1. Sustained Low Efficiency Dialysis
Dr Sidharth Kumar Sethi
Pediatric Nephrology
Kidney and Urology Institute
Medanta-The Medicity
INDIA

2. Outline Need for SLED? Technical Issues Drug & Nutrition clearance
Current available evidence
Adults
Children
Cost Considerations
Pros & Cons

3. CRRT Cons! Cost Complexities Initial specialized machinery
Running cost of lines & filters
Replacement fluid
Complexities
Procedural
Increased workload for already busy ICU nurses!
Unexpected interruptions

4. 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

5. SLED Lower cost Simplicity Convenience Earlier attempts – 1980’s
Common form of RRT in ICU in Adults
P. Palvesky C JASN 2007, 2: 623
Ricci & Ronco NDT –
Kudoh & Kilhara Jpn Cir J 1988
Nephron 1999

6. SLED vs CRRT vs IHD

7. SLED Technical considerations
Flexible options
QD allowing low flows
hybrid treatments
Dedicated hybrid therapy screen
Standard procedure for changing between HD & hybrid therapy

8. SLED Fresenius 2008 – H (US) Hybrid – F 2008 K USA Gambro Artis
Fresenius Genius
NX stage system one
5008-H

9. SLED Dialysate composition
Bicarbonate proportioning system single pass
Duration > 8 hrs
K – 4.0 meq/L, HCO meq/L, Ca meq/L
Duration < 8 hrs
K – 3.0 meq/L, HCo meq/L, Ca meq/L

10. SLED Prescription Circuit QB Anticoagulation
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. 2000,29:620
Madison et al . JASN 2005

11. SLED Ultrafiltration rate
Goals
Clinical need & tolerance
Cardiovascular stability

12. SLED Electrolyte & Nutritional Considerations
Alkalosis
Hypophosphatemia – Phosphate supplement
No albumin losses
amino acid losses of gms in adults
Kidney Int. 2001;60(2):777.
Intensive Care Med. 1997;23(1):110.

13. SLED Drug 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):

14. 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 less
Golestaneh. Clin Nephrol 2009;72:
Mushatt DM et al. Clin Infect Dis 2009;49:433–437
Dosage after therapy
Therapeutic drug monitoring

15. SLED Cost 5 – 8 times less expensive than CRRT SLED/SLED-F 100$
CRRT 500$ + ongoing costs
Alam et al AJKD 2000
Ma T et al – Nephrology 2000
Berbace KI 2006

16. Nursing responsibilities for SLED vs CRRT
Hybrid
CRRT
HD nurse/Tech.
ICU nurse
Setup + -
Initiation
Inservice ICU
N/R
Access Care
Troubleshooting
Extracorporeal circuit or hemodialyzer change
Routine discontinuation
Emergency continuation
Clearance
Blood draws
Hourly monitoring
Anticoagulation monitoring

17. Nursing responsibilities for SLED vs CRRT
Hybrid
CRRT
HD nurse/Tech.
ICU nurse
Setup + -
Initiation
Inservice ICU
N/R
Access Care
Troubleshooting
Extracorporeal circuit or hemodialyzer change
Routine discontinuation
Emergency continuation
Clearance
Blood draws
Hourly monitoring
Anticoagulation monitoring

18. SLED vs CVVHD: Adult data
2012
2013
2014

19. International Pediatric Dialysis Survey
Bunchman T, USA; Sethi SK, India; Raina R, USA; Askenazi D, USA; Akash Deep, UK

20. 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

21. 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

22. Availability of SLED International Pediatric Dialysis Modality Survey
Bunchman T, USA; Sethi SK, India; Raina R, USA; Askenazi D, USA; Akash Deep, UK

23. SLED in Adults: Evidence

27. Pediatric SLED: Evidence?

28. Taiwan
<20Kg excluded

30. p<0.02
p=0.15

31. 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’.