Sustained low-efficiency dialysis (SLED) with prostacyclin in critically ill patients with acute renal failure.
BACKGROUND
Prostacyclin is an easy-to-use and safe antihaemostatic drug for continuous renal replacement therapies (RRTs). No study has been performed so far about its use in critically ill patients with acute renal failure (ARF) treated with sustained low-efficiency dialysis (SLED), a hybrid modality between conventional intermittent and continuous RRTs.


METHODS
We studied 35 consecutive ICU patients with ARF, in whom data on safety and efficacy were prospectively collected in a single-centre experience over 15 months since August 2001. There were 25 males and 10 females; mean age, 72.1 (SD 11.4); mean APACHE II score at ICU admission, 24 (range 14-43); at RRT start, 27.4 (20-43); 28 patients (80%) were on mechanical ventilation and 17 (48.6%) had sepsis. SLED was performed using a conventional dialysis machine, with blood flow at 200 ml/min, bicarbonate-based ultrapure dialysate running at 100 ml/min, dialysate temperature 35 degrees C and low-flux polysulfone filters. Prostacyclin, under the form of its synthetic analogue epoprostenol, was infused at 6 ng/kg/min before the filter.


RESULTS
Out of 185 daily sessions performed (8-10 h, median 4 per patient, range 1-19), 19 (in 11 patients) were prematurely interrupted (10.3%; 95% CI: 5.4-18.6), after an average 58.5% of the prescribed treatment time (nine sessions in six patients for circuit clotting). This finding compared favourably with the experience we had at our unit using SLED with saline flushes. With the use of prostacyclin, two episodes of upper gastrointestinal bleeding were observed in 2/35 patients during SLED (5.7%; 95% CI: 0.7-19.2), corresponding to 1.1 episodes per 100 person-day on SLED. Therapeutic intervention for hypotension (fluids and/or vasopressor increase) was required in 45/185 (in 20 patients) of the sessions monitored (24.3%; 95% CI: 17.4-32.9); two sessions had to be interrupted because of refractory hypotension. Urea reduction ratio was 0.50 (SD 0.12); mean prescribed and obtained net ultrafiltration were 1.96 l (range 0.5-5.0) and 1.99 l (0.5-5.0), respectively. In-hospital mortality was 46%; mortality predicted by the APACHE II model at ICU admission was 42%; at SLED start, 51%.


CONCLUSIONS
Prostacyclin is a safe and effective antihaemostatic agent for SLED.
Fiaccadori
Enrico
E
Dipartimento di Clinica Medica, Nefrologia & Scienze della Prevenzione Universitá degli Studi di Parma, Via Gramsci 14, 43100 Parma, Italy. enrico.fiaccadori@unipr.it
Maggiore
Umberto
U
Parenti
Elisabetta
E
Giacosa
Roberto
R
Picetti
Edoardo
E
Rotelli
Carlo
C
Tagliavini
Dante
D
Cabassi
Aderville
A
D058186:Acute Kidney Injury / Q000628:therapy*; D000368:Aged; D016638:Critical Illness / Q000628:therapy; D015314:Dialysis Solutions; D011464:Epoprostenol / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D006435:Renal Dialysis / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome
D015314:Dialysis Solutions; D010975:Platelet Aggregation Inhibitors; D011464:Epoprostenol