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

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

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

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

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 – 2006 21-690 Kudoh & Kilhara Jpn Cir J 1988 Nephron 1999

SLED vs CRRT vs IHD

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

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

SLED Dialysate 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

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

SLED Ultrafiltration rate Goals Clinical need & tolerance Cardiovascular stability

SLED Electrolyte & 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.

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): 329-332.

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;72:286-291 Mushatt DM et al. Clin Infect Dis 2009;49:433–437 Dosage after therapy Therapeutic drug monitoring

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

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

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

SLED vs CVVHD: Adult data 2012 2013 2014

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

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

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

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

SLED in Adults: Evidence

Pediatric SLED: Evidence?

Taiwan <20Kg excluded

p<0.02 p=0.15

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’.