The hemodynamic tolerability and feasibility of sustained low efficiency dialysis in the management of critically ill patients with acute kidney injury

Heather E Fieghen,Ron Wald,Jan O Friedrich,Stephen E Lapinsky,Robert M Richardson,Neill K Adhikari,Karen E Burns,Rosane Nisenbaum,Michelle A Hladunewich,University Of Toronto Acute Kidney Injury Research Group

doi:10.1186/1471-2369-11-32

Abstract

BackgroundMinimization of hemodynamic instability during renal replacement therapy (RRT) in patients with acute kidney injury (AKI) is often challenging. We examined the relative hemodynamic tolerability of sustained low efficiency dialysis (SLED) and continuous renal replacement therapy (CRRT) in critically ill patients with AKI. We also compared the feasibility of SLED administration with that of CRRT and intermittent hemodialysis (IHD).MethodsThis cohort study encompassed four critical care units within a single university-affiliated medical centre. 77 consecutive critically ill patients with AKI who were treated with CRRT (n = 30), SLED (n = 13) or IHD (n = 34) and completed at least two RRT sessions were included in the study. Overall, 223 RRT sessions were analyzed. Hemodynamic instability during a given session was defined as the composite of a > 20% reduction in mean arterial pressure or any escalation in pressor requirements. Treatment feasibility was evaluated based on the fraction of the prescribed therapy time that was delivered. An interrupted session was designated if < 90% of the prescribed time was administered. Generalized estimating equations were used to compare the hemodynamic tolerability of SLED vs CRRT while accounting for within-patient clustering of repeated sessions and key confounders.ResultsHemodynamic instability occurred during 22 (56.4%) SLED and 43 (50.0%) CRRT sessions (p = 0.51). In a multivariable analysis that accounted for clustering of multiple sessions within the same patient, the odds ratio for hemodynamic instability with SLED was 1.20 (95% CI 0.58-2.47), as compared to CRRT. Session interruption occurred in 16 (16.3), 30 (34.9) and 11 (28.2) of IHD, CRRT and SLED therapies, respectively.ConclusionsIn critically ill patients with AKI, the administration of SLED is feasible and provides comparable hemodynamic control to CRRT.

Highlights

Minimization of hemodynamic instability during renal replacement therapy (RRT) in patients with acute kidney injury (AKI) is often challenging
We evaluated the relationship between RRT modality (SLED vs continuous renal replacement therapy (CRRT)) and hemodynamic instability using generalized estimating equations, in order to account for intra-patient clustering associated with the receipt of repeated RRT sessions
We identified 34 patients who were predominantly treated with intermittent hemodialysis (IHD), 30 with CRRT and 13 with sustained low efficiency dialysis (SLED)

Summary

Introduction

Minimization of hemodynamic instability during renal replacement therapy (RRT) in patients with acute kidney injury (AKI) is often challenging. We examined the relative hemodynamic tolerability of sustained low efficiency dialysis (SLED) and continuous renal replacement therapy (CRRT) in critically ill patients with AKI. Acute kidney injury (AKI) is a frequent complication of critical illness, and is associated with high mortality and morbidity [1]. Continuous renal replacement therapy (CRRT) has been advocated in hemodynamically unstable patients as need for circuit anticoagulation and associated monitoring, patient immobility, intensive nursing requirements and higher overall costs [12,13,18]. Several studies have demonstrated that SLED is well tolerated in critically ill patients, with comparable ultrafiltration and solute removal to CRRT [12,13,14,15,16]

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Discussion

Conclusion