Sled dialysis

In the continuing dispute about the superiority of either intermittent or continuous renal replacement therapy for the critically ill, hybrid methods such as sustained low-efficiency dialysis (SLED) combining the advantages of both modalities - that is, excellent hemodynamic stability and low costs - receive growing attention. The study by Schwenger and colleagues is the first randomized trial indicating that there may be no significant difference in survival at 90 days between patients treated with SLED as compared with those treated with continuous veno-venous hemofiltration. A closer look at the study still leaves us with some hesitation. First of all, dialysis using a batch dialysis system requires a central dialysate preparation unit in a separate room with significant investments. The proportional costs for a single renal replacement therapy treatment depend on the number of machines in use as well as the number of treatments, and would be much higher for units with lower frequencies. Furthermore, insufficient purity of water and contamination of the dialysate have been a reported problem for dialysis units [ Therefore, although SLED holds some promise for becoming the new low-cost carrier for renal replacement therapy, we still need further stringent economic as well clinical evaluation of SLED compared with CRRT performed in a current state-of-the-art way before any general changes to treatment patterns can be recommended on solid grounds. • Schwenger V, Weigand MA...

OVERVIEW Continuous renal replacement therapy (CRRT) is the modality most widely used in Australia and New Zealand ICUs. There is no evidence suggesting mortality benefit for one modality over another (Cochrane Systemic Review) Abbreviations: • IHD = intermittent haemodialysis • CRRT = continuous renal replacement therapy • SLED = sustained low-efficiency dialysis or SLEDD =sustained low-efficiency daily dialysis • VD = volume of distribution PROS AND CONS OF DIFFERENT MODALITIES 1 2 3 4 IHD SLEDD CRRT Name Intermittent hemodialysis Slow (or sustained) low efficiency daily dialysis Continuous renal replacement therapy Mechanism and molecules removed Dialysis – mostly low MWt Small + middle molecules with SLEDD/F Small + middle molecules with CVVHDF Use • Ambulatory CRF • Hyperkalemia • Critically ill • Hyperkalemia • Critically ill • Non-ambulatory Blood flow 300 - 400 mL/min 100 - 150 mL/min 150 - 200 mL/min Dialysate flow • 500 mL/min • 30 L/h • 100-200 mL/min • 6-12 L/h • CVVHF: nil • CVVHDF: 1 L/h Efficiency High Moderate Low (but increased clearance of high VD molecules over time) Urea clearance (mL/min) 150 80 30 (CVVHDF) Hemodynamic stability Poor (hypotension common) Good Good Duration 3-4 h 3x/week 6-12 h daily Continuous (24h/filter) Access Fistula or vascath (must be good!) Fistula or vascath (must be good!) Vascath only Anticoagulation Not needed Usually not needed (if filter clots can lose ~150 mL blood) Important (if filter clots can lose ~150 mL blood) Dialy...

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Abstract Background. Sustained low-efficiency daily dialysis (SLEDD) is an increasingly popular renal replacement therapy for intensive care unit (ICU) patients. SLEDD has been previously reported to provide good solute control and haemodynamic stability. However, continuous renal replacement therapy (CRRT) is considered superior by many ICU practitioners, due first to the large amounts of convective clearance achieved and second to the ability to deliver treatment independently of nephrology services. We report on a program of sustained low-efficiency daily diafiltration (SLEDD- f) delivered autonomously by ICU nursing personnel, and benchmark solute clearance data with recently published reports that have provided dose–outcome relationships for renal replacement therapy in this population. Methods. SLEDD- f treatments were delivered using countercurrent dialysate flow at 200 ml/min and on-line haemofiltration at 100 ml/min for 8 h on a daily or at least alternate day basis. All aspects of SLEDD- f were managed by ICU nursing personnel. Clinical parameters, patient outcomes and solute levels were monitored. Kt/V, corrected equivalent renal urea clearance (EKRc) and theoretical Kt/V B12 were calculated. Results. Fifty-six SLEDD- f treatments in 24 critically ill acute renal failure patients were studied. There were no episodes of intradialytic hypotension or other complications. Observed hospital mortality was 46%, not significantly different from the expected mortality as...

It is a CVVHDF modality, with a prescribed rate of ultrafiltrate fluid removal • Blood flow rate: ~ 100-300 ml/min • Dialysate flow rate: ~ 100-300ml/min… typically 150 • Runs over 6-12 hours Those who cannot afford, or are unable to physically lift Critical Care Nephrology can find very helpful information in an older article by Mark Marshall et al (2001), or a more recent 2007 review by Tolwani et al. Cardinal features which distinguish SLED from CRRT Its neither IHD or CRRT; its a "hybrid" therapy. • Employs features of both IHD and CRRT • Runs for 6-12 hours • Blood flow rates 100-300ml/min • Dialysate does not come in pre-made bags: it is either generated from water that comes from a wall outlet, or it is mixed from pre-packaged electrolytes and sterile water. • "Single-pass" machines use a dialysate generated "on-line" from reverse osmosis purified water • "Batch" machines contain a huge tank ("batch") full of sterile water mixed with prepackaged salts. • The dialysate flow rate is usually about 300ml/min, particularly for shorter treatments. Advantages of SLED From basic principles, one can establish that • The sessions are shorter, and therefore the duration of exposure to anticoagulant is shorter. • The patient is off-circuit for a large portion of the day. In fact, most places perform nocturnal SLED so that the patient can be mobile and active during the day. • Haemodynamically, it is better tolerated than IHD. Furthemore, a good pro-SLEDD review has reported sev...

Background Sustained low efficiency dialysis (SLED) is increasingly used as a renal replacement modality in critically ill patients with acute kidney injury (AKI) and hemodynamic instability. SLED may reduce the hemodynamic perturbations of intermittent hemodialysis, while obviating the resource demands of CRRT. Although SLED is being increasingly used, few studies have evaluated its impact on clinical outcomes. Methods We conducted a cohort study comparing SLED (target 8 h/session, blood flow 200 mL/min, predominantly without anticoagulation) to CRRT in four ICUs at an academic medical centre. The primary outcome was mortality 30 days after RRT initiation, adjusted for demographics, comorbidity, baseline kidney function, and Sequential Organ Failure Assessment score. Secondary outcomes were persistent RRT dependence at 30 days and early clinical deterioration, defined as a rise in SOFA score or death 48 h after starting RRT. Results We identified 158 patients who initiated treatment with CRRT and 74 with SLED. Mortality at 30 days was 54 % and 61 % among SLED- and CRRT-treated patients, respectively [adjusted odds ratio (OR) 1.07, 95 % CI 0.56–2.03, as compared with CRRT]. Among SLED recipients, the risk of RRT dependence at 30 days (adjusted OR 1.36, 95 % CI 0.51–3.57) and early clinical deterioration (adjusted OR 0.73, 95 % CI 0.40–1.34) were not different as compared to patients who initiated CRRT. Conclusions Notwithstanding the limitations of this s...

Sustained low efficiency dialysis or SLED, is a recent hybrid dialysis methodology, which is increasingly used for patients with renal failure in the intensive care unit. Advantages: • Efficient clearance of small solutes • Good hemodynamic tolerability • Flexible treatment schedules • Lower costs • This form of treatment is a more viable alternative to traditional methods, in the case of critically ill patients Apollo dialysis clinic offers SLED in Bangalore, Delhi, Gurgaon, and Chennai. It is also available in tier 2 cities of Andhra Pradesh, Karnataka, Assam, Bihar, Telangana, and Tamil Nadu.