Tailoring Kidney Replacement Therapy (KRT) for the ICU: How Sequential SLED Therapy Enhances Patient Care
Summary
In critical care nephrology, sequential Sustained Low-Efficiency Dialysis (SLED) therapy can transform the dialysis experience for ICU patients by prioritizing flexibility and patient-centered care. Dr. Sevag Demirjian, Director of Critical Care Nephrology at the Cleveland Clinic, shared how sequential SLED therapy, combined with the Tablo® Hemodialysis System, is addressing common dialysis challenges in the ICU and helping to improve patient outcomes.
This blog has been adapted from Dr. Demirjian’s conversation with Dr. Cynthia Silva, Outset’s VP of Clinical Affairs. To learn more, view the full webinar here.
Overcoming the Limitations of Traditional SLED Therapy
Traditional SLED therapy provides an intermediate option between intermittent and continuous dialysis by using lower blood and dialysate flow rates to improve hemodynamic stability. However, it can pose challenges within the critical care environment, where precise, individualized therapy is essential. Dr. Demirjian identified key issues with traditional SLED, including variability in drug clearance rates, disproportionate phosphate removal, and logistical constraints impacting operational flow.
“It’s very easy with traditional SLED to over-dialyze the patient. It’s very easy to drive the phosphate levels very low. It’s very easy if you’re not used to SLED prescriptions, for the potassium to get very low,” explained Dr. Demerjian. “We are way behind with [traditional] SLED therapy and proper antibiotic dosing.”
Sequential SLED addresses these challenges by separating the diffusion and ultrafiltration (UF) phases. By targeting UF goals with more controlled rates, sequential SLED allows clinicians to safely adjust treatment durations without risking over-dialysis or undershooting drug dosing requirements. This flexible approach makes it easier to manage electrolyte levels and volume, especially for patients who may not tolerate standard SLED or continuous dialysis.
How Tablo Supports Sequential SLED
Tablo facilitates sequential SLED by automating dialysis adjustments and allowing for high-intensity, 4-hour dialysis sessions followed by lower-intensity ultrafiltration. This structure helps patients receive the specific volume management they need while reducing potential complications associated with solute removal.
“Tablo made sense to us because it does have that flexibility,” said Dr. Demirjian. “You can have the flexibility of using the potassium baths, and the change of sodium, and change the intensity all the way to intermittent dialysis, and you do it with one machine.”
Tablo’s ease of use allows ICU nurses and dialysis-trained staff alike to manage treatments efficiently. “When you have a machine that’s easier to train people on and easier to troubleshoot, you introduce efficiencies into your system without needing highly specialized staff,” Dr. Demirjian added.
Patient Outcomes and Advantages of Sequential SLED
Sequential SLED therapy, especially when delivered through Tablo, offers multiple clinical advantages for critically ill patients. Dr. Demirjian shared data comparing sequential SLED to traditional SLED and continuous dialysis, showing that sequential SLED patients experienced lower rates of hypophosphatemia, better volume control, and more consistent drug dosing. “It’s about matching volume management to the patient’s needs,” Dr. Demirjian explained, stressing the importance of flexible treatment duration in achieving optimal patient outcomes.
By adjusting UF rates and duration to align with each patient’s unique requirements, sequential SLED helps prevent complications associated with over-dialysis. The protocol also enables “dialysis-free” hours, giving patients time to engage in other recovery activities, like physical therapy and respiratory weaning, that are critical in the ICU.
Operational and Cost Considerations
In addition to clinical benefits, sequential SLED offers substantial operational and cost efficiencies, particularly when implemented with Tablo. Dr. Demirjian underscored how Tablo simplifies critical care workflows: “The beauty of having one machine that can do it all is you don’t have to worry about training staff on multiple devices — they become proficient with one system.” This versatility enables ICU nurses to confidently manage sequential SLED, alleviating the need for dedicated dialysis staff and streamlining patient care.
Tablo’s automation enables smooth transitions between dialysis phases, reducing setup time and minimizing human error by removing manual steps. This operational flexibility not only improves workflow but also reduces both labor and equipment costs, offering a sustainable and scalable solution for delivering high-quality dialysis care in critical care environments.
Sequential SLED therapy, particularly when paired with Tablo, is advancing dialysis care for critically ill patients. By adapting dialysis schedules and intensities to individual patient needs, sequential SLED not only helps to optimize patient outcomes but also enhances operational efficiency and can reduce costs. For healthcare providers seeking to optimize kidney replacement therapy in critical care settings, sequential SLED represents an adaptable, efficient solution that aligns with the modern needs of nephrology care.