Sustained Low Efficiency Dialysis in the Continuous Mode (C-SLED)

Abstract

Background and objectives: Oliguric, hypotensive patients who require large amounts of fluids may benefit from sustained low-efficiency dialysis performed continuously (C-SLED). C-SLED through higher clearance may improve survival, or through greater nutritional loss may worsen survival. No studies have assessed survival on C-SLED. The objective was to examine patient outcomes and survival predictors on C-SLED.Design, setting, participants, & measurements: The data of 199 consecutive cancer patients treated with C-SLED were analyzed. The median duration of C-SLED was 50 h. With 48 h of C-SLED, the blood urea nitrogen (BUN) and serum creatinine levels had decreased by 80% and 73%, respectively. The mean arterial pressure (MAP) was maintained despite higher ultrafiltration and reduced vasopressor use. The 30-d mortality rate was 65%. Despite excellent dialysis, the sequential organ failure assessment (SOFA) score remained predictive of mortality. In the univariate model, higher SOFA scores and lower values for MAP, blood pH, and serum albumin and creatinine levels were associated with higher mortality. Administration of total parenteral nutrition (TPN) was, however, associated with lower mortality.Results: In the multivariate model, the higher SOFA score and lower blood pH, MAP and C-SLED duration were associated with higher mortality. In a subset analysis of 129 patients who received C-SLED for at least 48 h, those with higher BUN levels, which were associated with higher TPN infusion, had a lower mortality risk.Conclusion: This first detailed report on C-SLED indicates that C-SLED can be effective and suggests a link between nutrition and survival.

Onconephrology

“…4,[11][12][13] The cause of AKI in hospitalized patients with cancer is almost always mutifactorial, with hypovolemia, sepsis, and toxic drugs often contributing concomitantly. 14,15 A higher rate of AKI in patients with cancer is not surprising given the effects of cancer or cancer therapy on several factors that cause AKI, such as volume depletion, increased propensity to develop contrast nephropathy, tumor lysis syndrome, abnormal uric acid homeostasis, hypercalcemia, myeloma and myeloma kidney, direct parenchymal involvement of the tumor, intense chemotherapy protocols often involving nephrotoxic drugs, stem cell transplants with immunosuppression leading to sepsis, veno-occlusive disease, graft versus host disease, thrombotic microangiopathy, and a variety of additional causes and mechanisms. [16][17][18][19][20][21][22][23] Furthermore, cancer therapy is increasingly available to elderly patients, a subpopulation that is particularly vulnerable to nephrotoxic drugs and intravenous radiocontrast media.…”

“…13,20 Dialysis was required in 10% of these patients, and nearly 30%-40% of oligoanuric patients requiring dialysis had to be treated with continuous renal replacement treatment because of severe septic shock, fluid overload, or tumor lysis syndrome. 15 The experience from MDACC also shows that sustained low-efficiency dialysis in the continuous mode simplifies continuous renal replacement therapy while providing effective dialysis and meeting the need for continuous fluid removal in these patients, who often receive a large amount of blood products. 15 It is often discussed whether it is appropriate to administer dialysis to critically ill patients with cancer.…”

Onco-Nephrology

“…However, where it has been studied, the data suggest that cancer patients with AKI requiring dialysis in the intensive care unit have similar mortality to patients without cancer (16,17). Moreover, although mortality is high, initiating renal replacement therapy for AKI in cancer patients does not condemn them to chronic dialysis in many cases.…”

Hemodynamic Tolerability of Sustained Low Efficiency Dialysis in Critically Ill Patients with Acute Kidney Injury

“…The commonest complication was hypotension (n=31 sessions) which required increase in dosage of inotrope or addition of inotrope. But no 5 Though solute and fluid removal are slower than conventional iHD, but faster than CRRT; several prospective controlled studies have shown that SLED clears small solutes with an efficacy comparable to that of iHD and CRRT. At the same time it is less expensive than CRRT.…”

“…Our findings contribute to an expanding literature supporting the use of SLED in critically ill patients in circumstances where CRRT would typically be considered. 1,5 dialysis had to be discontinued for any of the complications. No complication due to heparin occurred in any of the dialysis sessions which were done with heparin (n=77).…”