sustained low efficiency dialysis dr sidharth kumar sethi pediatric nephrology kidney and urology...
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Sustained Low Efficiency Dialysis
Dr Sidharth Kumar SethiPediatric NephrologyKidney and Urology
InstituteMedanta-The Medicity
INDIA
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Outline
• Need for SLED?• Technical Issues• Drug & Nutrition clearance• Current available evidence
– Adults– Children
• Cost Considerations• Pros & Cons
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CRRT Cons!
• Cost– Initial specialized machinery
– Running cost of lines & filters
– Replacement fluid
• Complexities– Procedural
– Increased workload for already busy ICU nurses!
– Unexpected interruptions
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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
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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
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SLED vs CRRT vs IHD
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SLEDTechnical considerations
• Flexible options
– QD allowing low flows
– hybrid treatments
• Dedicated hybrid therapy screen
• Standard procedure for changing between HD &
hybrid therapy
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SLED
• Fresenius 2008 – H (US)
• Hybrid – F 2008 K USA
• Gambro Artis
• Fresenius Genius
• NX stage system one
5008-H
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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
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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
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SLEDUltrafiltration rate
Goals – Clinical need & tolerance – Cardiovascular stability
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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.
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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.
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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
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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
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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
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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
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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
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International Pediatric Dialysis Survey
Bunchman T, USA; Sethi SK, India; Raina R, USA; Askenazi D, USA; Akash Deep, UK
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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
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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
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Availability of SLED
International Pediatric Dialysis Modality Survey Bunchman T, USA; Sethi SK, India; Raina R, USA; Askenazi D, USA; Akash Deep, UK
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SLED in Adults: Evidence
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Pediatric SLED: Evidence?
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Taiwan <20Kg excluded
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p<0.02 p=0.15
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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’.