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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2021  |  Volume : 32  |  Issue : 5  |  Page : 1495-1496
Heparin-free sustained low-efficiency dialysis in critical children in resource-constraint settings

1 Department of Pediatric Nephrology, Kidney Institute, Medanta , – The Medicity, Gurgaon, Haryana, India
2 Department of Pediatric Nephrology and Transplantation, Children's Hospital of Richmond at VCU, Richmond, VA, USA
3 Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
4 Department of Pediatric Nephrology, Akron Children's Hospital, Ohio, Cleveland, USA

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Date of Web Publication4-May-2022

How to cite this article:
Sethi SK, Bunchman T, Sarkar S, Alhasan K, Raina R. Heparin-free sustained low-efficiency dialysis in critical children in resource-constraint settings. Saudi J Kidney Dis Transpl 2021;32:1495-6

How to cite this URL:
Sethi SK, Bunchman T, Sarkar S, Alhasan K, Raina R. Heparin-free sustained low-efficiency dialysis in critical children in resource-constraint settings. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Jul 3];32:1495-6. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1495/344776

To the Editor,

Acute kidney injury (AKI) is common in hospitalized children, and the incidence varies depending on the underlying clinical state.[1] The options available for dialyzing sick children are acute peritoneal dialysis (PD), intermittent hemodialysis (IHD), and continuous renal replacement therapy (CRRT). IHD is not well tolerated in sick patients, especially those who are on inotropes, due to rapid fluid shifts. CRRT is comparatively tolerated better, but complications and cost-effectiveness pose problems, especially in resource-limited settings.[1] Raina et al reported that PD and HD are used more commonly in the developing world as a first-line therapy for sick children, in contrast to CRRT in the developed world.[1] These variations in the choice of modalities between the developing and developed countries can find their possible reasons at low income, lack of trained pediatric nephrologists, and resource deficiency in the developing countries.

Sustained low-efficiency dialysis (SLED) is a conceptual and technical hybrid of IHD and CRRT, and is now an increasingly popular method of renal replacement for adult AKI patients. Further, SLED is comparable to CRRT with respect to renal recovery, time to renal recovery, episodes of hypotension, and episodes of hemodynamic instability leading to vasopressor use with no statistically significant difference in between the two modalities in these regards in adult patients.[2] Lee et al reported the first use of SLED-f (SLED with pre-filter replacement) in the pediatric population. They reported in their cohort of sick children, SLED-f helped in improvement of hemodynamic parameters, fluid overload, metabolic acidosis and hyperkalemia. Further, they also showed a statistically significant drop in inflammatory markers.[3] Sethi et al demonstrated the feasibility of SLED in a multicentric retrospective record review. A total of 68 children (median age: 9.7 years) received 211 sessions of SLED. Twenty-seven sessions (12.7%) had to terminate prematurely, of which seven sessions (3.3% of total) due to circuit clotting. Post-SLED hypophosphatemia and hypokalemia were reported in six sessions (3%) and 59 sessions (28%) respectively. Heparin-free sessions were achievable in 153 sessions (72%). Out of 211 sessions, 148 sessions were on at least one inotrope (70.1%). Intradialytic hypotension or need for inotrope administration was seen in 31 (15%) sessions, but premature termination of the session due to hypotension was required in only 20 (9%) sessions.[4] In the first ever study on heparin-free pediatric SLED-f with pre-filter replacement, Sethi et al reported 242 sessions of SLED-f in 70 children. Only 23 sessions (9.5%) had to terminate prematurely, of which 21 (8.6% of total) were due to hypotension and two sessions (0.8% of total) due to circuit clotting. Post-SLED hypocalcemia, hypophosphatemia, and hypokalemia were reported in 15 sessions (6.2%), one session (0.4%), and 17 sessions (7.0%), respectively.[5]

[Table 1] shows complications reported in children undergoing SLED in medical literature.
Table 1: Complications of sustained low-efficiency dialysis in pediatric population in different studies.

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SLED, especially SLED-f appears to be an excellent kidney replacement modality with less cost and virtually no need for heparin or citrate anticoagulation, and has been endorsed by PCRRT-ICONIC group for resource constraint settings.[5] The cost-efficacy, safety, and less need for anticoagulation warrants more prospective studies on the use of this modality in the pediatric population.

Conflict of interest: None declared.

   References Top

Raina R, Chauvin AM, Bunchman T, et al. Treatment of AKI in developing and developed countries: An international survey of pediatric dialysis modalities. PLoS One 2017;12: e0178233.  Back to cited text no. 1
Sethi SK, Mittal A, Nair N, et al. Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children. Hemodial Int 2020;24:237-51.  Back to cited text no. 2
Lee CY, Yeh HC, Lin CY. Treatment of critically ill children with kidney injury by sustained low-efficiency daily diafiltration. Pediatr Nephrol 2012;27:2301-9.  Back to cited text no. 3
Sethi SK, Sinha R, Jha P, Wadhwani N, Raghunathan V, Dhaliwal M, et al. Feasibility of sustained low efficiency dialysis in critically sick pediatric patients: A multicentric retrospective study. Hemodial Int 2018;22:228-34.  Back to cited text no. 4
Sethi SK, Bansal SB, Khare A, et al. Heparin free dialysis in critically sick children using sustained low efficiency dialysis (SLEDD-f): A new hybrid therapy for dialysis in developing world. PLoS One 2018;13:e0195536.  Back to cited text no. 5

Correspondence Address:
Rupesh Raina
Department of Pediatric Nephrology, Akron Children's Hospital, Ohio, Cleveland
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.344776

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