Sustained Low-efficiency Daily Dialysis Research Articles

Switching from continuous veno-venous hemodiafiltration to intermittent sustained low-efficiency daily hemodiafiltration (SLED-f) in pediatric acute kidney injury: A prospective cohort study.

Continuous kidney replacement therapy (CKRT) is the preferred modality in critically ill children with acute kidney injury. Upon improvement, intermittent hemodialysis is usually initiated as a step-down therapy, which can be associated with several adverse events. Hybrid therapies such as Sustained low-efficiency daily dialysis with pre-filter replacement (SLED-f) combines the slow sustained features of a continuous treatment, ensuring hemodynamic stability, with similar solute clearance along with the cost effectiveness of conventional intermittent hemodialysis. We examined the feasibility of using SLED-f as a transition step-down therapy after CKRT in critically ill pediatric patients with acute kidney injury. A prospective cohort study was conducted in children admitted to our tertiary care pediatric intensive care units with multi-organ dysfunction syndrome including acute kidney injury who received CKRT for management. Those patients receiving fewer than two inotropes to maintain perfusion and failed a diuretic challenge were switched to SLED-f. Eleven patients underwent 105 SLED-f sessions (mean of 9.55 +/- 4.90 sessions per patient), as a part of step-down therapy from continuous hemodiafiltration. All (100%) our patients had sepsis associated acute kidney injury with multiorgan dysfunction and required ventilation. During SLED-f, urea reduction ratio was 64.1 +/- 5.3%, Kt/V was 1.13 +/- 0.1, and beta-2 microglobulin reduction was 42.5 +/-4%. Incidence of hypotension and requirement of escalation of inotropes during SLED-f was 18.18%. Filter clotting occurred twice in one patient. SLED-f is a safe and effective modality for use as a transition therapy between CKRT and intermittent hemodialysis in children in the PICU.

Utility of Citrate Dialysis in Patients with Contraindication for Heparin in a Limited-Resource Setting

Background: Hemodialysis among critical care patients with acute kidney injury (AKI) is challenging, especially if heparin is contraindicated. Objectives: This study assessed the utility of citrate dialysis for such patients in a limited-resource setting. Methods: In this prospective study, patients were divided into group A (heparin-free saline flush dialysis), group B (heparin-free citrate dialysis without flushing), and group C (heparin-free citrate dialysis with flushing). The subjects underwent completed sustained low-efficiency daily dialysis (blood flow = 150 mL/minute, dialysate = 300 mL/minute) or intermittent hemodialysis (blood flow = 250 mL/minute, dialysate flow = 500 mL/minute). Statistical tests using SPSS software (version 26) were used to determine safety and effectiveness differences. Results: Among 25 patients studied with multiple hemodialysis sessions, blood flow and dialysate flow were observed to be better in heparin-free citrate dialysis with flushing. There were further advantages of lesser dialyzer clotting and more reuse of dialyzers. Metabolic differences were insignificant. Heparin-free citrate dialysis with or without flushing was equally effective and safe, compared to heparin-free saline flush dialysis, in patients with or without liver impairment. Conclusions: Citrate dialysis is observed to be a safe and effective alternative to heparin-free saline flushing dialysis in intensive care unit patients with AKI. More such studies are required in limited-resource settings to utilize citrate dialysis in patients with heparin contraindication.

Abstract No.: ABS0279: Retrospective analysis of acute dialysis in ICU setting in a tertiary care hospital

Background and Aims:To study the clinical profile and evaluate in-hospital and 30-day mortality in patients undergoing acute dialysis in the intensive care unit (ICU) in a multi-disciplinary hospital.Methods:Thirty one consecutive patients who underwent acute dialysis between August 2020 and August 2021 in ICU were included in the study. All patients were evaluated with basic clinical assessment, laboratory investigations, indications for dialysis, the process of dialysis, the time lag for initiation of dialysis following the clinician’s orders, an increase in requirement of vasopressors following dialysis, and access for dialysis. Any other complications occurring during dialysis were also noted. All the patients were further evaluated with sequential organ failure assessment (SOFA) score and all the parameters mentioned above as possible predictors of in-hospital and 30-day mortality with logistic regression analysis.Results:Out of 31 patients, 17 had sepsis, six had acute febrile illness, and five had acute myocardial infarction, resulting in dialysis. Common indications were anuria >24 hours, pulmonary oedema, and severe metabolic acidosis. SOFA score was an independent predictor of both in-hospital (p = 0.03) and 30-day mortality (p = 0.048) with an increase of each unit, increasing the 30-day mortality by 1.5 times. Sustained low-efficiency daily dialysis (SLEDD) had 13.5 times higher mortality risk compared to ischaemic heart disease (IHD), inferring that patients with greater haemodynamic lability or vasopressor requirement had higher 30-day mortality.Conclusion:Sepsis remains the most common cause of dialysis in ICU, followed by acute febrile illness, including leptospirosis and dengue. Each unit of increase in SOFA score increases the 30-day mortality by 1.5 times in these patients. SLEDD was associated with a 13.5 times increased risk of mortality over IHD, inferring that patients with haemodynamic lability or vasopressor requirement had higher 30-day mortality.

Anticoagulation in patients with acute kidney injury undergoing kidney replacement therapy.

Kidney replacement therapy (KRT) is used to provide supportive therapy for critically ill patients with severe acute kidney injury and various other non-renal indications. Modalities of KRT include continuous KRT (CKRT), intermittent hemodialysis (HD), and sustained low efficiency daily dialysis (SLED). However, circuit clotting is a major complication that has been investigated extensively. Extracorporeal circuit clotting can cause reduction in solute clearances and can cause blood loss, leading to an upsurge in treatment costs and a rise in workload intensity. In this educational review, we discuss the pathophysiology of the clotting cascade within an extracorporeal circuit and the use of various types of anticoagulant methods in various pediatric KRT modalities.

Covid-19 and Renal Replacement Therapy: A Single-Center Perspective from Southern Italy

Introduction: The outbreak of cases of coronavirus disease (COVID-19), a very contagious disease, poses a serious threat to human health, especially in the elderly and in co-morbid populations like patients with kidney disease requiring renal replacement therapy (RRT). Furthermore, data about HD patients and how to best dialyze them during the COVID-19 pandemic are scarce. The aim of the study is to describe the organizational model and clinical outcomes of patients confirmed COVID-19 needing RRT, admitted in a COVID Hospital in Southern Italy. Methods: This study is a cohort study of hospitalized patients with COVID-19 enrolled at Miulli General Hospital, one of the major designated hospitals providing medical care for COVID-19 patients in the Apulia Region. We included all consecutive patients requiring RRT, either due to ESKD or AKI. Demographic data, information on clinical symptoms or signs at presentation, and laboratory results were extracted by the electronic medical record. A group of pair-matched COVID-19 patients, with normal renal function, were considered as controls. All the RRT sessions were performed with the Genius system. Results: From March 10 through May 24, 2020, Miulli Hospital admitted 217 patients with COVID-19 infection, including 11 (5%) maintenance HD and 29 critically ill patients (13.3%) referred for ICU admission, of whom 3 with AKI. Overall, 140 bedside treatments were performed in the COVID Hospital, 122 bicarbonate standard in 11 HD patients, and 18 sustained low-efficiency daily dialysis (SLEDD) in 3 patients with AKI. Mean session time and mean weekly sessions were 3.64 ± 0.40 hours, and 3.4 ± 0.45 HD/week; while session time has been 7.4 ± 0.58 hours for SLEDD. The phenotype and clinical symptoms at the admission were not different between HD patients and controls. Compared to non-HD, HD patients showed lower serum levels of inflammatory markers, but only C-reactive protein reached significant levels (p=0.030), and lower hospital stay (p=0.020). In-hospital mortality was not different between the two groups. All AKI patients showed a severe systemic hyperinflammation at the admission and died in ICU. Conclusions: Our data show that an organizational model based on the HD bedside with the Genius system, adopting the strict protocol, allows a personalized treatment with efficacy and safety for the patients and staff. The HD patients, SARS-Cov-2 infected, seem to have a lower inflammatory profile and shorter in-hospital stay compared with non-HD COVID-19 patients.

Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

BackgroundCritically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH).MethodsRetrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT.ResultsIn patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively.ConclusionsUFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment.Graphical abstract

Single-best Choice Between Intermittent Versus Continuous Renal Replacement Therapy: A Review.

Critically ill patients often develop multiorgan dysfunction syndrome. Acute kidney injury (AKI) is part of it. Renal replacement therapy (RRT) remains the primary choice of treatment in severely ill patients who develop AKI. Recent data have shown increased use of RRT in AKI patients. Therefore, the right choice of RRT plays an important role in the renal recovery of such patients. The question of which mode of RRT to apply has been the topic of study in the last two decades. Whether RRT should be conducted in intermittent mode, as intermittent hemodialysis (IHD), or in continuous mode, as continuous renal replacement therapy (CRRT), is still being investigated. CRRT has a hypothetical advantage when compared to IHD, as it involves a process in which there is gradual removal of fluids, better control of urea, better maintenance of the acid/base balance, and hemodynamic stability. However, IHD is more practical, cost-effective, does not require anticoagulation, decreases the bleeding risk, and removes the solute efficiently and rapidly in acute life-threatening conditions.Other modalities of RRT like sustained low-efficiency daily dialysis (SLEDD) and prolonged intermittent renal replacement therapy (PIRRT) have shown to encompass the benefits of both CRRT in terms of hemodynamic stability and IHD in terms of cost-efficiency. Although SLEDD is progressively being used as an alternative to CRRT and IHD, very few studies have shown to support it. In this article, we try to summarize the advantages and disadvantages of the different techniques used in RRT. With SLEDD gaining more popularity among the different modalities of RRT, we want to assess the possibility of its routine implementation as the single-best choice for RRT.

Elimination of Contrast Agent Gadobutrol with Sustained Low Efficiency Daily Dialysis Compared to Intermittent Hemodialysis

Background: In patients with renal failure, gadolinium-based contrast agents (GBCA) can be removed by intermittent hemodialysis (iHD) to prevent possible toxic effects. There is no data on the efficacy of GBCA removal via sustained low efficiency daily dialysis (SLEDD) which is mainly used in intensive care unit (ICU) patients. Methods: We compared the elimination of the GBCA gadobutrol in 6 ICU patients treated with SLEDD (6–12 h, 90 L dialysate) with 7 normal ward inpatients treated with iHD (4 h, dialysate flow 500 mL/min). Both groups received 3 dialysis sessions on 3 consecutive days starting after the application of gadobutrol. Blood samples were drawn before and after each session and total dialysate, as well as urine was collected. Gadolinium (Gd) concentrations were measured using mass spectrometry and eliminated Gd was calculated from dialysate and urine. Results: The initial mean plasma Gd concentration was 385 ± 183 µM for the iHD and 270 ± 97 µM for the SLEDD group, respectively (p > 0.05). The Gd-reduction rate after the first dialysis session was 83 ± 9 and 67 ± 9% for the iHD and the SLEDD groups, respectively (p = 0.0083). The Gd-reduction rate after the second and third dialysis was 94–98 and 89–96% for the iHD and the SLEDD groups (p > 0.05). The total eliminated Gd was 89 ± 14 and 91 ± 4% of the dose in the iHD and the SLEDD groups, respectively (p > 0.05). Gd dialyzer clearance was 95 ± 22 mL/min and 79 ± 19 mL/min for iHD and SLEDD, respectively (p > 0.05). Conclusions: Gd-elimination with SLEDD is equally effective as iHD and can be safely used to remove GBCA in ICU patients.

Side Effects of Long-Term Continuous Intra-arterial Nimodipine Infusion in Patients with Severe Refractory Cerebral Vasospasm after Subarachnoid Hemorrhage.

Long-term continuous intra-arterial nimodipine infusion (CIAN) is a rescue therapy option in cases of severe refractory cerebral vasospasm (CV) following acute non-traumatic subarachnoid hemorrhage (SAH). However, CIAN therapy can be associated with relevant side effects. Available studies focus on intracerebral complications, whereas extracerebral side effects are rarely examined. Aim of the present study was to generate descriptive data on the clinical course during CIAN therapy and expectable extracerebral side effects. All patients treated with CIAN therapy for at least 5days between May 2011 and December 2015 were included. We retrospectively extracted data from the patient data management system regarding the period between 2days before the beginning and 5days after the termination of CIAN therapy to analyze the course of ventilation parameters and pulmonary gas exchange, hemodynamic support, renal and liver function, integrity of the gastrointestinal tract, and the occurrence of infectious complications. In addition, we recorded the mean daily values of intracranial pressure (ICP) and intracerebral problems associated with CIAN therapy. Data from 28 patients meeting inclusion criteria were analyzed. The mean duration of long-term CIAN therapy was 10.5±4.5days. Seventeen patients (60.7%) reached a good outcome level (Glasgow Outcome Scale [GOS] 4-5) 6months after SAH. An impairment of the pulmonary gas exchange occurred only at the very beginning of CIAN therapy. The required vasopressor support with norepinephrine was significantly higher on all days during and the first day after CIAN therapy compared to the situation before starting CIAN therapy. Two patients required short-time resuscitation due to cardiac arrest during CIAN therapy. Acute kidney injury was observed in four patients, and one of them required renal replacement therapy with sustained low-efficiency daily dialysis. During CIAN therapy, 23 patients (82.1%) needed the escalation of a previous antiinfective therapy or the onset of antibiotics which was in line with a significant increase of C-reactive protein and white blood cell count. Obstipation was observed in 22 patients (78.6%). Ten patients (35.7%) even showed insufficient defecation on at least seven consecutive days. Compared to the situation before, ICP was significantly higher during the whole period of CIAN therapy. Long-term CIAN therapy is associated with diverse side effects. The leading problems are an impairment of the hemodynamic situation and cardiac problems, an increase in infectious complications, a worsening of the motility of the gastrointestinal tract, and rising ICP values. Teams on neurointensive care units must be aware of these side effects to avoid that the beneficial effects of CIAN therapy on CV reported elsewhere are foiled by the problems this technique can be associated with.

Comparative Study of Chronic Renal Failure Patients' Efficacy Between Sustained Low-efficiency Daily Dialysis (SLEDD) and Intermittent Hemodialysis (IHD)

Comparative Study of Chronic Renal Failure Patients' Efficacy Between Sustained Low-efficiency Daily Dialysis (SLEDD) and Intermittent Hemodialysis (IHD)

High Cut-Off Renal Replacement Therapy for Removal of Myoglobin in Severe Rhabdomyolysis and Acute Kidney Injury: A Case Series

Background/Aim: Rhabdomyolysis is associated with the release of myoglobin into the circulation, promoting acute kidney injury (AKI). In severe rhabdomyolysis, dialysis-dependent AKI doubles mortality. Standard blood purification techniques have limited efficacy in removing myoglobin. We describe high cut-off (HCO) renal replacement therapy (RRT) as a novel approach for extracorporeal elimination of myoglobin in rhabdomyolysis-associated AKI. Methods: With an in vivo molecular cut-off at 45 kDa, HCO filters are effective in removing myoglobin (17.8 kDa). Clearances across standard and HCO filters using continuous or intermittent RRT are reviewed in a case series of 11 patients with severe rhabdomyolysis and dialysis-dependent AKI. Results: Median myoglobin clearance across standard high-flux filters was 3.3 (interquartile range 2.3–3.9) ml/min for sustained low-efficiency daily dialysis (SLEDD) batch hemodialysis (HD) and 3.7 (2.9–6.7) ml/min for conventional HD. Respective clearances using HCO filters (membrane surface area: 1.1 m²) were 21.7 (20.3–26.1) ml/min (SLEDD) and 44.2 (41.3–47.0) ml/min (HD). Corrected for filter size, up to 20-fold higher clearances were obtained using HCO filters, resulting in profound and sustained reduction of plasma myoglobin concentration. Conclusions: As a novel approach, HCO RRT allows for rapid and effective removal of myoglobin from the circulation. In light of the pathogenic role in AKI, reducing exposure of the kidney to myoglobin may improve renal recovery and patient outcome. Our data pave the way for prospective trials, addressing this issue.

70 Sustained Low Efficiency Daily Dialysis (SLEDD) in the ICU: Outcomes Compared to Intermittent Hemodialysis (IHD)

70 Sustained Low Efficiency Daily Dialysis (SLEDD) in the ICU: Outcomes Compared to Intermittent Hemodialysis (IHD)

Sustained Low-Efficiency Daily Dialysis as Renal Replacement Therapy for the Critically Ill

Understanding proper management of acute kidney injury (AKI) is important given that studies consistently demonstrate an increasing incidence rate of AKI in the critically ill. AKI carries a significant risk for mortality, which only increases if dialysis becomes a necessary treatment. It is not clear whether modalities other than conventional intermittent hemodialysis improve outcomes in AKI. Sustained low-efficiency daily dialysis (SLEDD) is a more recent extracorporeal treatment whose distinguishing characteristic is its hybrid integration of both continuous and intermittent hemodialysis modalities. Besides providing comparable hemodynamic stability through its decreased blood flow rate and extended hours of use, SLEDD is less complicated, is less expensive, and is convenient for staff and patient. As a result, its use in critical care is on the rise.

Adequacy Indices for Dialysis in Acute Renal Failure: Kinetic Modeling

Many aspects of the management of renal replacement therapy in acute renal failure (ARF), including the appropriate assessment of dialysis adequacy, remain unresolved, because ARF patients often are not in a metabolic steady state. The aim of this study was to evaluate a system of adequacy indices for dialysis in ARF patients using urea and creatinine kinetic modeling. Kinetic modeling was performed for two different fictitious patients (A and B) with characteristics described by the average parameters for two patient groups and for two blood purification treatments: sustained low efficiency daily dialysis (SLEDD) in Patient A and continuous venovenous hemofiltration (CVVH) in Patient B, based on data from a clinical report. Urea and creatinine generation rates were estimated according to the clinical data on the solute concentrations in blood. Then, using estimated generation rates, two hypothetical treatments were simulated, CVVH in Patient A and SLEDD in Patient B. KT/V, fractional solute removal (FSR) and equivalent renal clearance (EKR) were calculated according to the definitions developed for metabolically unstable patients. CVVH appeared as being more effective than SLEDD because KT/V, FSR, and EKR were higher for CVVH than SLEDD in Patients A and B. Creatinine KT/V, FSR, and EKR were lower and well correlated to the respective indices for urea. Urea and creatinine generation rates were overestimated more than twice in Patient A and by 30-40% in Patient B if calculated assuming the metabolically stable state than if estimated by kinetic modeling. Adequacy indices and solute generation rates for ARF patients should be estimated using the definition for unsteady metabolic state. EKR and FSR were higher for urea and creatinine with CVVH than with SLEDD, because of higher K.T and minimized compartmental effects for CVVH.

Pro/con debate: Continuous versus intermittent dialysis for acute kidney injury: a never-ending story yet approaching the finish?

The question of whether renal replacement therapy should be applied in an intermittent or continuous mode to the patient with acute kidney injury has been the topic of several controlled studies and meta-analyses. Although continuous renal replacement therapy (CRRT) has a theoretical advantage due to offering the opportunity to remove excess fluid more gradually, none of the several outcome studies that have been undertaken in the meanwhile was able to demonstrate its superiority over intermittent renal replacement therapy (IRRT). In the present article, therefore, questions are raised regarding which are the specific advantages of each strategy, and which are the specific populations that might benefit from their application. Although several advantages have been attributed to CRRT - especially more hemodynamic stability allowing more adequate fluid removal, better recovery of renal function, and more efficient removal of small and large metabolites - none of these could be adequately proven in controlled trials. CRRT is claimed to be better tolerated in combined acute liver and kidney failure and in acute brain injury. IRRT is more practical, flexible and cost-effective, allows the clinician to discontinue or to minimize anticoagulation with bleeding risks, and removes small solutes such as potassium more efficiently in acute life-threatening conditions. Sustained low-efficiency daily dialysis is a hybrid therapy combining most of the advantages of both options.

Treatment of metformin-associated lactic acidosis with sustained low-efficiency daily dialysis.

Sir, Sustained low-efficiency daily dialysis (SLEDD) is an intermittent prolonged dialysis modality which is increasingly used for the treatment of acute renal failure [1,2], as it combines most of the advantages of both the classic intermittent treatments and the continuous modalities in terms of safety, efficacy, haemodynamic stability and costs. GENIUS® 90 Therapy System (GENIUS) (Fresenius Medical Care, Bad Homburg, Germany) gained interest for application in SLEDD for the treatment of acute renal failure [1,2] as well as of acute drug intoxication [3–6]. No published experience exists about the use of SLEDD in metformin-associated lactic acidosis (MALA). Here we report the case of a 64-year-old diabetic woman who on 12 November 2007 was admitted to the gynaecology unit of our hospital in order to undergo a surgical intervention for the correction of hysterocele, cystocele and enterocele. On 14 November 2007 she underwent colpohysterectomy, McCall culdoplasty, urethrocystopexy and colpoperineoplasty. Her past medical history included mild chronic renal failure (serum creatinine levels were between 1.3 and 1.5 mg/dl), arterial hypertension and type II diabetes mellitus. At the time of admission she was being treated with the following drugs (daily doses): metformin 3000 mg, allopurinol 300 mg, verapamil 120 mg, irbesartan 300 mg and furosemide 25 mg. On 17 November serum creatinine level was 1.4 mg/dl; on 18 November the patient became oliguric, confused and started to be affected by nausea, vomiting, abdominal pain and anorexia. On 19 November serum creatinine level was 5.7 mg/dl and liver enzymes were normal. Irbesartan and metformin therapy were stopped. A renal ultrasound showed normal kidney volume with districtly reduced thickness, a small increase of echogenicity and no hydronephrosis. In the evening, the patient became anuric and presented diffuse oedema, rales at lung bases and tachypnoea. Drowsiness appeared. She was hypoglycaemic at 50 mg/dl; blood pressure was 90/40 mmHg; the serum creatinine level was 7.4 mg/dl. Lactic acidosis was diagnosed: pH 7.16, serum bicarbonate level 11.1 mmol/l, serum lactate level 13.8 mmol/l (normal values: 0.5–1.6 mmol/l). A double lumen 12 F central venous catheter was positioned in the left femoral vein and a 10-h SLEDD session with GENIUS was started. A low-flux polysulfone membrane (F7; surface area 1.6 m2; Fresenius Medical Care, Bad Homburg, Germany) was applied, blood/dialysate flow was set at 120 ml/min and the ultrafiltration rate at 150 ml/h. Anticoagulation of the circuit was obtained with heparin 5000 IU/treatment. Dialysate composition was as follows: calcium, 1.5 mmol/l; magnesium, 0.5 mmol/l; potassium, 3 mmol/l; sodium, 140 mmol/l; bicarbonate, 35 mmol/l; chloride, 111.5 mmol/l; hydrochloric acid, 2.0 mmol/l; glucose, 5.5 mmol/l and citrate, 0.084 mmol/l. At the start of the SLEDD session, blood pressure was 100/50 mmHg and was constant during the treatment. Blood samples were collected every hour for the serum bicarbonate and lactate level measurement. Five hours after the end of the first GENIUS treatment, the patient started a new 8-h SLEDD session with GENIUS (on 20 November), and on 21 November a further 6-h SLEDD session with GENIUS was started 18 h after the end of the second session. Serum bicarbonate and lactate levels are shown in Figure ​Figure1.1. There was a rapid decrease in serum lactate levels and the reciprocal increase in serum bicarbonate levels during the three SLEDD sessions. A complete normalization of acid–base balance and of serum lactate levels with cessation of anuria was observed after three treatments. On 23 November, pH was 7.41, serum bicarbonate levels 24.5 mmol/l and serum lactate levels 1.5 mmol/l. On 29 November the patient was discharged from the hospital with serum creatinine levels of 2.9 mg/dl. After 3 months her serum creatinine levels were back to 1.4 mg/dl. In conclusion, SLEDD with GENIUS is able to offer an adequate and well-tolerated dialysis treatment for the therapy of MALA associated with severe oligoanuric acute renal failure. Fig. 1 Hourly measurements of serum lactate (•) and bicarbonate levels (⧫) during the three sessions of SLEDD with GENIUS. Conflict of interest statement. None declared.

Sustained low-efficiency daily dialysis with hemofiltration for acute kidney injury in the presence of sepsis

Acute kidney injury (AKI) commonly occurs in critically ill patients with sepsis and is associated with poor outcomes. Unfortunately, the ideal mode of renal replacement therapy remains unknown. Because both higher doses of dialysis and hemofiltration have been associated with improved survival, we postulated that adding hemofiltration to the diffusive clearance achieved by sustained low-efficiency daily dialysis (SLEDD-f) would provide a survival advantage over SLEDD. From December 2003 to October 2005, we retrospectively analyzed all patients with multisystem organ failure, vasopressor-dependent hypotension and oliguric acute kidney failure secondary to nonoperative sepsis who were treated with renal replacement therapy (RRT). After exclusionary criteria were applied, 8 patients received SLEDD-f and 13 patients received SLEDD. All treatments were for 8 - 16 h/day. SLEDD-f was continued until vasopressors were reduced to a minimal dose. Outcomes were mortality and recovery of renal function at 30 days after initiation of RRT. APACHE- II scores were calculated at the time of dialysis initiation to predict mortality. Despite higher APACHE II scores, 30-day survival was 100% in the SLEDD-f group and 38% in the SLEDD group. Furthermore, most of the SLEDD-f patients were able to have vasopressors weaned quickly and all patients in the SLEDD-f group recovered significant renal function to allow discontinuation of RRT. While the optimal treatment remains unknown, this small study raises the possibility that SLEDD-f offers a survival advantage and increases the chance of renal recovery while decreasing the need for vasopressors. A large randomized trial comparing SLEDD-f with other forms of renal replacement therapy is needed.

Renal Replacement Therapy in Acute Renal Failure: Which Index is Best for Dialysis dose Quantification?

The "delivered dose" of dialysis may significantly affect the outcome of acute renal failure (ARF) patients requiring dialysis. Our study aimed to elucidate which dose quantification method offers an appropriate parameter to compare different treatments in ARF patients. Six sustained low-efficiency daily dialysis (SLEDD), and 7 continuous venovenous hemofiltration (CVVH) patients with a prescribed Kt/V of 1.0 were studied during a single treatment. CVVH was studied over the first 24 hours after initiation. SLEDD was performed for 6-12 h. Solute clearance (K) was determined by direct dialysate quantification (DDQ). The single-pool Kt/V (spKt/V), equilibrated Kt/V (eqKt/V), equivalent renal urea clearance (EKRc), and solute removal index (SRI) were calculated. There were no significant differences at enrollment between the SLEDD and the CVVH groups in any patient characteristics except for the serum creatinine levels. The prescribed Kt/V of both groups was similar (SLEDD, 0.9+/-0.22; CVVH, 1.10+/-0.12, p=NS). The EKRc, which is used to verify kinetic equivalence among patients treated with differing renal replacement therapies (RRT), was higher in CVVH (15.7 in SLEDD; 27.4 in CVVH, p<0.0001), despite the fact that there was no difference between the delivered spKt/V for the SLEDD (1.05+/-0.40) and the CVVH (1.10+/-0.11) groups. The values for SRIurea (0.61 in SLEDD; 1.04 in CVVH, p=0.001), SRIcreatinine (0.55 in SLED; 1.02 in CVVH, p<0.0001), and SRIphosphate (1.81 in SLED; 3.60 in CVVH, p=0.03) were higher in CVVH. The EKRc is calculated assuming a steady state, which is an incorrect assumption in ARF patients with hypercatabolism. The SRI calculated using direct dialysate effluent quantification appears to be more reliable as an index of the dialysis dose compared to other methods in ARF patients. However, the use of the dialysate-side SRI is limited by the difficulty of dialysate effluent collection.

Sustained low-efficiency daily dialysis: safe, successful and cost-effective ARF treatment

Sustained low-efficiency daily dialysis: safe, successful and cost-effective ARF treatment

Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and solute removal

Hemodialysis (HD) for critically ill patients with acute renal failure has been provided as intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). IHD is often complicated by hypotension and inadequate fluid removal, and CRRT by high cost of solutions and problems with anticoagulation. Sustained low-efficiency daily dialysis (SLED) has been suggested as an alternative treatment. This is an observational, prospective pilot study describing the introduction of SLED at our institution. We compared SLED (23 patients, 165 treatments) with CRRT (11 patients, 209 days), focusing on cost, anticoagulation, and small solute removal. SLED consisted of 8 h of HD 6 days a week, with blood flow of 200 ml/min, dialysate flows of 350 ml/min, and hemofiltration with 1 l of saline/h. CRRT patients were anticoagulated with either heparin or citrate, and SLED patients with either heparin or saline flushes. The weekly costs to the hospital were $1431 for SLED, $2607 for CRRT with heparin, and $3089 for CRRT with citrate. Sixty-five percent of SLED treatments were heparin-free; filter clotting occurred in 18% of heparin treatments and 29% of heparin-free treatments (NS). Weekly Kt/V was significantly higher for SLED (8.4+/-1.8) and time-averaged serum creatinine was lower; equivalent renal clearance (EKRjc) was 29+/-6 ml/min for SLED, similar to that for CRRT. In summary, SLED may be routinely performed without anticoagulation; it provides solute removal equivalent to CRRT at significantly lower cost.