Sustained low-efficiency extended dialysis (SLED) with single-pass batch system in critically-ill patients with acute kidney injury (AKI)

Archetypal sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring kidney replacement therapy: towards an adequate therapy

Sustained low-efficiency dialysis is a hybrid form of kidney replacement therapy that has gained increasing popularity as an alternative to continuous forms of kidney replacement therapy in intensive care unit settings. During the COVID-19 pandemic, the shortage of continuous kidney replacement therapy equipment led to increasing usage of sustained low-efficiency dialysis as an alternative treatment for acute kidney injury. Sustained low-efficiency dialysis is an efficient method for treating hemodynamically unstable patients and is quite widely available, making it especially useful in resource-limited settings. In this review, we aim to discuss the various attributes of sustained low-efficiency dialysis and how it is comparable to continuous kidney replacement therapy in efficacy, in terms of solute kinetics and urea clearance, and the various formulae used to compare intermittent and continuous forms of kidney replacement therapy, along with hemodynamic stability. During the COVID-19 pandemic, there was increased clotting of continuous kidney replacement therapy circuits, which led to increased use of sustained low-efficiency dialysis alone or together with extra corporeal membrane oxygenation circuits. Although sustained low-efficiency dialysis can be delivered with continuous kidney replacement therapy machines, most centers use standard hemodialysis machines or batch dialysis systems. Even though antibiotic dosing differs between continuous kidney replacement therapy and sustained low-efficiency dialysis, reports of patient survival and renal recovery are similar for continuous kidney replacement therapy and sustained low-efficiency dialysis. Health care studies indicate that sustained low-efficiency dialysis has emerged as a cost-effective alternative to continuous kidney replacement therapy. Although there is considerable data to support sustained low-efficiency dialysis treatments for critically ill adult patients with acute kidney injury, there are fewer pediatric data, even so, currently available studies support the use of sustained low-efficiency dialysis for pediatric patients, particularly in resource-limited settings.

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

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

CONCLUSION

SLED-f is a safe and effective modality for use as a transition therapy between CKRT and intermittent hemodialysis in children in the PICU.

Sustained Low Efficiency Dialysis in Critically Ill Children With Acute Kidney Injury: Single-Center Observational Cohort in a Resource-Limited Setting

OBJECTIVES

To evaluate use of sustained low efficiency dialysis (SLED) in critically ill children with acute kidney injury in a resource-limited setting.

DESIGN

Observational database cohort study (December 2016 to January 2020).

SETTING

PICU of a tertiary hospital in India.

PATIENTS

Critically ill children undergoing SLED were included in the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical data, prescription variables, hemodynamic status, complications, kidney, and patient outcomes of all children undergoing SLED in the PICU were analyzed. A total of 33 children received 103 sessions of SLED. The median (interquartile range, IQR) age and weight of children who received SLED were 9 years (4.5-12.8 yr) and 26 kg (15.2-34 kg), respectively. The most common diagnosis was sepsis with septic shock in 17 patients, and the mean (± sd ) Pediatric Risk of Mortality III score at admission was 11.8 (±6.4). The median (IQR) number and mean (± sd ) duration of inotropes per session were 3 hours (2-4 hr) and 96 (±82) hours, respectively. Of 103 sessions, the most common indication for SLED was oligoanuria with fluid overload and the need for creating space for fluid and nutritional support in 45 sessions (44%). The mean (± sd ) duration of SLED was 6.4 (±1.3) hours with 72 of 103 sessions requiring priming. The mean (± sd ) ultrafiltration rate per session achieved was 4.6 (±3) mL/kg/hr. There was significant decrease in urea and creatinine by end of SLED compared with the start, with mean change in urea and serum creatinine being 32.36 mg/dL (95% CI, 18.53-46.18 mg/dL) ( p < 0.001) and 0.70 mg/dL (95% CI, 0.35-1.06 mg/dL) ( p < 0.001), respectively. Complications were observed in 44 of 103 sessions, most common being intradialytic hypotension (21/103) and bleeding at the catheter site (21/103). Despite complications in one third of the sessions, only nine sessions were prematurely stopped, and 23 of 33 patients receiving SLED survived.

CONCLUSION

In critically ill children, our experience with SLED is that it is feasible and provides a viable form of kidney replacement therapy in a resource-limited setting.

Management of acute renal replacement therapy in critically ill cirrhotic patients

Renal replacement therapy (RRT) in cirrhotic patients encompasses a number of issues related to the particular characteristics of this population, especially in the intensive care unit (ICU) setting. The short-term prognosis of cirrhotic patients with acute kidney injury is poor, with a mortality rate higher than 65% in patients with RRT requirement, raising questions about the futility of its initiation. Regarding the management of the RRT itself, there is still no consensus with respect to the modality (continuous versus intermittent) or the anticoagulation required to improve the circuit life, which is shorter than similar at-risk populations, despite the altered haemostasis in traditional coagulation tests frequently found in these patients. Furthermore, volume management is one of the most complex issues in this cohort, where tools used for ambulatory dialysis have not yet been successfully reproducible in the ICU setting. This review attempts to shed light on the management of acute RRT in the critically ill cirrhotic population based on the current evidence and the newly available tools. We will discuss the timing of RRT initiation and cessation, the modality, anticoagulation and fluid management, as well as the outcomes of the RRT in this population, and provide a brief review of the albumin extracorporeal dialysis from the point of view of a nephrologist.

Acute Kidney Injury in COVID-19: 90 Days of the Pandemic in a Brazilian Public Hospital

Renal involvement is frequent in COVID-19 (4-37%). This study evaluated the incidence and risk factors of acute kidney injury (AKI) in hospitalized patients with COVID-19. Methodology: This study represents a prospective cohort in a public and tertiary university hospital in São Paulo, Brazil, during the first 90 days of the COVID-19 pandemic, with patients followed up until the clinical outcome (discharge or death). Results: There were 101 patients hospitalized with COVID-19, of which 51.9% were admitted to the intensive care unit (ICU). The overall AKI incidence was 50%; 36.8% had hematuria or proteinuria (66.6% of those with AKI), 10.2% had rhabdomyolysis, and mortality was 36.6%. Of the ICU patients, AKI occurred in 77.3% and the mortality was 65.4%. The mean time for the AKI diagnosis was 6 ± 2 days, and Kidney Disease Improving Global Outcomes (KDIGO) stage 3 AKI was the most frequent (58.9%). Acute renal replacement therapy was indicated in 61.5% of patients. The factors associated with AKI were obesity [odds ratio (OR) 1.98, 95% confidence interval (CI) 1.04-2.76, p < 0.05] and the APACHE II score (OR 1.97, 95% CI 1.08-2.64, p < 0.05). Mortality was higher in the elderly (OR 1.03, 95% CI 1.01-1.66, p < 0.05), in those with the highest APACHE II score (OR 1.08, 95% CI 1.02-1.98, p < 0.05), and in the presence of KDIGO stage 3 AKI (OR 1.11, 95% CI 1.05-2.57, p < 0.05). Conclusion: AKI associated with severe COVID-19 in this Brazilian cohort was more frequent than Chinese, European, and North American data, and the risk factors associated with its development were obesity and higher APACHE II scores. Mortality was high, mainly in elderly patients, in those with a more severe disease manifestation, and in those who developed KDIGO stage 3 AKI.

Mortality and Recovery of Renal Function in Acute Kidney Injury Patients Treated with Prolonged Intermittent Hemodialysis Sessions Lasting 10 versus 6 Hours: Results of a Randomized Clinical Trial

PURPOSE

This trial aimed to compare mortality and recovery of renal function in acute kidney injury (AKI) patients treated with different durations of prolonged hemodialysis (PHD) sessions (6 h versus 10 h).

METHODOLOGY

We included patients with sepsis-associated AKI, >18 years, who are in use of a norepinephrine (lower than 0.7 ucg/kg/min).

RESULTS

One hundred and ninety-four patients were treated with 531 sessions of PHD (G1=104 and G2=90 patients). The two groups were similar in age and SOFA. There was no significant difference in hypotension, hypokalemia, and anticoagulation during PHD sessions. The two groups showed differences in filter clotting, hypophosphatemia, and treatment discontinuation (12.3 versus 23.1%, p=0.002; 15.5 versus 25.8%, p=0.005; and 7.9 versus 15.6%, p=0.008, respectively). There was no difference in fluid balance (FB) before and after PHD sessions. Death and complete recovery of renal function were similar (81.3 versus 82.2%, p=0.87 and 21 versus 31.2%, p=0.7, respectively). At logistic regression, the positive FB before and after dialysis was identified as risk factor for death, while volume overload after three PHD sessions and predialysis creatinine were negatively associated with recovery of renal function in 28 days.

CONCLUSION

There was no difference in the mortality and recovery of renal function of AKI patients submitted to different durations of PHD and sessions lasting 10 h presented higher filter clotting, hypophosphatemia, and treatment discontinuation. ISRCTN Registry number is ISRCTN33774458.

Prolonged intermittent renal replacement therapy in children

Wide ranges of age and weight in pediatric patients makes renal replacement therapy (RRT) in acute kidney injury (AKI) challenging, particularly in the pediatric intensive care unit (PICU), wherein children are often hemodynamically unstable. Standard hemodialysis (HD) is difficult in this group of children and continuous veno-venous hemofiltration/dialysis (CVVH/D) has been the accepted modality in the developed world. Unfortunately, due to cost constraints, CVVH/D is often not available and peritoneal dialysis (PD) remains the common mode of RRT in resource-poor facilities. Acute PD has its drawbacks, and intermittent HD (IHD) done slowly over a prolonged period has been explored as an alternative. Various modes of slow sustained IHD have been described in the literature with the recently introduced term prolonged intermittent RRT (PIRRT) serving as an umbrella terminology for all of these modes. PIRRT has been widely accepted in adults with studies showing it to be as effective as CVVH/D but with an added advantage of being more cost-effective. Pediatric data, though scanty, has been promising. In this current review, we elaborate on the practical aspects of undertaking PIRRT in children as well as summarize its current status.

Pharmacokinetics of meropenem in septic patients on sustained low-efficiency dialysis: a population pharmacokinetic study

BACKGROUND

The aim of the study was to describe the population pharmacokinetics (PK) of meropenem in critically ill patients receiving sustained low-efficiency dialysis (SLED).

METHODS

Prospective population PK study on 19 septic patients treated with meropenem and receiving SLED for acute kidney injury. Serial blood samples for determination of meropenem concentrations were taken before, during and after SLED in up to three sessions per patient. Nonparametric population PK analysis with Monte Carlo simulations were used. Pharmacodynamic (PD) targets of 40% and 100% time above the minimal inhibitory concentration (f T _{> MIC}) were used for probability of target attainment (PTA) and fractional target attainment (FTA) against Pseudomonas aeruginosa.

RESULTS

A two-compartment linear population PK model was most appropriate with residual diuresis supported as significant covariate affecting meropenem clearance. In patients without residual diuresis the PTA for both targets (40% and 100% f T _{> MIC}) and susceptible P. aeruginosa (MIC ≤ 2 mg/L) was > 95% for a dose of 0.5 g 8-hourly. In patients with a residual diuresis of 300 mL/d 1 g 12-hourly and 2 g 8-hourly would be required to achieve a PTA of > 95% and 93% for targets of 40% f T _{> MIC} and 100% f T _{> MIC}, respectively. A dose of 2 g 8-hourly would be able to achieve a FTA of 97% for 100% f T _{> MIC} in patients with residual diuresis.

CONCLUSIONS

We found a relevant PK variability for meropenem in patients on SLED, which was significantly influenced by the degree of residual diuresis. As a result dosing recommendations for meropenem in patients on SLED to achieve adequate PD targets greatly vary. Therapeutic drug monitoring may help to further optimise individual dosing.

TRIAL REGISTRATION

Clincialtrials.gov, NCT02287493 .