title: Sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring renal replacement therapy: towards an adequate therapy.
abstract: BACKGROUND
  Sustained low-efficiency daily dialysis (SLEDD) is an increasingly popular renal replacement therapy for intensive care unit (ICU) patients. SLEDD has been previously reported to provide good solute control and haemodynamic stability. However, continuous renal replacement therapy (CRRT) is considered superior by many ICU practitioners, due first to the large amounts of convective clearance achieved and second to the ability to deliver treatment independently of nephrology services. We report on a program of sustained low-efficiency daily diafiltration (SLEDD-f) delivered autonomously by ICU nursing personnel, and benchmark solute clearance data with recently published reports that have provided dose-outcome relationships for renal replacement therapy in this population.
  
  
  METHODS
  SLEDD-f treatments were delivered using countercurrent dialysate flow at 200 ml/min and on-line haemofiltration at 100 ml/min for 8 h on a daily or at least alternate day basis. All aspects of SLEDD-f were managed by ICU nursing personnel. Clinical parameters, patient outcomes and solute levels were monitored. Kt/V, corrected equivalent renal urea clearance (EKRc) and theoretical Kt/V(B12) were calculated.
  
  
  RESULTS
  Fifty-six SLEDD-f treatments in 24 critically ill acute renal failure patients were studied. There were no episodes of intradialytic hypotension or other complications. Observed hospital mortality was 46%, not significantly different from the expected mortality as determined from the APACHE II illness severity scoring system. Electrolyte control was excellent. Kt/V per completed treatment was 1.43+/-0.28 (0.96-2.0). Kt/V(B12) per completed treatment was 1.02+/-0.21 (0.6-1.38). EKRc for patients was 35.7+/-6.4 ml/min (25.0-48.2).
  
  
  CONCLUSIONS
  SLEDD-f provides stable renal replacement therapy and good clinical outcomes. Logistic elements of SLEDD-f delivery by ICU nursing personnel are satisfactory. Small solute clearance is adequate by available standards for CRRT and intermittent haemodialysis, and larger solute clearance considerable. SLEDD-f is a viable alternative to CRRT in this setting.
authors.affiliation: Department of Renal Medicine, Middlemore Hospital, Private Bag 93311, Auckland, New Zealand. mrmarshall@middlemore.co.nz
authors.forename: Mark R
authors.initials: MR
authors.lastname: Marshall
authors.forename: Tianmin
authors.initials: T
authors.lastname: Ma
authors.forename: David
authors.initials: D
authors.lastname: Galler
authors.forename: Alan Patrick Nigel
authors.initials: AP
authors.lastname: Rankin
authors.forename: Anthony Brendan
authors.initials: AB
authors.lastname: Williams
mesh_terms: D058186:Acute Kidney Injury / Q000628:therapy*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness; D005260:Female; D017583:Hemodiafiltration / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies