Extracorporeal Membrane Oxygenation-What the Nephrologist Needs to Know

Extracorporeal membrane oxygenation and acute kidney injury: a single-center retrospective cohort

To assess the relationship between acute kidney injury (AKI) with outcomes among patients requiring extracorporeal membrane oxygenation (ECMO). This is a single-center, retrospective cohort study of adult patients admitted to intensive care units (ICU) at a tertiary referral hospital requiring ECMO from July 1, 2015, to August 30, 2019. We assessed the temporal relationship of AKI and renal replacement therapy with ECMO type (VV vs. VA). The primary outcome was in-hospital mortality rates. We used Kruskal-Wallis or chi-square tests for pairwise comparisons, cause-specific Cox proportional hazards models were utilized for the association between AKI prevalence and in-hospital mortality, and a time-dependent Cox model was used to describe the association between AKI incidence and mortality. After the screening, 190 patients met eligibility criteria [133 (70%) AKI, 81 (43%) required RRT]. The median age was 61 years, and 61% were males. Among AKI patients, 48 (36%) and 85 (64%) patients developed AKI before and after ECMO, respectively. The SOFA Day 1, baseline creatinine, respiratory rate (RR), use of vasopressin, vancomycin, proton pump inhibitor, antibiotics, duration of mechanical ventilation and ECMO, and ICU length of stay were higher in AKI patients compared with those without AKI (P < 0.01). While ICU and in-hospital mortality rates were 46% and 50%, respectively, there were no differences based on the AKI status. The type and characteristics of ECMO support were not associated with AKI risk. Among AKI patients, 77 (58%) were oliguric, and 46 (60%) of them received diuretics. Urine output in the diuretic group was only higher on the first day than in those who did not receive diuretics (P = 0.03). Among ECMO patients, AKI was not associated with increased mortality but was associated with prolonged duration of mechanical ventilation and ICU length of stay.

Factors associated with acute kidney injury in patients undergoing extracorporeal membrane oxygenation: retrospective cohort

OBJECTIVE

To identify factors associated with acute kidney injury in patients undergoing extracorporeal membrane oxygenation.

METHOD

Retrospective cohort study conducted in an adult Intensive Care Unit with patients undergoing extracorporeal membrane oxygenation from 2012 to 2021. The research used the Kidney Disease Improving Global Outcomes as criteria for definition and classification of acute kidney injury. A multiple logistic regression model was developed to analyze the associated factors.

RESULTS

The sample was composed of 122 individuals, of these, 98 developed acute kidney injury (80.3%). In multiple regression, the associated factors found were vasopressin use, Nursing Activities Score, and glomerular filtration rate.

CONCLUSION

The use of vasopressin, the Nursing Activities Score, and the glomerular filtration rate were considered as factors related to the development of acute kidney injury in patients undergoing extracorporeal membrane oxygenation.

Extracorporeal Membrane Oxygenation and Continuous Kidney Replacement Therapy: Technology and Outcomes - A Narrative Review

The number of patients using critical care is increasing as our populations live longer thanks to advances in medical therapies. This is reflected by an increase in both usage and number of critical care beds as compared with total hospital beds across the United States. As this aging population suffers more and more from multiorgan dysfunction, including but not limited to respiratory failure, cardiac failure, and acute kidney injury, technologies are used to facilitate recovery in those that would have assuredly passed away years ago. Some of these advancements include extracorporeal membrane oxygenation and continuous kidney replacement therapy. In this article, we review the literature regarding the history, technology, indications, and outcomes of synchronous extracorporeal membrane oxygenation and kidney replacement therapy.

Incidence and Impact of Acute Kidney Injury in Patients Receiving Extracorporeal Membrane Oxygenation: A Meta-Analysis

BACKGROUND

Although acute kidney injury (AKI) is a frequent complication in patients receiving extracorporeal membrane oxygenation (ECMO), the incidence and impact of AKI on mortality among patients on ECMO remain unclear. We conducted this systematic review to summarize the incidence and impact of AKI on mortality risk among adult patients on ECMO.

METHODS

A literature search was performed using EMBASE, Ovid MEDLINE, and Cochrane Databases from inception until March 2019 to identify studies assessing the incidence of AKI (using a standard AKI definition), severe AKI requiring renal replacement therapy (RRT), and the impact of AKI among adult patients on ECMO. Effect estimates from the individual studies were obtained and combined utilizing random-effects, generic inverse variance method of DerSimonian-Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42018103527).

RESULTS

41 cohort studies with a total of 10,282 adult patients receiving ECMO were enrolled. Overall, the pooled estimated incidence of AKI and severe AKI requiring RRT were 62.8% (95%CI: 52.1%-72.4%) and 44.9% (95%CI: 40.8%-49.0%), respectively. Meta-regression showed that the year of study did not significantly affect the incidence of AKI (p = 0.67) or AKI requiring RRT (p = 0.83). The pooled odds ratio (OR) of hospital mortality among patients receiving ECMO with AKI on RRT was 3.73 (95% CI, 2.87-4.85). When the analysis was limited to studies with confounder-adjusted analysis, increased hospital mortality remained significant among patients receiving ECMO with AKI requiring RRT with pooled OR of 3.32 (95% CI, 2.21-4.99). There was no publication bias as evaluated by the funnel plot and Egger's regression asymmetry test with p = 0.62 and p = 0.17 for the incidence of AKI and severe AKI requiring RRT, respectively.

CONCLUSION

Among patients receiving ECMO, the incidence rates of AKI and severe AKI requiring RRT are high, which has not changed over time. Patients who develop AKI requiring RRT while on ECMO carry 3.7-fold higher hospital mortality.

Successful use of extracorporeal membrane oxygenation in a child with obstructive shock due to massive bilateral pulmonary embolism

BACKGROUND

Acute massive pulmonary embolism (PE) is a very rare condition in children. We report the successful use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) as a lifesaving modality in a child with acute massive PE.

CASE PRESENTATION

A nine-year-old female with spinal muscular atrophy type 1, chronic respiratory failure with tracheostomy and ventilator dependence presented with tachypnea and hypoxia. She had recent coiling of her pulmonary arterio-venous malformation. A chest computerized tomography scan showed massive bilateral PE. Urgent catheter-directed thrombolysis failed. She was placed on VA-ECMO with stabilization of hemodynamics. She underwent surgical thrombo-embolectomy followed by weaning of ECMO support.

DISCUSSION

The use of VA ECMO supported the cardio-respiratory status and perfusion to facilitate surgical embolectomy.