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Sun K, Yao C, Xu G, Wang J, Shou S, Jin H. Research progress on the pathogenesis of AKI complicated by ECMO. Clin Exp Nephrol 2024:10.1007/s10157-024-02559-7. [PMID: 39340702 DOI: 10.1007/s10157-024-02559-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 09/02/2024] [Indexed: 09/30/2024]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) stands as a pivotal intervention for patients grappling with cardiopulmonary insufficiency. However, alongside its therapeutic benefits, ECMO carries the risk of complications, with acute kidney injury (AKI) emerging as a significant concern. The precise pathophysiological underpinnings of AKI in the context of ECMO remain incompletely elucidated. METHODS A comprehensive literature review was conducted to explore the epidemiology and pathophysiological mechanisms underlying the utilization of ECMO in the management of AKI. RESULTS ECMO initiates a multifaceted cascade of inflammatory reactions, encompassing complement activation, endothelial dysfunction, white blood cell activation, and cytokine release. Furthermore, factors such as renal hypoperfusion, ischemia-reperfusion injury, hemolysis, and fluid overload exacerbate AKI. Specifically, veno-arterial ECMO (VA-ECMO) may directly induce renal hypoperfusion, whereas veno-venous ECMO (VV-ECMO) predominantly impacts pulmonary function, indirectly influencing renal function. CONCLUSION While ECMO offers significant therapeutic advantages, AKI persists as a potentially fatal complication. A thorough comprehension of the pathogenesis underlying ECMO-associated AKI is imperative for effective prevention and management strategies. Moreover, additional research is warranted to delineate the incidence of AKI secondary to ECMO and to refine clinical approaches accordingly.
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Affiliation(s)
- Keke Sun
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Congcong Yao
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Guowu Xu
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Jinxiang Wang
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Songtao Shou
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Heng Jin
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China.
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Felling RJ, Kamerkar A, Friedman ML, Said AS, LaRovere KL, Bell MJ, Bembea MM. Neuromonitoring During ECMO Support in Children. Neurocrit Care 2023; 39:701-713. [PMID: 36720837 DOI: 10.1007/s12028-023-01675-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
Extracorporeal membrane oxygenation is a potentially lifesaving intervention for children with severe cardiac or respiratory failure. It is used with increasing frequency and in increasingly more complex and severe diseases. Neurological injuries are important causes of morbidity and mortality in children treated with extracorporeal membrane oxygenation and include ischemic stroke, intracranial hemorrhage, hypoxic-ischemic injury, and seizures. In this review, we discuss the epidemiology and pathophysiology of neurological injury in patients supported with extracorporeal membrane oxygenation, and we review the current state of knowledge for available modalities of monitoring neurological function in these children. These include structural imaging with computed tomography and ultrasound, cerebral blood flow monitoring with near-infrared spectroscopy and transcranial Doppler ultrasound, and physiological monitoring with electroencephalography and plasma biomarkers. We highlight areas of need and emerging advances that will improve our understanding of neurological injury related to extracorporeal membrane oxygenation and help to reduce the burden of neurological sequelae in these children.
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Affiliation(s)
- Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Suite 2158, Baltimore, MD, USA.
| | - Asavari Kamerkar
- Department of Anesthesia Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew L Friedman
- Division of Pediatric Critical Care, Indiana School of Medicine, Indianapolis, IN, USA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Kapoor S, Kolchinski A, Gusdon AM, Premraj L, Cho SM. Plasma biomarkers for brain injury in extracorporeal membrane oxygenation. Acute Crit Care 2023; 38:389-398. [PMID: 38052506 PMCID: PMC10718502 DOI: 10.4266/acc.2023.01368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/24/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with refractory cardiorespiratory failure. Despite its benefits, ECMO carries a significant risk of neurological complications, including acute brain injury (ABI). Although standardized neuromonitoring and neurological care have been shown to improve early detection of ABI, the inability to perform neuroimaging in a timely manner is a major limitation in the accurate diagnosis of neurological complications. Therefore, blood-based biomarkers capable of detecting ongoing brain injury at the bedside are of great clinical significance. This review aims to provide a concise review of the current literature on plasma biomarkers for ABI in patients on ECMO support.
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Affiliation(s)
- Shrey Kapoor
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anna Kolchinski
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M. Gusdon
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Lavienraj Premraj
- Griffith University School of Medicine, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia
| | - Sung-Min Cho
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Grins E, Leacche M, Shrestha NM, Bjursten H, Ederoth P, Jovinge S. Interleukin-10: A Potential Pre-Cannulation Marker for Development of Acute Kidney Injury in Patients Receiving Veno-Arterial Extracorporeal Membrane Oxygenation. Blood Purif 2023; 52:631-641. [PMID: 37586332 DOI: 10.1159/000531328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 05/18/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Acute kidney injury (AKI) in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is associated with high mortality. The objective of this study was to investigate whether cytokine levels before the initiation of ECMO treatment could predict AKI. We also aimed to investigate the impact of AKI on 30-day and 1-year mortality. METHODS Serum cytokine levels were analyzed in 100 consecutive VA-ECMO-treated patients at pre-cannulation, at 48 h post-cannulation, and at 8 days. Clinical data to establish the incidence and outcome of AKI after the start of ECMO was retrieved from the local ECMO registry. SETTING The study was conducted at tertiary care, university hospital. Participants included 100 patients treated with VA-ECMO. INTERVENTIONS The blood samples for cytokine analysis were collected before VA-ECMO treatment, at 48 h after VA-ECMO treatment was started, and at 8 days. RESULTS Pre-cannulation serum IL-10 levels were significantly higher in patients who developed AKI (212 [38.9, 620.7]) versus those who did not (49.0 [11.9, 102.2]; p = 0.007), and the development of AKI can be predicted by pre-cannulation IL-10 levels (p = 0.025, OR = 1.2 [1.02-1.32]). The development of AKI during ECMO treatment is associated with increased 30-day mortality (p = 0.049) compared to patients who did not develop AKI and had a pre-cannulation estimated glomerular filtration rate ≥ 45 mL/min. The 1-year survival rate for patients with AKI who survived the first 30 days of ECMO treatment is comparable to that of patients without AKI. CONCLUSION Increased pre-cannulation IL-10 levels are associated with the development of AKI during VA-ECMO support. AKI is associated with increased 30-day mortality compared to patients with no AKI and better renal function. However, patients with AKI who survive the first 30 days have a 1-year survival rate similar to those without AKI.
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Affiliation(s)
- Edgars Grins
- Department of Anesthesiology and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiothoracic and Vascular Surgery, Anesthesia, and Intensive Care, Skåne University Hospital, Lund, Sweden
- DeVos Cardiovascular Research Program, Spectrum Health and Van Andel Institute, Grand Rapids, Michigan, USA
| | - Marzia Leacche
- DeVos Cardiovascular Research Program, Spectrum Health and Van Andel Institute, Grand Rapids, Michigan, USA
- Fredrik Meijer Heart and Vascular Institute, Spectrum Health Grand Rapids, Grand Rapids, Michigan, USA
| | - Nabin Manandhar Shrestha
- DeVos Cardiovascular Research Program, Spectrum Health and Van Andel Institute, Grand Rapids, Michigan, USA
- Fredrik Meijer Heart and Vascular Institute, Spectrum Health Grand Rapids, Grand Rapids, Michigan, USA
| | - Henrik Bjursten
- Department of Cardiothoracic and Vascular Surgery, Anesthesia, and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Per Ederoth
- Department of Anesthesiology and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiothoracic and Vascular Surgery, Anesthesia, and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Stefan Jovinge
- DeVos Cardiovascular Research Program, Spectrum Health and Van Andel Institute, Grand Rapids, Michigan, USA
- Fredrik Meijer Heart and Vascular Institute, Spectrum Health Grand Rapids, Grand Rapids, Michigan, USA
- Cardiovascular Institute Stanford University, Palo Alto, California, USA
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Marchetto L, Alshammari H, Todd M, Guerguerian AM. It All Circles Back to Cerebral Autoregulation: Understanding the Risk of Hypocapnia and Arterial Hypertension When Initialing Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2023; 24:614-617. [PMID: 37409897 DOI: 10.1097/pcc.0000000000003290] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Luca Marchetto
- SickKids ECLS Program, Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Hadeel Alshammari
- SickKids ECLS Program, Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mark Todd
- SickKids ECLS Program, Departments of Critical Care Medicine and Respiratory Therapy, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anne-Marie Guerguerian
- SickKids ECLS Program, Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Rajsic S, Breitkopf R, Oezpeker UC, Treml B. ECMO in Cardiogenic Shock: Time Course of Blood Biomarkers and Associated Mortality. Diagnostics (Basel) 2022; 12:diagnostics12122963. [PMID: 36552970 PMCID: PMC9776439 DOI: 10.3390/diagnostics12122963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a temporary life support for severe cardiogenic shock, gaining time for organ recovery, permanent assistance, or transplantation. In this work, we aimed to investigate the trends of blood biomarkers over the period of ECMO support and their role in patient outcome. METHODS This retrospective study comprised patients receiving va-ECMO support over the period of 14 years at a tertiary university center. RESULTS Of 435 patients, 62% (268/435) survived to discharge, and the most frequent adverse event was hemorrhage (46%), followed by thrombosis (25%). Deceased patients had increased blood levels of C-reactive protein, procalcitonin, and white blood cells during the whole observation period, with higher peaks compared with survivors. The multivariable model identified hemorrhage (HR 1.73, p = 0.005) and higher levels of procalcitonin (HR 1.01, p = 0.001) as independent risk factors for death. CONCLUSIONS In our population of critically ill patients receiving va-ECMO support, deceased patients had increased inflammatory biomarkers during the whole observation period. Patients having higher values of procalcitonin and experiencing bleeding events showed an increased risk for mortality. Further studies focusing on inflammation in ECMO patients, clarifying its role in patient outcome and potential therapeutic interventions, are warranted.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Ulvi Cenk Oezpeker
- Department of Cardiac Surgery, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-22748
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Tierradentro-Garcia LO, Stern JA, Dennis R, Hwang M. Utility of Cerebral Microvascular Imaging in Infants Undergoing ECMO. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1827. [PMID: 36553271 PMCID: PMC9776869 DOI: 10.3390/children9121827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Infants who require extracorporeal membrane oxygenation (ECMO) therapy have an increased risk of neurological complications and mortality. Microvascular imaging (MVI) is an advanced Doppler technique that allows high-resolution visualization of microvasculature in the brain. We describe the feasibility and utility of MVI for the evaluation of cerebral microvascular perfusion in patients undergoing ECMO. METHODS We retrospectively analyzed brain MVI scans of neonates undergoing ECMO. Two pediatric radiologists qualitatively assessed MVI scans to determine the presence or absence of tortuosity, symmetry, heterogeneity, engorgement, and hypoperfusion of the basal ganglia-thalamus (BGT) region, as well as the presence or absence of white matter vascular engorgement and increased peri-gyral flow in the cortex. We tested the association between the presence of the aforementioned brain MVI features and clinical outcomes. RESULTS We included 30 patients, 14 of which were male (46.7%). The time of ECMO duration was 11.8 ± 6.9 days. The most prevalent microvascular finding in BGT was lenticulostriate vessel tortuosity (26/30, 86.7%), and the most common microvascular finding in the cortex was increased peri-gyral flow (10/24, 41.7%). Cortical white matter vascular engorgement was significantly associated with the presence of any poor outcome as defined by death, seizure, and/or cerebrovascular events on magnetic resonance imaging (p = 0.03). CONCLUSION MVI is a feasible modality to evaluate cerebral perfusion in infants undergoing ECMO. Additionally, evidence of white matter vascular engorgement after ECMO cannulation could serve as a predictor of poor outcomes in this population.
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Affiliation(s)
| | - Joseph A. Stern
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Rebecca Dennis
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Misun Hwang
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Stroke in pediatric ECMO: a target for prevention and improvement. Pediatr Res 2022; 92:629-630. [PMID: 35906305 DOI: 10.1038/s41390-022-02199-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 11/08/2022]
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