Aim of the Study: Acute kidney injury (AKI) in septic shock has poor outcomes. Sustained low-efficiency dialysis (SLED) is increasingly replacing continuous renal replacement therapy as the preferred modality in Intensive Care Units (ICUs). However, the essential aspects of hemodynamic tolerability and efficacy of SLED in septic shock AKI has been minimally studied.
Patients and Methods: We describe hemodynamic tolerability using modified vasopressor index (VI) and vasopressor dependency (VD) and efficacy using a combination of Kt/v, correction of acidosis, electrolyte, and fluid overload. Adult ICU patients of septic shock in AKI requiring SLED were included in this study.
Results: One hundred and twenty-four patients of septic shock AKI requiring SLED were enrolled in the study. There were 74 nonsurvivors (NSs). Approximately, 56% (278/498) of the sessions in which vasopressors were required were studied. Metabolic acidosis (49%) was the predominant indication for the initiation of SLED in these patients. Baseline characteristics between survivors and NSs were comparable, except for age, severity scores, AKI stage, and coexisting illness. VI and VD prior to the initiation of SLED and delta VI and VD during SLED were significantly higher in NSs. Hemodynamic tolerability and efficacy of SLED was achievable only at lower vasopressor doses.
Conclusion: VI, VD, and combination of Kt/v together with correction of acidosis, electrolyte, and fluid overload can be used to describe hemodynamic tolerability and efficacy of SLED in septic shock AKI. However, at higher vasopressor doses in septic shock, hemodynamic tolerability and efficacy of SLED requires further evidence.
Liaño F, Junco E, Pascual J, Madero R, Verde E. The spectrum of acute renal failure in the Intensive Care Unit compared with that seen in other settings. The Madrid Acute Renal Failure Study Group. Kidney Int Suppl 1998;66:S16-24.
Ostermann M, Chang RW. Acute kidney injury in the Intensive Care Unit according to RIFLE. Crit Care Med 2007;35:1837-43.
Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, et al. Acute renal failure in critically ill patients: A multinational, multicenter study. JAMA 2005;294:813-8.
Metnitz PG, Krenn CG, Steltzer H, Lang T, Ploder J, Lenz K, et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002;30:2051-8.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2012;1:1-138.
Schwenger V, Weigand MA, Hoffmann O, Dikow R, Kihm LP, Seckinger J, et al. Sustained low efficiency dialysis using a single-pass batch system in acute kidney injury - A randomized interventional trial: The REnal Replacement Therapy Study in Intensive Care Unit PatiEnts. Crit Care 2012;16:R140.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39:165-228.
Wernovsky G, Wypij D, Jonas RA, Mayer JE Jr., Hanley FL, Hickey PR, et al. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants. A comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation 1995;92:2226-35.
Zuppa AF, Nadkarni V, Davis L, Adamson PC, Helfaer MA, Elliott MR, et al. The effect of a thyroid hormone infusion on vasopressor support in critically ill children with cessation of neurologic function. Crit Care Med 2004;32:2318-22.
Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: The EUPHAS randomized controlled trial. JAMA 2009;301:2445-52.
Daugirdas JT. Second generation logarithmic estimates of single-pool variable volume Kt/V: An analysis of error. J Am Soc Nephrol 1993;4:1205-13.
Rabindranath K, Adams J, Macleod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev 2007;12:CD003773.
Zhang L, Yang J, Eastwood GM, Zhu G, Tanaka A, Bellomo R. Extended daily dialysis versus continuous renal replacement therapy for acute kidney injury: A meta-analysis. Am J Kidney Dis 2015;66:322-30.
Kielstein JT, Schiffer M, Hafer C. Back to the future: Extended dialysis for treatment of acute kidney injury in the Intensive Care Unit. J Nephrol 2010;23:494-501.
Fieghen HE, Friedrich JO, Burns KE, Nisenbaum R, Adhikari NK, Hladunewich MA, et al. The hemodynamic tolerability and feasibility of sustained low efficiency dialysis in the management of critically ill patients with acute kidney injury. BMC Nephrol 2010;11:32.
Baldwin I, Bellomo R, Naka T, Koch B, Fealy N. A pilot randomized controlled comparison of extended daily dialysis with filtration and continuous veno-venous hemofiltration: Fluid removal and hemodynamics. Int J Artif Organs 2007;30:1083-9.
Marshall MR, Golper TA, Shaver MJ, Alam MG, Chatoth DK. Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy. Am J Kidney Dis 2002;39:556-70.
Silversides JA, Pinto R, Kuint R, Wald R, Hladunewich MA, Lapinsky SE, et al. Fluid balance, intradialytic hypotension, and outcomes in critically ill patients undergoing renal replacement therapy: A cohort study. Crit Care 2014;18:624.