Sustained Low Efficiency Dialysis

Dr Sidharth Kumar SethiPediatric NephrologyKidney and Urology

InstituteMedanta-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: 623Ricci & Ronco NDT – 2006 21-690Kudoh & Kilhara Jpn Cir J 1988 Nephron 1999

SLED vs CRRT vs IHD

SLEDTechnical 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

SLEDDialysate 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

SLEDPrescription

• Circuit – Standard extracorporeal tubing & dialyzers

• QB – maximized to tolerance of the patient &

extra-corporeal circuit clotting• Anticoagulation

– lower QB used clotting– Heparin; Citrate dialysate– Frequent saline flush

Tu & Ahmad. Dial Trans. 2000,29:620Madison et al . JASN 2005

SLEDUltrafiltration rate

Goals – Clinical need & tolerance – Cardiovascular stability

SLEDElectrolyte & 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.

SLEDDrug 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 – High water

solubility– Low molecular

weight (<500 dalton)

– Small Vd (<1 l ⁄ kg) – Minimal protein

binding

• Intermittent nature– Vancomycin

• total reduction-36% (8 hr treatment)

• Below therapeutic window at end of 8 hrs

• Removal maximum during 1st 4 hrs

• Rebound lessGolestaneh. Clin Nephrol 2009;72:286-291Mushatt DM et al. Clin Infect Dis

2009;49:433–437

Dosage after therapyTherapeutic drug monitoring

SLEDCost

5 – 8 times less expensive than CRRTSLED/SLED-F 100$CRRT 500$ + ongoing costs

Alam et al AJKD 2000Ma T et al – Nephrology 2000Berbace KI 2006

Hybrid CRRT

HD nurse/Tech. 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 + + + +Blood draws N/R N/R + +Hourly monitoring + - + +Anticoagulation monitoring N/R N/R + +

Nursing responsibilities for SLED vs CRRT

Hybrid CRRT

HD nurse/Tech. 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 + + + +Blood draws N/R N/R + +Hourly monitoring + - + +Anticoagulation monitoring N/R N/R + +

Nursing responsibilities for SLED vs CRRT

SLED vs CVVHD: Adult data

834

1037

1460

260 20098

0

200

400

600

800

1000

1200

1400

1600

Year 2011 Year 2012 Year 2013

SLED

CVVHD

2012 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’.