HAEMODIALYSIS MODALITY

AND SLED
OUTLINE
1. Uremic toxin
2. Solutes clearance
3. Haemodialysis (HD)
4. Sequential ultrafiltration (SU)
5. Hemodiafiltration (HDF)
6. Expanded haemodialysis (HDX)
7. Sustained low-efficiency dialysis (SLED)
8. Summary
OUTLINE
1. Uremic toxin
2. Solutes clearance
3. Haemodialysis (HD)
4. Sequential ultrafiltration (SU)
5. Hemodiafiltration (HDF)
6. Expanded haemodialysis (HDX)
7. Sustained low-efficiency dialysis (SLED)
8. Summary
UREMIC TOXIN
•Uremia is a broad term that has been variably used to describe the buildup of
various metabolic waste products that occurs with diminished kidney function.

•Along with the retention of these metabolic waste products, patients will experience a
constellation of symptoms named uremic symptoms.

•Urea is merely a marker for uremic toxin and it is far from perfect.

CJASN December 2021, 16 (12) 1918-1928

CJASN December 2021, 16 (12) 1918-1928
OUTLINE
1. Uremic toxin
2. Solutes clearance
3. Haemodialysis (HD)
4. Sequential ultrafiltration (SU)
5. Hemodiafiltration (HDF)
6. Expanded haemodialysis (HDX)
7. Sustained low-efficiency dialysis (SLED)
8. Summary
 DIFFUSION
Diffusion is the movement of solutes across
a semi-permeable membrane along the
solute concentration gradient.

Diffusion is directly proportionate to:

 Solute concentration
 Solute velocity
 Temperature
 Surface area of the membrane
 DIFFUSION
Diffusion is the movement of solutes across
a semi-permeable membrane along the
solute concentration gradient.

Diffusion is directly proportionate to:

 Solute concentration
 Temperature
 Surface area of the membrane
 CONVECTION
Convective clearance refers to the
movement of solutes out of the blood
compartment along with movement of
water or ultrafiltration.

Solutes are dragged along with water

across the dialysis membrane as long as the
solute can fit through the membrane pore.

The larger the pore size and thinner the

membrane, the higher its convective
clearance
 CONVECTION
Convective clearance refers to the
movement of solutes out of the blood
compartment along with movement of
water or ultrafiltration.

Solutes are dragged along with water

across the dialysis membrane as long as the
solute can fit through the membrane pore.

The larger the pore size and thinner the

membrane, the higher its convective
clearance
OUTLINE
1. Uremic toxin
2. Solutes clearance
3. Haemodialysis (HD)
4. Sequential ultrafiltration (SU)
5. Hemodiafiltration (HDF)
6. Expanded haemodialysis (HDX)
7. Sustained low-efficiency dialysis (SLED)
8. Summary
 RRT
Modalities

Intermittent Continuous

IHD PD

SLED CRRT
HAEMODIALYSIS (HD)
HD - BLOOD
HD - DIALYSATE
 TRANSPORT ACROSS MEMBRANE
Blood flow and Dialysate flow are in counter current flow to maintain the concentration
gradient along length of fibers.

Transport of toxins, electrolytes and water occurs from blood to dialysate and of electrolytes
from dialysate to blood.
HAEMODIALYSIS (HD)
•Effectively clear small, water soluble solutes mainly by diffusive
clearance.

•Small solute clearance are flow dependent.

• Blood Flow 300-400 ml/min

• Dialysate Flow 500ml/min

• Frequency 3x/week
ADVANTAGES
•Rapid solute and volume removal.
•Rapid correction of electrolyte
disturbances, such as hyperkalemia
•Rapid removal of drugs or other
substances in fatal intoxications.
•Decreased need for anticoagulation as
compared with other types of RRT.
DISADVANTAGES
•Risk of systemic hypotension caused by
rapid electrolyte
•Rapid solute removal from the
intravascular space can cause cerebral
edema and increased intracranial
pressured fluid removal
OUTLINE
1. Uremic toxin
2. Solutes clearance
3. Haemodialysis (HD)
4. Sequential ultrafiltration (SU)
5. Hemodiafiltration (HDF)
6. Expanded haemodialysis (HDX)
7. Sustained low-efficiency dialysis (SLED)
8. Summary
SEQUENTIAL ULTRAFILTRATION (SU)
•Ultrafiltration is done when we want to
predominantly remove fluid.

•So solutes are removed via convective clearance

together with the ultrafiltration but the amount is
minimal compared to HD.

•Better hemodynamic tolerability due to preservation

of osmotic pressure in the intravenous compartment.
OUTLINE
1. Uremic toxin
2. Solutes clearance
3. Haemodialysis (HD)
4. Sequential ultrafiltration (SU)
5. Hemodiafiltration (HDF)
6. Expanded haemodialysis (HDX)
7. Sustained low-efficiency dialysis (SLED)
8. Summary
HEMODIAFILTRATION (HDF)
•HDF is an extracorporeal blood clearance treatment that
combines both diffusive and convective solute clearance using
high flux dialyser and convective volume > 20% of total
processed blood.

•Convective volume is the total ultrafiltration volume

(Replacement fluid + extraction volume).

•Aim to remove solutes in the middle molecule spectrum.

•Ultrapure solution fluid is mandatory for HDF.

HDF – CONSIDERED IN
•Recurrent intradialytic hemodynamic instability

•Inadequate dialysis dose with conventional HD

•Treatment resistant hyperphosphatemia

•Congestive heart failure

•Protein energy wasting

•Growth retardation in children.

OUTLINE
1. Uremic toxin
2. Solutes clearance
3. Haemodialysis (HD)
4. Sequential ultrafiltration (SU)
5. Hemodiafiltration (HDF)
6. Expanded haemodialysis (HDX)
7. Sustained low-efficiency dialysis (SLED)
8. Summary
EXPANDED HAEMODIALYSIS (HDX)
•Use of Medium-cut-off / High-retention-onset membrane enables middle molecules clearance.

•Using conventional haemodialysis circuit with no need for large volume of replacement fluid.
This is achieved through internal filtration and back filtration
HDX – BENEFIT?
•No difference in all cause mortality.

•Pruritus, recovery time and restless leg syndrome improved with moderate confidence.

•Seems to reduce hospitalization days and infections

•QoL scores seemed to improve

•EPO resistive index and iron use seems to be on a reduced trend.

OUTLINE
1. Uremic toxin
2. Solutes clearance
3. Haemodialysis (HD)
4. Sequential ultrafiltration (SU)
5. Hemodiafiltration (HDF)
6. Expanded haemodialysis (HDX)
7. Sustained low-efficiency dialysis (SLED)
8. Summary
SUSTAINED LOW-EFFICIENCY DIALYSIS (SLED)
•Hybrid of IHD and CRRT

•Slower dialytic modalities run for prolonged periods using conventional HD

machines with modification of blood and dialysate flows.

•Combine the advantages of CRRT and IHD. It allows for improved

hemodynamic stability through gradual solute and volume removal as in CRRT
and provide high solute clearances as in IHD.
OUTLINE
1. Uremic toxin
2. Solutes clearance
3. Haemodialysis (HD)
4. Sequential ultrafiltration (SU)
5. Hemodiafiltration (HDF)
6. Expanded haemodialysis (HDX)
7. Sustained low-efficiency dialysis (SLED)
8. Summary
SUMMARY
1. RRT modalities are complementary; not competitive.

2. Personalised modality choice and prescription is the key.

3. Can switch between modalities as patient condition changes.

4. Optimise performance and delivery of RRT.