Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Technology Insight: treatment of renal failure in the intensive care unit with extended dialysis

Abstract

Sustained low-efficiency dialysis (SLED) is an increasingly popular extracorporeal renal replacement therapy for patients with renal failure in the intensive care unit (ICU). Several centers across the world employ this 'hybrid' technique, which has advantages of both intermittent and continuous methods. The goal of these centers is to provide an easy-to-perform treatment with reduced solute clearances for prolonged periods. Many centers use standard, sophisticated dialysis equipment for SLED. An increasing number of hospitals in Europe and South America employ a single-pass batch dialysis system, the procedural simplicity of which makes it an ideal modality for SLED in the ICU. All systems offer the advantages of flexible timing of treatment and reduced costs; their ease of handling means that SLED is readily accepted by ICU staff. Prospective controlled studies have shown that SLED clears small solutes with an efficacy comparable to that of intermittent hemodialysis and continuous venovenous hemofiltration (even when the latter employs high rates of fluid substitution). Cardiovascular tolerability associated with SLED is similar to that associated with continuous renal replacement therapy, even in severely ill patients. Nocturnal dialysis—a special form of SLED—has all the advantages outlined above, with the added benefit of unrestricted physician access to the patient during the day, minimizing the interference of renal replacement therapy with other ICU activities.

Key Points

  • Renal failure in the intensive care unit is increasingly being managed with prolonged dialysis at low blood and dialysate flow rates ('sustained low-efficiency dialysis' or SLED)

  • Advantages of SLED are efficient clearance of small solutes, good cardiovascular tolerability, low risk of microbiological contamination, flexible treatment schedules and reduced costs

  • Standard dialysis equipment or single-pass batch systems can be used for SLED

  • Studies comparing outcomes of SLED with those of standard intermittent and continuous modalities are being performed

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Variation in patient temperature during sustained low-efficiency dialysis.

Similar content being viewed by others

References

  1. Himmelfarb J and Ikizler TA (2000) Quantitating urea removal in patients with acute renal failure: lost art or forgotten science? Semin Dial 13: 147–149

    Article  CAS  Google Scholar 

  2. Uchino S et al. (2005) Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 294: 813–818

    Article  CAS  Google Scholar 

  3. Augustine JJ et al. (2004) A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis 44: 1000–1007

    Article  Google Scholar 

  4. Lameire N et al. (2005) Acute renal failure. Lancet 365: 417–430

    Article  CAS  Google Scholar 

  5. Metnitz PG et al. (2002) Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 30: 2051–2058

    Article  Google Scholar 

  6. Kellum JA et al. (2002) The first international consensus conference on continuous renal replacement therapy. Kidney Int 62: 1855–1863

    Article  Google Scholar 

  7. Uehlinger DE et al. (2005) Comparison of continuous and intermittent renal replacement therapy for acute renal failure. Nephrol Dial Transplant 20: 1630–1637

    Article  Google Scholar 

  8. Venkataraman R et al. (2002) Dosing patterns for continuous renal replacement therapy at a large academic medical center in the United States. J Crit Care 17: 246–250

    Article  Google Scholar 

  9. Manns B et al. (2003) Cost of acute renal failure requiring dialysis in the intensive care unit: clinical and resource implications of renal recovery. Crit Care Med 31: 449–455

    Article  Google Scholar 

  10. Cole L et al. (2001) High-volume haemofiltration in human septic shock. Intensive Care Med 27: 978–986

    Article  CAS  Google Scholar 

  11. Schrier RW et al. (2004) Acute renal failure: definitions, diagnosis, pathogenesis, and therapy. J Clin Invest 114: 5–14

    Article  CAS  Google Scholar 

  12. Ronco C et al. (2000) Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 356: 26–30

    Article  CAS  Google Scholar 

  13. Schiffl H et al. (2002) Daily hemodialysis and the outcome of acute renal failure. N Engl J Med 346: 305–310

    Article  Google Scholar 

  14. Kudoh Y et al. (1988) Slow continuous hemodialysis—new therapy for acute renal failure in critically ill patients—Part 2. Animal experiments and clinical implication. Jpn Circ J 52: 1183–1190

    Article  CAS  Google Scholar 

  15. Kudoh Y and Iimura O (1988) Slow continuous hemodialysis—new therapy for acute renal failure in critically ill patients—Part 1. Theoretical consideration and new technique. Jpn Circ J 52: 1171–1182

    Article  CAS  Google Scholar 

  16. Tam PY et al. (1988) Slow continuous hemodialysis for the management of complicated acute renal failure in an intensive care unit. Clin Nephrol 30: 79–85

    CAS  PubMed  Google Scholar 

  17. Schlaeper C et al. (1999) High clearance continuous renal replacement therapy with a modified dialysis machine. Kidney Int Suppl 72: S20–S23

    Article  CAS  Google Scholar 

  18. Kumar VA et al. Extended daily dialysis: a new approach to renal replacement for acute renal failure in the intensive care unit. Am J Kidney Dis 36: 294–300

  19. Lonnemann G et al. (2000) Extended daily veno-venous high-flux haemodialysis in patients with acute renal failure and multiple organ dysfunction syndrome using a single path batch dialysis system. Nephrol Dial Transplant 15: 1189–1193

    Article  CAS  Google Scholar 

  20. Marshall MR et al. (2001) Sustained low-efficiency dialysis for critically ill patients requiring renal replacement therapy. Kidney Int 60: 777–785

    Article  CAS  Google Scholar 

  21. Kielstein JT et al. (2004) Efficacy and cardiovascular tolerability of extended dialysis in critically ill patients: a randomized controlled study. Am J Kidney Dis 43: 342–349

    Article  CAS  Google Scholar 

  22. Marshall MR et al. (2002) Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy. Am J Kidney Dis 39: 556–570

    Article  CAS  Google Scholar 

  23. Kumar VA et al. (2004) Extended daily dialysis vs continuous hemodialysis for ICU patients with acute renal failure: a two-year single center report. Int J Artif Organs 27: 371–379

    Article  CAS  Google Scholar 

  24. Fiaccadori E et al. (2004) Removal of linezolid by conventional intermittent hemodialysis, sustained low-efficiency dialysis, or continuous venovenous hemofiltration in patients with acute renal failure. Crit Care Med 32: 2437–2442

    Article  CAS  Google Scholar 

  25. Ratanarat R et al. (2005) Phosphate kinetics during different dialysis modalities. Blood Purif 23: 83–90

    Article  CAS  Google Scholar 

  26. Dhondt AW et al. (2003) Studies on dialysate mixing in the Genius® single-pass batch system for hemodialysis therapy. Kidney Int 63: 1540–1547

    Article  Google Scholar 

  27. Fliser D and Kielstein JT (2004) A single-pass batch dialysis system: an ideal dialysis method for the patient in intensive care with acute renal failure. Curr Opin Crit Care 10: 483–488

    Article  Google Scholar 

  28. Barenbrock M et al. (2000) Effects of bicarbonate- and lactate-buffered replacement fluids on cardiovascular outcome in CVVH patients. Kidney Int 58: 1751–1757

    Article  CAS  Google Scholar 

  29. Liao Z et al. (2003) Kinetic comparison of different acute dialysis therapies. Artif Organs 27: 802–807

    Article  Google Scholar 

  30. Marshall MR et al. (2004) Sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring renal replacement therapy: towards an adequate therapy. Nephrol Dial Transplant 19: 877–884

    Article  Google Scholar 

  31. Finkel KW and Foringer JR (2005) Safety of regional citrate anticoagulation for continuous sustained low efficiency dialysis (C-SLED) in critically ill patients. Ren Fail 27: 541–545

    Article  CAS  Google Scholar 

  32. Marshall MR et al. (2003) Regional citrate anticoagulation during simulated treatments of sustained low efficiency diafiltration. Nephrology 8: 302–310

    Article  CAS  Google Scholar 

  33. Morgera S et al. (2004) A simple, safe and effective citrate anticoagulation protocol for the genius dialysis system in acute renal failure. Nephron Clin Pract 98: c35–c40

    Article  CAS  Google Scholar 

  34. Kielstein JT et al. (2002) High-flux hemodialysis—an effective alternative to hemoperfusion in the treatment of carbamazepine intoxication. Clin Nephrol 57: 484–486

    Article  CAS  Google Scholar 

  35. Kielstein JT et al. (2003) Efficiency of high-flux hemodialysis in the treatment of valproic acid intoxication. J Toxicol Clin Toxicol 41: 873–876

    Article  CAS  Google Scholar 

  36. Kielstein JT et al. (2004) One for all—a multi-use dialysis system for effective treatment of severe thallium intoxication. Kidney Blood Press Res 27: 197–199

    Article  CAS  Google Scholar 

  37. Lund B et al. (2005) Efficacy of sustained low-efficiency dialysis in the treatment of salicylate toxicity. Nephrol Dial Transplant 20: 1483–1484

    Article  Google Scholar 

  38. Hicks LK and McFarlane PA (2001) Valproic acid overdose and haemodialysis. Nephrol Dial Transplant 16: 1483–1486

    Article  CAS  Google Scholar 

  39. Zazzo JF et al. (1995) High incidence of hypophosphatemia in surgical intensive care patients: efficacy of phosphorus therapy on myocardial function. Intensive Care Med 21: 826–831

    Article  CAS  Google Scholar 

  40. Mueller BA et al. (2003) Higher renal replacement therapy dose delivery influences on drug therapy. Artif Organs 27: 808–814

    Article  CAS  Google Scholar 

  41. Ahern JW et al. (2004) Experience with vancomycin in patients receiving slow low-efficiency dialysis. Hospital Pharmacy 39: 138–143

    Article  Google Scholar 

  42. Fish DN and Chow AT (1997) The clinical pharmacokinetics of levofloxacin. Clin Pharmacokinet 32: 101–119

    Article  CAS  Google Scholar 

  43. Kielstein JT et al. (2005) Pharmacokinetics and total elimination of meropenem and vancomycin in intensive care unit patients undergoing extended daily dialysis. Crit Care Med 33 (online ahead of print) [10.1097/01.ccm.0000190243.88133.3f]

  44. van der Sande FM et al. (2001) Thermal effects and blood pressure response during postdilution hemodiafiltration and hemodialysis: the effect of amount of replacement fluid and dialysate temperature. J Am Soc Nephrol 12: 1916–1920

    CAS  PubMed  Google Scholar 

  45. Kanagasundaram NS et al. (2003) A preliminary survey of bacterial contamination of the dialysate circuit in continuous veno-venous hemodialysis. Clin Nephrol 59: 47–55

    Article  CAS  Google Scholar 

  46. Kielstein JT et al. (2004) Low dialysance of asymmetric dimethylarginine (ADMA)—in vivo and in vitro evidence of significant protein binding. Clin Nephrol 62: 295–300

    Article  CAS  Google Scholar 

  47. Kielstein JT et al. (2005) Dialysate concentration and pharmacokinetics of 2F-Ara-A in a patient with acute renal failure. Eur J Haematol 74: 533–534

    Article  Google Scholar 

  48. Liefeldt L et al. (2004) Treatment of secondary pulmonary hypertension with bosentan and its pharmacokinetic monitoring in ESRD. Am J Kidney Dis 43: 923–926

    Article  Google Scholar 

  49. Alam M et al. (2000) Cost comparison between sustained low efficiency hemodialysis (SLED) and continuous venovenous hemofiltration (CVVH) for ICU patients with ARF. Am J Kidney Dis 35: A9

    Article  Google Scholar 

  50. Ma T et al. (2002) Cost comparison between sustained low efficiency daily dialysis/diafiltration (SLEDD) and continuous renal replacement therapy for ICU patients with ARF. Nephrology 7: A54

    Article  Google Scholar 

  51. Naka T et al. (2004) Prolonged daily intermittent renal replacement therapy in ICU patients by ICU nurses and ICU physicians. Int J Artif Organs 27: 380–387

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Danilo Fliser.

Ethics declarations

Competing interests

Dr Fliser has received speaker's fees and financial support for research from Fresenius Medical Care, Germany. Dr Kielstein has received speaker's fees from Fresenius Medical Care, Germany.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Fliser, D., Kielstein, J. Technology Insight: treatment of renal failure in the intensive care unit with extended dialysis. Nat Rev Nephrol 2, 32–39 (2006). https://doi.org/10.1038/ncpneph0060

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpneph0060

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing