A Pilot Randomized Controlled Trial of Comparison between Extended Daily Hemodialysis and Continuous Veno-venous Hemodialysis in Patients of Acute Kidney Injury with Septic Shock

Comparison of outcomes of different modalities of renal replacement therapy in patients of acute kidney injury: a single centre prospective observational study

BACKGROUND

Acute Kidney Injury (AKI) is one of the most important causes of in-hospital mortality. The global burden of AKI continues to rise without a marked reduction in mortality. As such, the use of renal replacement therapy (RRT) forms an integral part of AKI management, especially in critically ill patients. There has been much debate over the preferred modality of RRT between continuous, intermittent and intermediate modes. While there is abundant data from Europe and North America, data from tropical countries especially the Indian subcontinent is sparse. Our study aims to provide an Indian perspective on the dialytic management of tropical AKI in a tertiary care hospital setup.

METHODS

90 patients of AKI, 30 each undergoing Continuous Renal Replacement Therapy (CRRT), Intermittent Hemodialysis (IHD) and SLED (Sustained Low-Efficiency Dialysis) were included in this prospective cohort study. At the end of 28 days of hospital stay, discharge or death, outcome measures were ascertained which included mortality, duration of hospital stay, recovery of renal function and requirement of RRT after discharge. In addition median of the net change of renal parameters was also computed across the three groups. Lastly, Kaplan Meier analysis was performed to assess the probability of survival with the use of each modality of RRT.

RESULTS

There was no significant difference in the primary outcome of mortality between the three cohorts (p=0.27). However, CRRT was associated with greater renal recovery (p= 0.015) than IHD or SLED. On the other hand, SLED and IHD were associated with a greater net reduction in blood urea (p=0.004) and serum creatinine (p=0.053).

CONCLUSION

CRRT, IHD and SLED are all complementary to each other and are viable options in the treatment of AKI patients.

Is SLED Efficient in Sepsis Associated Acute Kidney Injury: Hope but Hold!!

How to cite this article: Chhallani AA. Is SLED Efficient in Sepsis Associated Acute Kidney Injury: Hope but Hold!! Indian J Crit Care Med 2024;28(1):5-7.

The Use of Sustained Low-efficiency Dialysis in the Treatment of Sepsis-associated Acute Kidney Injury in a Low-income Country: A Prospective Cohort Study

Background

Limited data are available regarding the management and outcomes of patients with sepsis-associated acute kidney injury (SA-AKI) requiring dialysis in Sudan. Continuous renal replacement therapy (CRRT) is a highly favored treatment modality in such patients. However, it stays unavailable and expensive treatment in most low-income countries. We aimed to evaluate the use of sustained low-efficiency dialysis (SLED) in the treatment of hemodynamically unstable patients with SA-AKI admitted to the intensive care unit (ICU).

Materials and methods

A prospective cohort was conducted in Baraha Medical City, Khartoum, Sudan. Patients above 18 years of age, who were admitted to the ICU between January and September 2020 with SA-AKI, and required SLED or CRRT were enrolled. These were followed up till death or discharge from the ICU. They were observed regarding their dialysis tolerance, rate of renal recovery, ICU mortality, and cost of therapy. Data analysis was done using SPSS.

Results

Fifty-three adults were enrolled. Their mean age was 62 ± 11 years, and 56.6% were males. Thirty-one patients (58.5%) received SLED and 22 (41.5%) underwent CRRT. Patients in the two groups were age and sex matched and showed no significant differences in their comorbid conditions, source of sepsis, sequential organ failure assessment (SOFA) score, and their indications for dialysis (p > 0.05). Patients treated with SLED showed similar dialysis tolerance, rate of renal recovery, length of ICU admission, and risk of death compared to those treated with CRRT (p > 0.05). Moreover, SLED treatments were less expensive than CRRT, and the costs of ICU admission among the SLED group were significantly less (p < 0.001).

Conclusion

Our study shows that SLED is safe and effective. It is readily available and can be routinely performed in the treatment of hemodynamically unstable patients with SA-AKI at a significantly lower cost.

How to cite this article

Taha AKA, Shigidi MMT, Abdulfatah NM, Alsayed RK. The Use of Sustained Low-efficiency Dialysis in the Treatment of Sepsis-associated Acute Kidney Injury in a Low-income Country: A Prospective Cohort Study. Indian J Crit Care Med 2024;28(1):30-35.

Feasibility and Efficacy of Sustained Low-Efficiency Dialysis in Critically Ill Children with Severe Acute Kidney Injury

OBJECTIVES

To examine the feasibility, efficacy, and safety of sustained low-efficiency dialysis (SLED) in hemodynamically unstable, critically ill children.

METHODS

Critically ill patients, 1-18 y old with hemodynamic instability (≥ 1 vasoactive drugs) and severe acute kidney injury (AKI) requiring kidney replacement therapy (KRT) in a tertiary care pediatric intensive care unit were prospectively enrolled. Patients weighing ≤ 8 kg or with mean arterial pressure < 5^th percentile despite > 3 vasoactive drugs, were excluded. Patients underwent SLED until hemodynamically stable and off vasoactive drugs, or lack of need for dialysis. The primary outcome was the proportion of patients in whom the first session of SLED was initiated within 12 h of its indication and completed without premature (< 6 h) termination. Efficacy was estimated by ultrafiltration, urea reduction ratio (URR), and equilibrated Kt/V. Other outcomes included: changes in hemodynamic scores, circuit clotting, adverse events, and changes in indices on point-of-care ultrasonography and echocardiography.

RESULTS

Between November 2018 and March 2020, 18 patients with median age 8.6 y and vasopressor dependency index of 83.2, underwent 41 sessions of SLED. In 16 patients, SLED was feasible within 12 h of indication. No session was terminated prematurely. Ultrafiltration achieved was 4.0 ± 2.2 mL/kg/h, while URR was 57.7 ± 16.2% and eKt/V 1.17 ± 0.56. Hemodynamic scores did not change significantly. Asymptomatic hypokalemia was the chief adverse effect. Sessions were associated with a significant improvement in indices on ultrasound and left ventricular function. Fourteen patients died.

CONCLUSIONS

SLED is feasible, safe, and effective in enabling KRT in hemodynamically unstable children with severe AKI.

Sustained low efficiency dialysis is non-inferior to continuous renal replacement therapy in critically ill patients with acute kidney injury: A comparative meta-analysis

BACKGROUND

Critically ill adults with acute kidney injury (AKI) experience considerable morbidity and mortality. This systematic review aimed to compare the effectiveness of continuous renal replacement therapy (CCRT) versus sustained low efficiency dialysis (SLED) for individuals with AKI.

METHODS

We carried out a systematic search of existing databases according to standard methods and random effects models were used to generate the overall estimate. Heterogeneity coefficient was also calculated for each outcome measure.

RESULTS

Eleven studies having 1160 patients with AKI were included in the analyses. Meta-analysis results indicated that there was no statistically significant difference between SLED versus continuous renal replacement therapy (CRRT) in our primary outcomes, like mortality rate (rate ratio [RR] 0.67, 95% confidence interval [CI] 0.44-1.00; P = .05), renal recovery (RR 1.08, 95% CI 0.83-1.42; P = .56), and dialysis dependence (RR = 1.03, 95% CI 0.69-1.53; P = .89). Also, no statistically significant difference was observed for between SLED versus CRRT in the secondary outcomes: that is, length of intensive care unit stay (mean difference -0.16, 95% CI -0.56-0.22; P = .41) and fluid removal rate (mean difference -0.24, 95% CI -0.72-0.24; P = .32). The summary mean difference indicated that there was a significant difference in the serum phosphate clearance among patients treated with SLED and CRRT (mean difference -1.17, 95% CI -1.90 to -0.44, P = .002).

CONCLUSIONS

The analysis indicate that there was no major advantage of using continuous renal replacement compared with sustained low efficiency dialysis in hemodynamically unstable AKI patients. Both modalities are equally safe and effective in treating AKI among critically ill patients.

Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy

BACKGROUND

Acute kidney injury (AKI) is a common complication amongst people who are critically ill, and it is associated with an increased risk of death. For people with severe AKI, continuous kidney replacement therapy (CKRT), which is delivered over 24 hours, is needed when they become haemodynamically unstable. When CKRT is interrupted due to clotting of the extracorporeal circuit, the delivered dose is decreased and thus leading to undertreatment.

OBJECTIVES

This review assessed the efficacy of non-pharmacological measures to maintain circuit patency in CKRT.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 25 January 2021 which includes records identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) (parallel-group and cross-over studies), cluster RCTs and quasi-RCTs that examined non-pharmacological interventions to prevent clotting of extracorporeal circuits during CKRT.  DATA COLLECTION AND ANALYSIS: Three pairs of review authors independently extracted information including participants, interventions/comparators, outcomes, study methods, and risk of bias. The primary outcomes were circuit lifespan and death due to any cause at day 28. We used a random-effects model to perform quantitative synthesis (meta-analysis). We assessed risk of bias in included studies using the Cochrane Collaboration's tool for assessing risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

A total of 20 studies involving 1143 randomised participants were included in the review. The methodological quality of the included studies was low, mainly due to the unclear randomisation process and blinding of the intervention. We found evidence on the following 11 comparisons: (i) continuous venovenous haemodialysis (CVVHD) versus continuous venovenous haemofiltration (CVVH) or continuous venovenous haemodiafiltration (CVVHDF); (ii) CVVHDF versus CVVH; (iii) higher blood flow (≥ 250 mL/minute) versus standard blood flow (< 250 mL/minute); (iv) AN69 membrane (AN69ST) versus other membranes; (v) pre-dilution versus post-dilution; (vi) a longer catheter (> 20 cm) placing the tip targeting the right atrium versus a shorter catheter (≤ 20 cm) placing the tip in the superior vena cava; (vii) surface-modified double-lumen catheter versus standard double-lumen catheter with identical geometry and flow design; (viii) single-site infusion anticoagulation versus double-site infusion anticoagulation; (ix) flat plate filter versus hollow fibre filter of the same membrane type; (x) a filter with a larger membrane surface area versus a smaller one; and (xi) a filter with more and shorter hollow fibre versus a standard filter of the same membrane type. Circuit lifespan was reported in 9 comparisons. Low certainty evidence indicated that CVVHDF (versus CVVH: MD 10.15 hours, 95% CI 5.15 to 15.15; 1 study, 62 circuits), pre-dilution haemofiltration (versus post-dilution haemofiltration: MD 9.34 hours, 95% CI -2.60 to 21.29; 2 studies, 47 circuits; I² = 13%), placing the tip of a longer catheter targeting the right atrium (versus placing a shorter catheter targeting the tip in the superior vena cava: MD 6.50 hours, 95% CI 1.48 to 11.52; 1 study, 420 circuits), and surface-modified double-lumen catheter (versus standard double-lumen catheter: MD 16.00 hours, 95% CI 13.49 to 18.51; 1 study, 262 circuits) may prolong circuit lifespan. However, higher blood flow may not increase circuit lifespan (versus standard blood flow: MD 0.64, 95% CI -3.37 to 4.64; 2 studies, 499 circuits; I² = 70%). More and shorter hollow fibre filters (versus standard filters: MD -5.87 hours, 95% CI -10.18 to -1.56; 1 study, 6 circuits) may reduce circuit lifespan. Death from any cause was reported in four comparisons We are uncertain whether CVVHDF versus CVVH, CVVHD versus CVVH or CVVHDF, longer versus a shorter catheter, or surface-modified double-lumen catheters versus standard double-lumen catheters reduced death due to any cause, in very low certainty evidence. Recovery of kidney function was reported in three comparisons. We are uncertain whether CVVHDF versus CVVH, CVVHDF versus CVVH, or surface-modified double-lumen catheters versus standard double-lumen catheters increased recovery of kidney function. Vascular access complications were reported in two comparisons. Low certainty evidence indicated using a longer catheter (versus a shorter catheter: RR 0.40, 95% CI 0.22 to 0.74) may reduce vascular access complications, however the use of surface-modified double lumen catheters versus standard double-lumen catheters may make little or no difference to vascular access complications.

AUTHORS' CONCLUSIONS

The use of CVVHDF as compared with CVVH, pre-dilution haemofiltration, a longer catheter, and surface-modified double-lumen catheter may be useful in prolonging the circuit lifespan, while higher blood flow and more and shorter hollow fibre filter may reduce circuit life. The Overall, the certainty of evidence was assessed to be low to very low due to the small sample size of the included studies. Data from future rigorous and transparent research are much needed in order to fully understand the effects of non-pharmacological interventions in preventing circuit coagulation amongst people with AKI receiving CKRT.

Renal replacement therapy modality in critically ill patients with acute kidney injury - A network meta-analysis of randomized controlled trials

PURPOSE

This network meta-analysis aims to compare the efficacy and safety of various renal replacement therapy (RRT) modalities in critically ill patients with acute kidney injury (AKI).

MATERIALS AND METHODS

We searched the electronic databases for randomized controlled trials (RCTs) comparing different RRT modalities, including continuous RRT, intermittent RRT, hybrid RRT, and peritoneal dialysis (PD), in critically ill patients with AKI through July 26, 2020. The primary outcomes were renal recovery and short-term mortality. The study protocol was registered with PROSPERO (CRD42020188115).

RESULTS

Twenty-three studies were included. No difference in the renal recovery or short-term mortality was observed among the four RRT modalities (low certainty). The four RRT modalities had similar effects on the incidence of infectious complications (low certainty). PD was associated with less fluid removal volume and lower incidence of hypotension compared with the extracorporeal modalities, yet no difference in the two outcomes was identified among the extracorporeal modalities (very low to moderate certainty).

CONCLUSIONS

No superiority of one particular RRT modality over another in terms of renal recovery and short-term mortality in critically ill patients with AKI. PD exhibited worse fluid removal and better safety in the prevention of hypotension than the extracorporeal modalities.

Changing the terminology from kidney replacement therapy to kidney support therapy

Kidney replacement therapy (KRT) is a common supportive treatment for renal dysfunction, especially acute kidney injury. However, critically ill or immunosuppressed patients with renal dysfunction often have dysfunction in other organs as well. To improve patient outcomes, clinicians began to initiate kidney replacement therapy in situations where nonrenal conditions may lead to acute kidney injury, such as septic shock, hematopoietic stem cell transplantation, veno-occlusive renal disease, cardiopulmonary bypass, chemotherapy, tumor lysis syndrome, hyperammonemia, and various others. In this review, we discuss the use of various modes of kidney replacement therapy in treating renal and nonrenal complications to illustrate why kidney support therapy is a more appropriate terminology than kidney replacement therapy.

Evaluation on treatment of sustained low-efficiency hemodialysis against patients with multiple organ dysfunction syndrome following wasp stings

Background

To evaluate the treatment of sustained low-efficiency hemodialysis (SLED) against patients with multiple organ dysfunction syndrome (MODS) following wasp stings.

Methods

Clinical data of 35 patients with MODS following wasp stings were retrospectively analysed. These patients were divided into three groups according to the treatment strategy used: 1) hemodialysis (HD) group, 2) continuous veno-venous hemofiltration (CVVH)/HD group, and 3) SLED/HD group. The clinical parameters, treatment outcome, and safety findings were compared among the three groups.

Results

The recovery rate (76.92% vs 77.78% vs 91.67%, p = 0.621) and mortality rate (15.38% vs 11.11% vs 8.33%, p = 0.999) were similar among the three groups. When compared to the HD group, patients treated with CVVH/HD or SLED/HD required a shorter period of time to enter into polyuria stage [(24.7 ± 4.3) days vs (20.2 ± 4.7) days vs (18.2 ± 3.0) days, F = 9.11, p = 0.0007], and required a shorter time for serum creatinine to return to normal [(45.7 ± 13.4) days vs (33.1 ± 9.4) days vs (31.9 ± 9.8), F = 5.83, p = 0.0069]; while such parameters had no significant differences between SLED/HD group and CVVH/HD group. The adverse events of hypotension and arrhythmia were found in the HD group, while no adverse events were reported in the SLED/HD and CVVH/HD groups. There was no significant difference in the cost of blood purification treatment between the SLED/HD group and HD group.

Conclusion

The use of SLED, CVVH and HD provided a comparable recovery and survival rates in patients with MODS secondary to wasp stings. Compared to HD, the use of SLED is recommended as a treatment strategy because of the efficacy on recover of renal function, satisfactory safety outcome, as well as the reasonable treatment cost.