Heparin free dialysis in critically sick children using sustained low efficiency dialysis (SLEDD-f): A new hybrid therapy for dialysis in developing world

Abstract

BackgroundIn critically sick adults, sustained low efficiency dialysis [SLED] appears to be better tolerated hemodynamically and outcomes seem to be comparable to CRRT. However, there is paucity of data in critically sick children. In children, two recent studies from Taiwan (n = 11) and India (n = 68) showed benefits of SLED in critically sick children.Aims and objectivesThe objective of the study was to look at the feasibility and tolerability of sustained low efficiency daily dialysis-filtration [SLEDD-f] in critically sick pediatric patients.Material and methodsDesign: Retrospective study Inclusion criteria: All pediatric patients who had undergone heparin free SLEDD-f from January 2012 to October 2017. Measurements: Data collected included demographic details, vital signs, PRISM III at admission, ventilator parameters (where applicable), number of inotropes, blood gas and electrolytes before, during, and on conclusion of SLED therapy. Technical information was gathered regarding SLEDD-f prescription and complications.ResultsBetween 2012–2017, a total of 242 sessions of SLEDD-f were performed on 70 patients, out of which 40 children survived. The median age of patients in years was 12 (range 0.8–17 years), and the median weight was 39 kg (range 8.5–66 kg). The mean PRISM score at admission was 8.77±7.22. SLEDD-f sessions were well tolerated, with marked improvement in fluid status and acidosis. Premature terminations had to be done in 23 (9.5%) of the sessions. There were 21 sessions (8.6%) terminated due to hypotension and 2 sessions (0.8%) terminated due to circuit clotting. Post- SLEDD-f hypocalcemia occurred in 15 sessions (6.2%), post- SLEDD-f hypophosphatemia occurred in 1 session (0.4%), and post- SLEDD-f hypokalemia occurred in 17 sessions (7.0%).ConclusionsThis study is the largest compiled data on pediatric SLEDD-f use in critically ill patients. Our study confirms the feasibility of heparin free SLEDD-f in a larger pediatric population, and even in children weighing <20 kg on inotropic support.

Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children

“…Of these patients, the percentage of fluid overload was lower among those who survived (5.8 ± 3.6 (6.8%) compared against those who did not survive (8.5 ± 4.5 (11.3%)). In the other study by the same group, it was seen that fluid overload was higher among those who survived compared to those who did not (mean fluid overload = 8.11 ± 7.39, among survivors: 8.83 ± 8.34, and among nonsurvivors: 6.81 ± 5.1) …”

“…Lee et al found that children were on an average of 1.1 ± 1.4 inotropes before PIRRT initiation to an average of three inotropes in those who did not survive; the difference in survival was significantly higher . In the studies from India, it was seen that the number of inotropes in children who underwent PIRRT was 1.08 ± 1.06, and the difference in number of inotropes among those who survived vs. nonsurvivors was not significant (1.01 ± 0.98 vs. 1.32 ± 1.10) . In the other cohort from the same author, it was noted that the children were on an average of 1.1 ± 1.2 inotropes at PIRRT initiation with no difference between survivors and nonsurvivors …”

“…Sethi et al found that all children who could not survive suffered from MODS, while an average of 42.9% of all children who underwent PIRRT had MODS . In Sethi et al's second trial, 94.1% children on average had MODS at PIRRT initiation, of which 71.7% of the survivors had MODS .…”

“…For children heavier than 30 kg, blood and dialysate flow rates were 150 mL/min and 300 mL/min, respectively. According to blood flow (Q b ) and filtration rate (Q f ), total predilution replacement fluid was calculated as (Q f × Q b )/(Q b − Q f ) × 60 × treatment duration (hours) . Another study from Taiwan by Lee et al used the following operational definition of SLED‐F; wherein the therapy lasted for 8 to 10 hours, blood flow rates were set at 5 mL/kg/min for bodyweight up to 40 kg or 200 mL/min for bodyweight >40 kg, counter current dialysate flow to 260 mL/min, and filtration rate to 35 ml/kg/h in predilution mode.…”

“…In the first study, the average PRISM score of those who survived was 11.4 ± 5.6 while the score was 15.5 ± 7.6 in those who did not survive . In another study by Sethi et al, the mean PRISM score of those who survived was 6.4 ± 5.8 against 12.9 ± 7.5 among those who died . This suggests that positive outcomes with PIRRT were correlated with lower PRISM scores.…”