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Jones K, Keiser AM, Miller JL, Atkinson MA. Bilateral renal agenesis: fetal intervention and outcomes. Pediatr Nephrol 2024:10.1007/s00467-024-06449-8. [PMID: 38997547 DOI: 10.1007/s00467-024-06449-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/11/2024] [Accepted: 06/11/2024] [Indexed: 07/14/2024]
Abstract
Bilateral renal agenesis (BRA) is a fetal anomaly which leads to anhydramnios and resultant pulmonary hypoplasia. Historically, this anomaly was universally fatal early in the neonatal period due to the severity of the associated lung disease. Over the last 30 years, innovations in fetal therapies-specifically, serial amnioinfusions-have led to instances of infant pulmonary survival and initiation of postnatal dialysis, raising the possibility that early neonatal death may not be inevitable. Amnioinfusions are not without risk, and maternal complications can include prelabor rupture of membranes, preterm labor, infection, and bleeding. The data detailing neonatal outcomes are still limited and actively being collected. Two case series and one non-randomized clinical trial have supplied most of the known outcome data for infants with BRA after prenatal amnioinfusion. Although there are survivors reported in the literature, mortality remains high, with many deaths in infancy due to dialysis-associated sepsis. In addition, previously unknown morbidities have been documented in these infants, including neurologic injury. These challenges, in addition to the mechanical difficulties of providing dialysis to extremely small infants, can result in significant burdens for patients and their caregivers and moral distress for the health care team. The present review aims to explain the pathophysiology of BRA, detail the historical context and rationale for serial amnioinfusions to treat the pulmonary insufficiency associated with BRA, describe the available data regarding outcomes of infants born following prenatal amnioinfusions, discuss ethical issues surrounding this fetal intervention, and describe critical aspects of prenatal counseling for patients considering the intervention.
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Affiliation(s)
- Katherine Jones
- Department of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University, Tripler Army Medical Center, 1 Jarrett White Rd., Honolulu, HI, 96859, USA.
| | - Amaris M Keiser
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jena L Miller
- Center for Fetal Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meredith A Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Short K, McBride M, Anderson S, Miller R, Ingram D, Coghill C, Sims B, Askenazi D. Survival of Infants With Severe Congenital Kidney Disease After ECMO and Kidney Support Therapy. Pediatrics 2024; 153:e2023062717. [PMID: 38303642 DOI: 10.1542/peds.2023-062717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 02/03/2024] Open
Abstract
Congenital kidney failure not only affects the homeostatic functions of the kidney, but also affects neonatal respiratory integrity. Until recently, extracorporeal membrane oxygenation (ECMO) support was not used in this population because the need for ECMO clearly established nonviability. Since 2016, 31 neonates have been admitted to the NICU at Children's of Alabama with congenital kidney failure. Five patients were placed on ECMO for severe respiratory distress unresponsive to conventional interventions. We evaluated neonates with congenital kidney failure and pulmonary hypoplasia/hypertension refractory to conventional therapies who received ECMO support within the first 9 postnatal days. We describe the pre and postnatal diagnoses, ECMO course details, dialysis modalities, complications, procedures, and long-term outcomes of these patients. All 5 patients received kidney support therapy by postnatal day 7. Diagnoses included posterior urethral valves, bilateral renal dysplasia, and autosomal recessive polycystic kidney disease. Gestational age ranged from 35.6 to 37.1 weeks. Birth weight ranged from 2740 to 3140 g. Days on ECMO ranged from 4 to 23. Four survived and are living today. Pulmonary hypertension resolved in surviving patients. Three surviving patients require no oxygen support, and 1 patient requires nocturnal oxygen. Three survivors received a kidney transplant, and 1 awaits transplant evaluation. Patients with congenital kidney failure with severe pulmonary hypoplasia/pulmonary hypertension no longer warrant a reflexive assignment of nonviability. Meticulous ECMO, respiratory, nutritional, and kidney support therapies may achieve a favorable long-term outcome. Further investigation of strategies for optimal outcome is needed.
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Affiliation(s)
- Kara Short
- Pediatric and Infant Center for Acute Nephrology at Children's of Alabama
- Children's of Alabama, Birmingham, Alabama
| | | | - Scott Anderson
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham
| | | | - Daryl Ingram
- Pediatric and Infant Center for Acute Nephrology at Children's of Alabama
- Children's of Alabama, Birmingham, Alabama
| | - Carl Coghill
- Department of Neonatology, University of Alabama at Birmingham
| | - Brian Sims
- Department of Neonatology, University of Alabama at Birmingham
| | - David Askenazi
- Pediatric and Infant Center for Acute Nephrology at Children's of Alabama
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Extracorporeal Membrane Oxygenation Then and Now; Broadening Indications and Availability. Crit Care Clin 2023; 39:255-275. [PMID: 36898772 DOI: 10.1016/j.ccc.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life support technology provided to children to support respiratory failure, cardiac failure, or cardiopulmonary resuscitation after failure of conventional management. Over the decades, ECMO has expanded in use, advanced in technology, shifted from experimental to a standard of care, and evidence supporting its use has increased. The expanded ECMO indications and medical complexity of children have also necessitated focused studies in the ethical domain such as decisional authority, resource allocation, and equitable access.
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Fletcher KL, Chapman R. Update on pre-ECMO evaluation and treatment for term infants in respiratory failure. Semin Fetal Neonatal Med 2022; 27:101401. [PMID: 36450631 DOI: 10.1016/j.siny.2022.101401] [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] [Indexed: 11/18/2022]
Abstract
The epidemiology, diagnostic and management approach to severe hypoxemic respiratory failure in the term and near-term neonate has evolved over time, as has the need for extracorporeal membrane oxygenation (ECMO) support in this patient population. Many patients who historically would have required ECMO support now respond to less invasive therapies, with patients requiring ECMO generally representing a higher risk and more heterogenous group of underlying diagnoses. This review will highlight these changes over time and the current available evidence for the diagnosis and management of these infants, as well as the current indications and relative contraindications to ECMO support when oxygen delivery cannot meet demand with less invasive management.
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Affiliation(s)
- Kathryn L Fletcher
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, 333 Cedar Street, LMP, 4085, USA.
| | - Rachel Chapman
- Department of Pediatrics, USC Keck School of Medicine, Fetal & Neonatal Institute, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA.
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Rose AT, Keene S. Changing populations being treated with ECMO in the neonatal period - who are the others? Semin Fetal Neonatal Med 2022; 27:101402. [PMID: 36414493 DOI: 10.1016/j.siny.2022.101402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Extracorporeal life support via extracorporeal membrane oxygenation (ECMO) has served the sickest of neonates for almost 50 years. Naturally, the characteristics of neonates receiving ECMO have changed. Advances in care have averted the need for ECMO for some, while complex cases with uncertain outcomes, previously not eligible for ECMO, are now considered. Characterizing the disease states and outcomes for neonates on ECMO is challenging as many infants do not fall into classic categories, i.e. meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or congenital diaphragmatic hernia (CDH). Since 2017, over one third of neonatal respiratory ECMO runs reported to the Extracorporeal Life Support Organization Registry are grouped as Other, a catch-all that encompasses those with a diagnosis not included in the classic categories. This review summarizes the historical neonatal ECMO population, reviews advances in therapy and technology impacting neonatal care, and addresses the unknowns in the ever-growing category of Other.
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Affiliation(s)
- Allison T Rose
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA, 30322, USA.
| | - Sarah Keene
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA, 30322, USA.
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Cuestas J, Lohmann P, Hagan JL, Vogel AM, Fernandes CJ, Garcia-Prats JA. Mortality trends in neonatal ECMO for pulmonary hypoplasia: A review of the Extracorporeal Life Support Organization database from 1981 to 2016. J Pediatr Surg 2021; 56:788-794. [PMID: 33012559 DOI: 10.1016/j.jpedsurg.2020.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/24/2020] [Accepted: 09/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The purpose of this review is to provide ECMO outcome data for medical personnel who counsel families of patients with pulmonary hypoplasia (PH), often secondary to renal abnormalities. We report diagnoses and outcomes associated with PH in neonates that were treated with ECMO over the past 35 years. METHODS Retrospective cohort study using the ELSO database for neonates born between 1981 and 2016 with a primary or secondary diagnosis of PH. Five patient groups were created based on ICD-9 codes. Mortality rates were compared and trends over time were investigated. RESULTS Thirty-three percent of the 1385 patients survived to discharge. Congenital diaphragmatic hernia (CDH) patients had significantly higher mortality than PH patients secondary to renal dysplasia (p < 0.001). Mortality decreased significantly over time for all groups (p < 0.001). The proportion of patients alive at discharge increased over time for CDH patients (p < 0.001), whereas survival decreased for patients with PH secondary to renal dysplasia (p = 0.012). CONCLUSIONS Neonates with PH that require ECMO have high mortality rates, which have generally decreased over the past 35 years; however, mortality for neonates with PH secondary to renal dysplasia continues to increase. We speculate that the apparent rise in mortality for these patients is because of changes in patient selection subsequent to improvements in non-ECMO ventilatory support. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Jenifer Cuestas
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA.
| | - Pablo Lohmann
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Joseph L Hagan
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Adam M Vogel
- Department of Surgery, Division of Pediatric Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Joseph A Garcia-Prats
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
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Extracorporeal Life Support Organization (ELSO): Guidelines for Neonatal Respiratory Failure. ASAIO J 2020; 66:463-470. [DOI: 10.1097/mat.0000000000001153] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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