CRRT. Sustained low efficiency daily dialysis, SLEDD. Sustained low efficiency daily diafiltration, SLEDD-f. inflammatory cytokine IL-1 IL-6 TNF-

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1 RRT, renal replacement therapy IHDCRRT CRRT 24 CRRT Sustained low efficiency daily dialysis, SLEDD 6 ~ Sustained low efficiency daily diafiltration, SLEDD-f inflammatory cytokine IL-1 IL-6 TNF- SLEDD-f 8 ~ : pirutsai@yahoo.com.tw 242

2 RRT renal replacement therapy 2,3 intermittent hemodialysis, IHD continuous venovenous hemofiltration, CVVH continuous arteriovenous hemofiltraton, CAVH diffusion convection diffusion convection Ultrafiltration Diffusion Ultrafiltation convection transmem-brane pressure hemodiafiltration HD hemodialysis diffusionhf hemofiltration convection hemodiafiltrationhd + HF HD HF IHD CRRT IHD CRRT 4-6 IHD diffusion CRRT convection IHD 3~4 3~4 CRRT 24 IHD CRRT CRRT IHD CRRT 24 heparin 243

3 48 4 Sustained low efficiency daily dialysis, SLEDD 5 8 ~ SLEDD Sustained Low-efficiency daily dialysis SLEDD IHD CRRT HD ~8 SLEDD Sustained low-efficiency daily dialysis SLEDD CRRT CRRT Berbece AN 2006 Kidney InternationalSLEDD CRRT 8 SLEDD CRRT small solute removal daily and weekly cost SLEDD CRRT heparin citrate SLEDD Weekly Kt/V CRRT vs creatinine SLEDD CRRT SLEDD SICU CRRT SLEDD fluid overload CRRT 63 SLEDD 38 Daily and weekly cost of SLEDD and CRRT SLEDD ($USD) CRRT citrate ($USD) CRRT heparin ($USD) Supply cost/day HD RN cost/day a Total cost/day Total cost/week RN, registered nurse; a Note: Based on one HD nurse treating two patients. Kidney International 2006;70:

4 Measures of small solute removal CRRT SLED p-value Morning serum creatinine after day 3 ( mol/l) Time-averaged serum creatinine ( mol/l) Weekly Kt/V <0.004 EKRj (ml/min) NS EKRjc (ml/min) NS EKR, equivalent renal clearance Kidney International 2006;70: SLEDD vs CRRT in NTUH CVVH (n = 63) SLEDD (n = 38) p Value 30-day AHD mortality % % ICU mortality % % Renal recovery % % AHD: after hospital discharge, ICU: intensive care unit 30 SLEDD CRRT CRRT SLEDD SLEDD CRRT SLEDD vs CRRT= $33250 vs $ SLEDD CRRT CRRT SICU SLEDD SLEDD SLEDD-f Sustained low-efficiency daily diafiltration 2004 Mark R.SLEDD-f Sustained low-efficiency daily diafiltration 9 8~ SLEDD-f SLEDDf SLEDD inflam- 245

5 matory factor IL-1 IL-6 TNF- SLEDD-f Fresenius 4008S ARrT plus Fresenius Medical Care AG, D Bad Hamburg, Germany On-line fluid production for filtrate replacement 11 on-line On-line replacement fluid depyrogen cytokine-inducing substances ultrafilter Ultrapure dialysate ultrafilter 13, CFU/ml 0.25 EU/ mlaami CFU/ml 0.03 EU/ml meq/lna Ca K Mg Cl Acetate 5.0 Bicarbonate 34.0 Dextrose 100 SafeLine Fresenius Medical Care AG, D Bad Hamburg, Germany SLEDDf FX-60, Helixone Polysulfone 1.4m 2 Fresenius Medical Care AG, D Bad Hamburg, Germany 35 6~ / / SLEDD-f SLEDD-f SLEDDf

6 3. CRRT CRRT CRRT ASAIO Journal 12 CVVH 20.9 CVVH ~2004 CVVH CVVH 91.15% SLEDD-f 8 ~ SLEDD-f CRRT CRRT AV-600; FMC- Asia Pacific 4550 HF Heparin 18 A B Rolikan $2250 / CRRT $11668 SLEDDf High Flux FX- 60 Helixone 1.4m SLEDD SLEDD-f SLEDD SLEDDf CRRT CRRT 01. Hoste EAJ, Kellum JA. Acute Kidney injury: epidemiology and diagnosis criteria. Current Opinion in Critical Care 2006;12: Bellomo R, Ronco C, Kellum JA, et al. the ADQI 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. Critical Care 2004;8:R204-R Evanson JA, Ikizler TA, Wingard R, et al. Measurement of the delivery of dialysis in acute renal failure. Kidney International Vol. 55, pp: Mehta RL, McDonald B, Gabbai FB, Pahl M, Pascual MTA, Farkas A, Kaplan RM, for the Collaborative Group for Treatment of ARF in the ICU. A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney International Vol.60, pp: Marshall MR, Golper TA, Shaver MJ, et al. Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy. Am J Kidney Dis 2002;39: Liao Z, Zhang W, Hardy PA, et al. Kinetic Comparison of Different Acute Dialysis Therapies. Artificial Organs 2003;27: Biesen WV, Vanholder R, Lameire N. Dialysis strategies in critically ill acute renal failure patients. Current Opinion in Critical Care 2003;9: Berbece AN, Richardson RMA. Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and 247

7 solute removal. Kidney International 2006;70: Marshall MR, Ma T, Galler D, et al. Sustained lowefficiency daily diafiltration (SLEDD-f) for critically ill patients requiring renal replacement therapy: towards an adequate therapy. Nephrol Dial Transplant 2004;19: Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000;356: Ronco C, Bellomo R, Kellum JA. Dialysate and Replacement Fluid Composition for CRRT. Contrib Nephrol. Basel, Karger. 2007; Vol 156: pp Uchini S, Fealy N, Baldwin I, Morimatsu H, Bellomo R. Continuous Venovenous Hemofiltration Without Anticoagulation. ASAIO Journal 2004;50: Brunet P, Berland Y. Water quality and complications of hemodialysis. Nephrol Dial Transplant 2004;15: Schiffl H et al. Effect of ultrapure dialysis fluid on nutritional status and inflammatory parameter. Nephrol Dial Transplant 2001;16:

8 SUSTAINED LOW-EFFICIENCY DAILY DIAFILTRATION (SLEDDf) IN THE SURGERY INTENSIVE CARE UNITS Pi-Ru Tsai, Wen-Je Ko Abstract Dialysis for patients in intensive care units who have developed acute renal failure (ARF) has traditionally been provided intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). IHD is often complicated by hypotension and inadequate fluid removal. Delivery of adequate solute removal is also problematic for a variety of reasons. Although CRRT addresses some of the drawbacks of IHD, it is associated with significantly greater complexity, the need for continuous anticoagulation, and substantially higher costs. Recently, prolonged HD using conventional equipment has been described as an alternative therapy. The most frequently used terms are extended daily dialysis, sustained low-efficiency hemodialysis (SLED), and sustained low-efficiency daily hemodiafiltration (SLEDD-f). All have in common the use of conventional HD machines, with the same blood flow as IHD but dialysate flow rates lower that of IHD. Treatment duration and frequency are more than in IHD. Hemodynamic tolerance and solute clearance have been good, whereas the complexity and the workload for ICU staff were significantly reduced. Conclusion: SLEDD-f provides stable renal replacement therapy and good clinical outcomes. SLEDD-f treatment can be prescribed by ICU physicians, and conducted by technician and nursing practitioner. SLEDD-f is a viable alternative to CRRT in critical care setting. Key words: Acute renal failure, Continuous renal replacement therapy, Intermittent hemodialysis, Sustained low-efficiency dialysis (SLED), Sustained lowefficiency daily diafiltration (SLEDD-f) Correspondence: Pi-Ru Tsai Department of Surgery, National Taiwan University Hospital, No 7 Chung-Shan S. Road, Taipei, Taiwan Phone: ext ; Fax: ; pirutsai@yahoo.com.tw 249