SLED

1. Dr Divyashree Shetty
PICU
SIMS Hospitals, Vadapalani, Chennai
1

2. “Acute renal failure(ARF)” changed to “Acute kidney injury (AKI)”
3 major advancements:
 AKI is an independent risk factor for mortality in most of the
conditions associated with it eg. sepsis, BMT etc.
 Standardized multidimensional AKI definitions (pRIFLE)
 Discovery and validation of novel urinary AKI biomarkers that
reflect kidney damage before loss of kidney function.
 Independent risk factor for mortality, 50 - 60% mortality in
critically ill
2

3. Definition of AKI
pRIFLE Criteria AKIN Criteria KDIGO Criteria
Stage SCr Based Urine Output
Stage
Sta
ge
SCr-Based Urine Output Sta
ge
SCr-Based Urine
Output
Risk >25% eCCl decrease <0.5
mL/kg/h
for 8 h
I SCr increase >0.3
mg/dL
OR
150%–200% in >48
hrs
<0.5 mL/kg/h
for 8 h
I SCr increase >0.3
mg/dL in 48 h
OR 1.5–1.9 times
<0.5
mL/kg/h
for 6–12 h
Injury >50% eCCl decrease<0.5
mL/kg/h for 16 h
II SCr increase 200%–
300%
<0.5 mL/kg/h
for 16 h
II SCr increase 2.0–2.9
times
<0.5
mL/kg/h
for 12 h
Failur
e
>75% eCCl
decrease OR
eCCl<35
mL/min/1.7
3 m2
<0.5 mL/kg/h
for 24 h OR
<0.3mL/kg/h
for 12 h
III SCr increase 200%–
300%
OR
SCr >4.0 mg/dL
<0.5 mL/kg/h
for 24 h
OR
<0.3 mL/kg/h
for 12 h
III SCr _3.0 increase
OR
SCr > 4.0 mg/dL
OR
if <18 y of age then eCCl
<35 mL/min/1.73 m2
<0.5
mL/kg/h
for 24 h
OR
<0.3
mL/kg/h
for 12 h
Loss Failure >4 weeks
ESRD Failure >3 months
3

4. Modes of Renal Replacement Techniques
Intermittent Continuous
Hybrid
IHD
Intermittent
haemodialysis
SLEDD
Sustained (or slow) low
efficiency daily dialysis
SLEDD-F
Sustained (or slow) low
efficiency daily dialysis with
filtration
CVVH
Continuous veno-venous
haemofiltration
CVVHD
Continuous veno-venous
haemodialysis
CVVHDF
Continuous veno-venous
haemodiafiltration
SCUF
Slow continuous
ultrafiltration
4

5. Case History
 12 Year old female
 AML relapse post allogenic stem cell transplant was undergoing
induction chemotherapy
 Developed Severe febrile neutropenia and septic shock for which
she was shifted to PICU
 Resuscitated with fluids and was started on antibiotics
(Meropenam & Teicoplanin) and antifungals(fluconazole)
5

6. Case Progress
 Liver dysfunction detected(Hyperbilirubinema and Increasing
liver enzymes )and started on N-acetyl cysteine infusion.
 Increasing abdominal distension requiring cessation of feeds and
starting of total parental nutrition
 Pancytopenia requiring multiple transfusions(packed cell and
platelets) and colony stimulating factor.
 Blood culture grew Trichosporon which was sensitive to
fluconazole and Amphotericin B.
6

7. Case Progress
 Amphotericin was added as she was not responding to
Fluconazole.
 Despite these measures she continued to have fever spikes, liver
dysfunction worsened and required multiple packed cell and
platelet transfusions during the course.
 This added to the fluid overload.
7

8.  In the due course she developed pneumonia and renal failure .
 Increasing respiratory distress - Started on HFNC
 Blood culture repeated again showed growth of Klebsiella
pneumoniae(13-12-2016)sensitive only to Colistin.
 In view of sensitivity pattern ,despite poor renal condition, colistin
was started at renal adjusted dose.
Case Progress
8

9. She also developed abdominal distention and obstipation not
responding to conservative therapy.
Multiple maculopapular skin lesions all over the body
CT abdomen was done to rule out septic focus which showed
multiple granulomatous lesions in the lung, liver and spleen
suggestive of disseminated fungal sepsis and features of colitis for
which she was started on metronidazole
Case Progress
9

10.  X-ray done showed features of pulmonary edema ,pleural effusion
 There was worsening renal function and fluid overload despite
possible fluid restriction.
Case Progress
10

11. Choice of Renal Replacement Therapy
 SLEDD-F versus CRRT
 SLEDD-F was started for the child as she not only required
dialysis but also fluid removal.
Case Progress
11

12. SLED day ULTRAFILTRATE RENAL
FUNCTION
TEST
HEMODYNAMIC
STABILITY
X-RAY
DAY 0
Urea-255
Creat-2.4
STABLE Pulmonary
edema
Pleural
effusion
DAY 1
2000/ 6 hrs Urea-138
Creat-1.4
STABLE Reduced
DAY 2
3000 / 8 hrs Urea-48
Creat-0.6
STABLE Reduced
DAY 3
3000 / 8 hrs Urea-47
Creat-0.6
STABLE
12

13.  Blood culture was repeated on 19-12-2016 which showed
repeated growth of trichosporon ,for which she was started
on voriconazole despite her worsening liver function
 Over the next 24 hours 0n 21-12-2017 she deteriorated with
unresponsiveness
 Hepatic encephalopathy sets in with worsening liver
function
13

14.  Intubated and ventilated.
 Shock requiring multiple fluid boluses and multiple inotropic
support
 Progressed to refractory shock
 Cardiac arrest from which she could not be revived.
Case Progress
14

15. Sustained Low Efficiency Dialysis(SLED) is a form of intermittent
hemodialysis using an extended (6-10hrs) session length and reduced
blood and dialysate flow rate
15

16. ADVANTAGES
 Easy to perform
 Flexible timing for treatments
 Six -Twelve hour or overnight treatments
 Increased patient mobility and access
 Small molecule clearance comparable to IHD and CRRT
 Cardiovascular stability comparable to CRRT
 ICU very accepting of SLED (in adult studies)
16

17. ADVANTAGES
 Composition of dialysate easily modified
 Effective in hyperkalaemia
 No mortality difference when compared to CRRT
 SLEDD-F can be used to remove of middle sized molecules in
SIRS
 Cost wise - cheaper than CRRT
17

18. DISADVANTAGES
 Clinical unfamiliarity
 Hypophosphataemia
 Unknown effects on PK of drugs
18

19. IHD SLEDD CRRT
Mechanism and
molecules
removed
Dialysis – mostly
low MWt
Small + middle
molecules
with SLEDD/F
Small + middle
molecules with
CVVHDF
Use Ambulatory CRF
Hyperkalemia
Critically ill
Hyperkalemia
Critically ill
Non-ambulatory
Blood flow 300-400 mL/min 200-300 mL/min 50-200 mL/min
Dialysate flow 500-800 mL/min 1-2L/h 2-3 L/h
Efficiency High Moderate Low
Hemodynamic
stability
Poor Good Good
Duration 3-4 h 3x/week 6-12 h daily Continuous
Anticoagulation Not needed Usually not needed Important
Logistics Need tap water supply,
need hygienic effluent
removal, Technically
difficult
High start up costs,
low familiarity,
low running costs,
Hypophosphatemia
High workload,
clearance limited by
interruptions, costly
sterile dialysate bags,
immobility
19

20. 20
CRRT SLED
Filter & circuit $235.00 Filter $13.00‐$20.00
Solutions bags $28.00
Tubing $10.00.
Drugs & Solutions $45.00
Total Cost over $1000.00 per
day
Total Cost about $300.00per
day
Our Hospital =approx
Rs25000/-day
Our Hospital = approx
Rs 6000/- day

21. 21

22.  Prospective pilot syudy
 SLED may be routinely performed without anticoagulation;
it provides solute removal equivalent to CRRT at significantly
lower cost
22

23. TRICHOSPORON
 Fungi that commonly inhabit soil
 Colonise skin, respiratory and gastrointestinal tract of humans
 Invasive Tricosporon is not only difficult to eliminate but can have
high mortality
 Common in immunocompromised patients
 Hematological malignancies account for 63% of reported cases.
 Mortality rate of 40-50% in patients with invasive disease
23

24. Clinical Features of invasive fungi
• Pulmonary infiltrates and respiratory symptoms may be
present.
• Flank pain, azotemia, hematuria, or red blood cell casts may
signal renal involvement.
 Skin involvement - discrete maculopapular rash
 The presence of skin lesions may represent a site for biopsy,
aiding in the diagnosis.
24

25. TREATMENT
 High dose amphotericin B/liposomal amphotericin has
been most commonly used with breakthrough cases
 Voriconazole and posaconazole show excellent in vitro
activity against trichosporon.
 Echinocandins have poor in vitro activity against the
fungus.
25

26. TREATMENT
 The cornerstone of treatment is combination therapy of
high dose amphotericin B with either or both 5-flucytosine
or voriconazole
 Recovery from predisposing immunocompromised state
may help but usually outcomes are bad for invasive
infections
26

27. Take Home Message
 Given the cost, effectiveness, decreased personnel
requirement and short duration SLED is becoming more
popular in the ICU setting.
 SLED – has best of both the world (Hybrid between IHD &
CRRT)
 Cheaper and can easily be done in small centres.
27

28. 28