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

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Midhun Ramesh
Satish Balan
Praveen Murlidharan


Introduction: AKI is a common complication of critical illness. Management of AKI may require the initiation of RRT to correct metabolic and fluid derangements. CRRT does have some advantages over conventional intermittent dialysis in critical care settings. The main disadvantage of CRRT is its exorbitant cost. SLED is a hybrid technique between CRRT and IHD, done using conventional HD machines and dialyzers.

Materials and Methods: The primary objective of the study was to determine the hemodynamic tolerability & feasibility of SLED in critically ill patients with AKI. All patients admitted to the ICU; who was started on SLED was included in this study. Data on demographic information, pre-dialysis Biochemical & Hematological parameters were collected. BP and vasopressor requirements during the SLED sessions were recorded. Survival predictors were described using a SOFA score at the time of initiation of the first SLED session.

Results: 427 SLED sessions were conducted in 148 patients. Two patients suffered from cardiac arrest during the SLED session. There was an increased requirement of inotropic support in 56 sessions which was labeled as a hemodynamically unstable session. Hypotension refractory to inotropic medication, requiring SLED discontinuation occurred in 14 sessions. 97.7% of the prescribed duration of treatment and 89.07% of the ultrafiltration goal was achieved with SLED in this study.

Conclusion: SLED is a well-tolerated, feasible, cost-effective RRT modality in resource-limited settings for critically ill patients with AKI.

Sustained low-efficiency dialysis (SLED), acute kidney injury (AKI), continuous renal replacement therapy (CRRT), renal replacement therapy (RRT)

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Ramesh, M., Balan, S., & Murlidharan, P. (2020). Feasibility and Hemodynamic Tolerability of Sustained Low- Efficiency Dialysis in Critically Ill Patients with Acute Kidney Injury. Asian Journal of Research in Nephrology, 3(1), 24-32. Retrieved from https://journalajrn.com/index.php/AJRN/article/view/30097
Original Research Article


Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012;2:1–138.

Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute dialysis quality initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8:R204-R212.

Bellomo R, Kellum JA, Ronco C. Defining and classifying acute renal failure: From advocacy to consensus and validation of the RIFLE criteria. Intens Care Med. 2007; 33:409-413.

Fang TC, Chou CL, Lai YH. Adult stem cell therapy for acute renal failure: The hope beyond the hype? Acta Nephrologica. 2009;23:61-76.

Dennen P, Douglas IS, Anderson R. Acute kidney injury in the intensive care unit: An update and primer for the intensivist. Crit Care Med. 2010;38:261-275.

Manns B, Doig CJ, Lee H, Dean S, Tonelli M, Johnson D, et al. Cost of acute renal failure requiring dialysis in the intensive care unit: Clinical and resource implications of renal recovery. Crit Care Med. 2003;31(2):449–55.

Klarenbach S, Manns B, Pannu N, Clement FM, Wiebe N, Tonelli M. Economic evaluation of continuous renal replacement therapy in acute renal failure. Int J Technol Assess Health Care. 2009; 25(3):331–8.

Marshall MR, Ma T, Galler D, Rankin AP, Williams AB: Sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring renal replacement therapy: Towards an adequate therapy. Nephrol Dial Transplant. 2004;19(4):877-884.

Marshall MR, Golper TA, Shaver MJ, Chatoth DK. Hybrid renal replacement modalities for the critically ill. Contrib Nephrol. 2001;132:252-257.

Kumar VA, Craig M, Depner TA, Yeun JY. Extended daily dialysis: A new approach to renal replacement for acute renal failure in the intensive care unit. Am J Kidney Dis. 2000;36(2):294–300.

Marshall MR, Creamer JM, Foster M, Ma TM, Mann SL, Fiaccadori E, et al. Mortality rate comparison after switching from continuous to prolonged intermittent renal replacement for acute kidney injury in three intensive care units from different countries. Nephrol Dial Transplant. 2011; 26(7):2169–75.

Marshall MR, Golper TA, Shaver MJ, Alam MG, Chatoth DK. Sustained low-efficiency dialysis for critically ill patients requiring renal replacement therapy. Kidney Int. 2001;60(2):777–85.

Naka T, Baldwin I, Bellomo R, Fealy N, Wan L. Prolonged daily intermittent renal replacement therapy in ICU patients by ICU nurses and ICU physicians. Int J Artif Organs. 2004;27(5): 380–7.

Wu VC, Huang TM, Shiao CC, Lai CF, Tsai PR, Wang WJ, et al. The hemodynamic effects during sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for uremic patients with brain hemorrhage: A crossover study. J Neurosurg. 2013; 119(5):1288–95.

Berbece AN, Richardson RM. Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and solute removal. Kidney Int. 2006;70(5):963–8.

Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, Suter PM, Thijs LG. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22(7):707-10.

Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26(11):1793-800 50.

Moreno R, Vincent JL, Matos R, Mendonça A, Cantraine F, Thijs L, Takala J, Sprung C, Antonelli M, Bruining H, Willatts S. The use of maximum SOFA score to quantify organ dysfunction/ failure in intensive care. Results of a prospective, multicentre study. Working Group on Sepsis related Problems of the ESICM. Intensive Care Med. 1999;25(7):686-96.

Fieghen H, Friedrich J, Burns K, Nisenbaum R, Adhikari N, Hladunewich M, et al. The hemodynamic tolerability and feasibility of sustained low efficiency dialysis in the management of critically ill patients with acute kidney injury. BMC Nephrology. 2010;11(1).

Misset B, Timsit JF, Chevret S, Renaud B, Tamion F, Carlet J. A randomized cross-over comparison of the hemodynamic response to intermittent hemodialysis and continuous hemofiltration in ICU patients with acute renal failure. Intensive Care Med. 1996;22(8):742-746.

Vinsonneau C, Camus C, Combes A, Costa de Beauregard MA, Klouche K, Boulain T, Pallot JL, Chiche JD, Taupin P, Landais P, et al: Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: A multicentre randomized trial. Lancet. 2006;368(9533):379-385.

Lins R, Elseviers M, Van der Niepen P, Hoste E, Malbrain M, Damas P et al. Intermittent versus continuous renal replacement therapy for acute kidney injury patients admitted to the intensive care unit: Results of a randomized clinical trial. Nephrology Dialysis Transplantation. 2008; 24(2):512-518.

Rabindranath KS, Adams J, MacLeod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database of Systematic Reviews. 2007;3:Art. No.: CD003773.

DOI: 10.1002/14651858.CD003773.pub3

Augustine JJ, Sandy D, Seifert TH, Paganini EP. A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis. 2004;44(6):1000-1007.

Kitchlu A, Adhikari N, Burns K, Friedrich J, Garg A, Klein D et al. Outcomes of sustained low efficiency dialysis versus continuous renal replacement therapy in critically ill adults with acute kidney injury: A cohort study. BMC Nephrology. 2015; 16(1).

Schwenger V, Weigand M, Hoffmann O, Dikow R, Kihm L, Seckinger J et al. Sustained low efficiency dialysis using a single-pass batch system in acute kidney injury - A randomized interventional trial: The Renal Replacement Therapy Study in Intensive Care Unit Patients. Critical Care. 2012;16(4):R140.

Kielstein JT, Kretschmer U, Ernst T, Hafer C, Bahr MJ, Haller H et al. Efficacy & cardiovascular tolerability of extended dialysis in critically ill patients: A randomized controlled study.Am J Kidney Dis. 2004;43(2):342-49.

Neuenfeldt T, Hopf HB. Sustained low efficiency dialysis in an interdisciplinary intensive care unit- a five year cost-benefit analysis. Rev Colomb Anestesiol. 2013; 41(2):88-96.

Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lo S et al. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009; 361:1627-38.

Vesconi S, Cruz DN, Fumagalli R, Kindgen-Milles D, MontiG, Marinho A et al. Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Critical Care. 2009;13(2):R57.


Faulhaber-Walter R, Hafer C, Jahr N, Vahlbruch J, Hoy L, Haller H et al. The Hannover Dialysis Outcome study: Comparison of standard versus intensified extended dialysis for treatment of patients with acute kidney injury in the intensive care unit. Nephrol Dial Transplant. 2009; 24:1-7.