensitive strategies integrating structured training and scalable quality-improvement frameworks.