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Sustained Low Efficiency Dialysis
Dr Sidharth Kumar Sethi
Pediatric Nephrology
Kidney and Urology Institute
Medanta-The Medicity
INDIA
Outline
•
•
•
•
Need for SLED?
Technical Issues
Drug & Nutrition clearance
Current available evidence
– Adults
– Children
• Cost Considerations
• Pros & Cons
CRRT Cons!
• Cost
– Initial specialized machinery
– Running cost of lines & filters
– Replacement fluid
• Complexities
– Procedural
– Increased workload for already busy ICU nurses!
– Unexpected interruptions
SLED
• Lower solute clearance
maintained for longer periods of time (not
necessarily continuous)
– Hybrid therapies
– Prolonged intermittent renal replacement
therapy (PIRRT)
– Extended daily dialysis (EDD)
• Utilize IHD machinery with minor modifications
SLED
•
•
•
•
•
Lower cost
Simplicity
Convenience
Earlier attempts – 1980’s
Common form of RRT in ICU in Adults
P. Palvesky C JASN 2007, 2: 623
Ricci & Ronco NDT – 2006 21-690
Kudoh & Kilhara Jpn Cir J 1988
Nephron 1999
SLED vs CRRT vs IHD
SLED
Technical considerations
• Flexible options
– QD allowing low flows
– hybrid treatments
• Dedicated hybrid therapy screen
• Standard procedure for changing between HD &
hybrid therapy
SLED
• Fresenius 2008 – H (US)
• Hybrid – F 2008 K USA
• Gambro Artis
• Fresenius Genius
• NX stage system one
5008-H
SLED
Dialysate composition
• Bicarbonate proportioning system single pass
• Duration > 8 hrs
K – 4.0 meq/L, HCO3 24-28 meq/L, Ca 1.5-2.5 meq/L
• Duration < 8 hrs
K – 3.0 meq/L, HCo3 28-32 meq/L, Ca 1.5-2.5 meq/L
SLED
Prescription
• Circuit
– Standard extracorporeal tubing & dialyzers
• QB
– maximized to tolerance of the patient & extracorporeal circuit clotting
• Anticoagulation
– lower QB used  clotting
– Heparin; Citrate dialysate
– Frequent saline flush
Tu & Ahmad. Dial Trans. 2000,29:620
Madison et al . JASN 2005
SLED
Ultrafiltration rate
Goals
– Clinical need & tolerance
– Cardiovascular stability
SLED
Electrolyte & Nutritional Considerations
• Alkalosis
• Hypophosphatemia – Phosphate supplement
• No albumin losses
– amino acid losses of 6.2-15.7 gms in adults
Kidney Int. 2001;60(2):777.
Intensive Care Med. 1997;23(1):110.
SLED
Drug clearance
• Considerable – in between IHD & CRRT
• Used for drug toxicity
Kielstein et al Crit. Care Med 2006; 34-51
Lund B et al
NDT 2005; 20:1483
NDT Plus (2008) 1 (5): 329-332.
Drug Pharmacokinetics
• Removal
• Intermittent nature
– High water solubility
– Low molecular weight
(<500 dalton)
– Small Vd (<1 l ⁄ kg)
– Minimal protein
binding
– Vancomycin
• total reduction-36% (8 hr
treatment)
• Below therapeutic window
at end of 8 hrs
• Removal maximum during
1st 4 hrs
• Rebound less
Golestaneh. Clin Nephrol 2009;72:286-291
Mushatt DM et al. Clin Infect Dis
2009;49:433–437
Dosage after therapy
Therapeutic drug monitoring
SLED
Cost
5 – 8 times less expensive than CRRT
SLED/SLED-F 100$
CRRT 500$ + ongoing costs
Alam et al AJKD 2000
Ma T et al – Nephrology 2000
Berbace KI 2006
Nursing responsibilities for SLED vs CRRT
Hybrid
HD nurse/Tech.
CRRT
ICU nurse
HD nurse/Tech.
ICU nurse
Setup
+
-
+
+
Initiation
+
-
+
+
Inservice ICU
N/R
N/R
+
+
Access Care
N/R
N/R
+
+
Troubleshooting
+
+
+
+
Extracorporeal circuit or
hemodialyzer change
+
-
+
-
Routine discontinuation
+
-
+
+
Emergency continuation
+
-
+
+
Clearance
+
+
+
+
N/R
N/R
+
+
+
-
+
+
N/R
N/R
+
+
Blood draws
Hourly monitoring
Anticoagulation monitoring
Nursing responsibilities for SLED vs CRRT
Hybrid
HD nurse/Tech.
CRRT
ICU nurse
HD nurse/Tech.
ICU nurse
Setup
+
-
+
+
Initiation
+
-
+
+
Inservice ICU
N/R
N/R
+
+
Access Care
N/R
N/R
+
+
Troubleshooting
+
+
+
+
Extracorporeal circuit or
hemodialyzer change
+
-
+
-
Routine discontinuation
+
-
+
+
Emergency continuation
+
-
+
+
Clearance
+
+
+
+
N/R
N/R
+
+
+
-
+
+
N/R
N/R
+
+
Blood draws
Hourly monitoring
Anticoagulation monitoring
SLED vs CVVHD: Adult data
1600
1460
1400
1200
1000
1037
834
800
SLED
600
CVVHD
400
260
200
200
98
0
Year
2011
2012
Year
2012
2013
Year
2013
2014
International Pediatric Dialysis Survey
Bunchman T, USA; Sethi SK, India; Raina R, USA;
Askenazi D, USA; Akash Deep, UK
Cost of care provided
• Not insured
• Out of pocket
expenses
International Pediatric Dialysis Modality Survey
Bunchman T, USA; Sethi SK, India; Raina R, USA; Askenazi D,
USA; Akash Deep, UK
Choice of modality in unstable pediatric patients
International Pediatric Dialysis Modality Survey
Bunchman T, USA; Sethi SK, India; Raina R, USA; Askenazi D,
USA; Akash Deep, UK
Availability of SLED
International Pediatric Dialysis Modality Survey
Bunchman T, USA; Sethi SK, India; Raina R, USA; Askenazi D,
USA; Akash Deep, UK
SLED in Adults: Evidence
Pediatric SLED: Evidence?
Taiwan
<20Kg excluded
p<0.02
p=0.15
SLED appears to be a durable renal replacement
therapy for critically ill patients with AKI and
combines the therapeutic advantages of CRRT
with logistic & cost advantages of IHD
Need for more studies
Dialysis Modality Choice and Initiation – Global preferences.
McCulloch, Sethi, Xu. ‘Pediatric Kidney Disease’.