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.