With the shortage of funds within the health service, can we really turn to SLED or SLEDD as an alternative to continuous renal replacement therapies?
Your question implies that there may be increased cost of SLED, compared to CVVHD/CVVHDF. This is not necessarily true. Costs will vary according the the number of patients (economies of scale) and the availability of equipment and trained staff.
For SLED, the cost of equipment is high. The equipment is more complex and more staff training is required. SLED typically (but not always) generates the dialysis fluid online from a pure water supply and liquid concentrates and dry powder. SLED can use the same equipment and trained staff as used for standard chronic dialysis. SLED typically runs for part of the day only (not continuous)
CVVHD or CVVHDF use a simpler machine running continuously. It requires approximately 50 litres per day of special bagged sterile fluid, which is expensive and creates logistical problems.
For a hospital which has facilities for dialysing patients with chronic renal failure, and only occasionally need to provide dialysis in ITU, SLEDD will be much cheaper than CVVHD. In this case, appropriately trained staff and equipment are already available in the chronic dialysis unit and could be transferred to the ITU when required. SLEDD may avoid the cost of the sterile bagged fluids.
For a hospital which regularly dialyses patients in ITU and does not have a chronic dialysis facility, CVVHD may be cheaper. In this case, the ITU staff will acquire and maintain the appropriate skills and equipment. The cost of the dedicated CVVHD equipment, logistical infrastructure and training will be shared between many ITU patients.
AT evidence in comparison with CRRT, SLED or Intermittent hemodialysis (IHD) had numerous advantages:
1/Less nursing workload,
2/ Possibility to transfer the patient outside the ICU for investigations or procedures,
3/More time free for the device and thus the possibility to treat two patients by day,
4/Possibility to be performed without anticoagulation
5/ the cost reduction.
Intensive renal support does not reduce mortality or improve renal recovery (Clin J Am Soc Neph 2010, 5: 956), thus, we may discuss the best RRT procedure: continuous or not?
IHD in patients with hemodynamic “stability”, even with NE infusion, is a good option, but the sodium concentration of the dialysate should be of 147 mmol/l, dialysate flow near 600 ml/min and the blood flow > 300 ml/min. Within these conditions, the Kt/V will reach at least 1.2 for a four hours process. To avoid hypotension, in absence of hypovolemia, NE increment just at the IHD start may be very useful. Within these conditions, IHD is safe and efficient. In contrast with the claims of some intensivists, IHD is not so harmful! They just forgot that Vinsonneau et al were unable to find a significant difference in hypotensive events between CRRT and IHD (Lancet 2006).
Of course in very hemodynamic unstable patients, continuous or “semi- continuous” RRT can be proposed. In the VA NIH ARF Trial ( N Engl J Med 2008), SLED, used less than 300 times versus IHD (> 5000), was analyzed with IHD treated patients, CRRT was provided nearly 6000 times. Thus, a SLED very low use, at least in the late 2000’.
Intermittent or continuous RRT procedures? The debate is still going on!
We have to decrease the nursing workload and to improve of our ICU costs. Thus, I suggest to promote a new era for IHD in the ICU. A safe and efficient procedure depending on a trained staff (nurses and an experimented physician on charge). 3 or 4 times weekly. In case of hemodynamic instability, IHD time procedure may be increased (to 6 h) and blood and/or dialysate flows lowered. Our local policy/guidelines when I was in charge of the ICU.
In case of severe instability SLED may be proposed, but WHY DAILY??
In the ICU’s which do not have the facilities for SLED or a well-trained staff, CRRT should be used only during the hemodynamic instability period, and secondarily switched to IHD
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