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Thanapongsatorn P, Wanichwecharungruang N, Srisawat N. Outcomes of continuous renal replacement therapy versus peritoneal dialysis as a renal replacement therapy modality in patients undergoing Venoarterial extracorporeal membrane oxygenation. J Crit Care 2024; 84:154895. [PMID: 39116642 DOI: 10.1016/j.jcrc.2024.154895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION The optimal modality for renal replacement therapy (RRT) in patients venoarterial extracorporeal membrane oxygenation (VA-ECMO) remains unclear. This study aimed to compare outcomes between continuous renal replacement therapy (CRRT) and peritoneal dialysis (PD) in VA-ECMO patients. METHODS This single-center retrospective study included VA-ECMO patients who developed AKI and subsequently required CRRT or PD. Data on patient demographics, comorbidities, clinical characteristics, RRT modality, and outcomes were collected. The primary outcome was in-hospital mortality, with secondary outcomes including length of stays, RRT durations, and complications associated with RRT. RESULTS A total of 43 patients were included (72.1% male, mean age 58.2 ± 15.7 years). Of these, 21 received CRRT and 22 received PD during ECMO therapy. In-hospital mortality rates did not significantly differ between CRRT and PD groups (80.9% vs 90.9%, p = 0.35). However, PD was associated with a higher incidence of catheter-related complications, including malposition (31.8% vs 4.7%, p = 0.046), infection (22.7% vs 4.7%, p = 0.19), and bleeding (18.2% vs 9.5%, p = 0.66), respectively. CONCLUSION Among patients receiving VA-ECMO-supported RRT, our study revealed comparable in-hospital mortality rates between CRRT and PD, although PD was associated with a higher incidence of catheter-related complications.
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Affiliation(s)
- Peerapat Thanapongsatorn
- Division of Nephrology, Department of Medicine, Thammasat University Hospital, Pathum Thani, Thailand; Nephrology Unit, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | | | - Nattachai Srisawat
- Division of Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand.
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Guru PK, Balasubramanian P, Ghimire M, Bohman JKK, Seelhammer TG, Kashani KB, Schears GJ. Acute kidney injury in patients before and after extracorporeal membrane oxygenation (ECMO) - Retrospective longitudinal analysis of the hospital outcomes. J Crit Care 2024; 81:154528. [PMID: 38295627 DOI: 10.1016/j.jcrc.2024.154528] [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: 09/26/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 02/02/2024]
Abstract
PURPOSE Acute Kidney Injury (AKI) occurs in up to 85% of patients managed by ECMO support. Limited data are available comparing the outcomes among patients who develop AKI before and after ECMO initiation. METHODS A retrospective longitudinal observational study was performed on all adult patients placed on ECMO from January 2000 to December 2015 at our institution. Longitudinal multivariate logistic regressional analysis was performed to identify the variables that are associated with the outcome measures (post-ECMO AKI and in-hospital mortality). RESULTS A total of 329 patients were included in our analysis in which AKI occurred in 176 (53%) and 137 (42%) patients before and after ECMO, respectively. In the multivariate analysis, increasing age, pre-existing chronic kidney disease (CKD), increasing bilirubin, decreasing fibrinogen, and use of LVAD had significant association with post-ECMO AKI. In-hospital mortality was seen in 128 out of 176 (73%) patients in the pre-ECMO AKI group and 32 out of 137 (42%) in the post-ECMO AKI group. In the multivariate analysis, age, interstitial lung disease, pre-ECMO AKI, and post-ECMO RRT requirement were independently associated with mortality. CONCLUSION AKI before ECMO initiation and the need for RRT post-ECMO are independently associated with poor patient survival.
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Affiliation(s)
- Pramod K Guru
- Department of Critical Care Medicine, Department of Transplantation, Division of Nephrology & Hypertension, Mayo Clinic, Jacksonville, FL, USA.
| | | | - Manoj Ghimire
- Department of Internal Medicine, St Barnabas Hospital, Bronx, NY, USA.
| | - J Kyle K Bohman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Kianoush B Kashani
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
| | - Gregory J Schears
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
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Teng Y, Li Y, Li K, Hu Q, Yan S, Liu G, Ji B, Gao G. Risk Factors for Acute Kidney Injury in Adult Patients Under Veno-Arterial Extracorporeal Membrane Oxygenation Support. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00228-3. [PMID: 38942685 DOI: 10.1053/j.jvca.2024.03.038] [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: 12/03/2023] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE To investigate the incidence and risk factors of acute kidney injury (AKI) stage 3 in adult patients under veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. DESIGN A retrospective case-control study. SETTING Single center, Fuwai Hospital. PARTICIPANTS Adult VA-ECMO patients age ≥18 years and older treated between January 2020 and December 2022 were included. INTERVENTIONS The patients were grouped by whether they developed AKI Kidney Disease: Improving Global Outcomes (KDIGO) stage 3 or <3. Multivariate logistic regression was performed t"o evaluate risk factors of AKI stage 3. MEASUREMENTS AND MAIN RESULTS Among enrolled patients, 40 (53.3%) developed AKI stage 3. The in-hospital mortality of AKI stage 3 patients was significantly higher than that of AKI stage <3 patients (67.5% vs 34.3%; p = 0.004). Multivariate logistic regression analysis revealed that concomitant hypertension (odds ratio [OR], 0.250; 95% confidence interval [CI], 0.063, 0.987), p = 0.048), pre-ECMO hemoglobin (OR, 0.969; 95% CI, 0.947-0.992; p = 0.009), pre-ECMO lactate (OR, 1.173; 95% CI, 1.028-1.339; p = 0.018), and pre-ECMO creatinine (OR, 1.014; 95% CI, 1.003-1.025; p = 0.011) were independent risk factors for AKI stage 3. CONCLUSIONS This study found a high incidence (53.3%) of AKI stage 3 in adult patients with VA-ECMO support and an association with increased in-hospital mortality. Concomitant hypertension, low pre-ECMO hemoglobin, and elevated pre-ECMO lactate and pre-ECMO creatinine were independent risk factors for AKI stage 3 in patients receiving VA-ECMO. It is imperative to identify and adjust these risk factors to enhance outcomes for those supported by VA-ECMO.
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Affiliation(s)
- Yuan Teng
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases & Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yuan Li
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases & Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - KunYu Li
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases & Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Hu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases & Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases & Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases & Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases & Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Guodong Gao
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases & Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
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Sommerfeld O, Neumann C, Pfeifer MD, Faerber G, Kirov H, von Loeffelholz C, Doenst T, Sponholz C. Predictive Value of Serial Model of End-Stage Liver Disease Score Determination in Patients with Postcardiotomy Extracorporeal Membrane Oxygenation. J Clin Med 2024; 13:1856. [PMID: 38610621 PMCID: PMC11012714 DOI: 10.3390/jcm13071856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/05/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
(1) Background: The use of extracorporeal membrane oxygenation (ECMO) in low cardiac output states after cardiac surgery may aid in patient recovery. However, in some patients, the clinical state may worsen, resulting in multiple organ failure and high mortality rates. In these circumstances, calculating a model of end-stage liver disease (MELD) score was shown to determine organ dysfunction and predicting mortality. (2) Methods: We evaluated whether serial MELD score determination increases mortality prediction in patients with postcardiotomy ECMO support. (3) Results: Statistically, a cutoff of a 2.5 MELD score increase within 48 h of ECMO initiation revealed an AUC of 0.722. Further, we found a significant association between hospital mortality and 48 h MELD increase (HR: 2.5, 95% CI: 1.33-4.75, p = 0.005) after adjustment for possible confounders. (4) Conclusions: Therefore, serial MELD score determinations on alternate days may be superior to single measurements in this special patient cohort.
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Affiliation(s)
- Oliver Sommerfeld
- Department of Anaesthesiology and Critical Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; (C.N.); (M.-D.P.); (C.v.L.); (C.S.)
| | - Caroline Neumann
- Department of Anaesthesiology and Critical Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; (C.N.); (M.-D.P.); (C.v.L.); (C.S.)
| | - Marcel-Dominic Pfeifer
- Department of Anaesthesiology and Critical Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; (C.N.); (M.-D.P.); (C.v.L.); (C.S.)
| | - Gloria Faerber
- Clinic for Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; (G.F.); (H.K.); (T.D.)
| | - Hristo Kirov
- Clinic for Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; (G.F.); (H.K.); (T.D.)
| | - Christian von Loeffelholz
- Department of Anaesthesiology and Critical Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; (C.N.); (M.-D.P.); (C.v.L.); (C.S.)
| | - Torsten Doenst
- Clinic for Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; (G.F.); (H.K.); (T.D.)
| | - Christoph Sponholz
- Department of Anaesthesiology and Critical Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; (C.N.); (M.-D.P.); (C.v.L.); (C.S.)
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Sun KP, Zhou SJ, Liu YY, Cao H, Zheng YR, Chen Q. Elevated Renal-Resistive Index as an Indicator of Acute Kidney Injury Associated With Neonatal Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2024; 38:739-744. [PMID: 38151455 DOI: 10.1053/j.jvca.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE The authors aimed to assess the relationship between elevated renal-resistive index (RRI) and acute kidney injury (AKI) related to extracorporeal membrane oxygenation (ECMO) in neonatal patients. DESIGN This was a retrospective study. SETTING The study was conducted at a teaching hospital. PARTICIPANTS Sixteen neonates treated with ECMO at the authors' hospital between June 2021 and December 2022 were included in this study. INTERVENTIONS Demographic and clinical data of patients were collected from the computer database. The RRI of patients before and during ECMO treatment was measured by bedside ultrasound. A receiver operating characteristic (ROC) curve was constructed to evaluate the diagnostic value of elevation of RRI as evidence of neonatal ECMO-related AKI. Logistic regression analysis was utilized to calculate the odds ratio (OR) with a 95% CI. MEASUREMENTS AND MAIN RESULTS A total of 16 patients met the inclusion criteria. For the primary outcome, the authors observed that the RRI during ECMO therapy was significantly elevated in patients with AKI compared to those without AKI. As for the secondary outcome, ROC curve analysis revealed an optimal RRI cutoff of 0.797, with an area under the curve of 0.855 (95% CI, 0.664-1, p = 0.027). The sensitivity and specificity of RRI values >0.797 for diagnosing AKI were 72.7% and 80%, respectively. Univariate logistic regression analysis indicated an OR of 1.433 (95% CI 1.192-1.873, p < 0.05) for RRI values above 0.797. This association remained statistically significant even after adjusting for serum cystatin C and Sequential Organ Failure Assessment score, with an adjusted OR of 1.352 (95% CI 1.108-1.612, p < 0.05). CONCLUSION The elevation of the RRI demonstrated a strong correlation with the onset of neonatal ECMO-related AKI, which may offer valuable support for diagnosing neonatal ECMO-related AKI.
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Affiliation(s)
- Kai-Peng Sun
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Si-Jia Zhou
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Ying-Ying Liu
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yi-Rong Zheng
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
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Lovrić D, Pašalić M, Križanac S, Kovačić K, Skorić B, Jurin H, Miličić D, Premužić V. The addition of Cytosorb in patients on VA-ECMO improves urinary output and ICU survival. Ther Apher Dial 2024; 28:103-111. [PMID: 37697687 DOI: 10.1111/1744-9987.14064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 03/18/2023] [Accepted: 09/01/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION The aim of this study was to analyze the efficiency of CytoSorb adsorber in patients presenting with cardiogenic shock and treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS Sixteen patients put on VA ECMO due to cardiogenic shock were included, stratified according to the use of Cytosorb adsorber in the first 24 h and compared across different clinical outcomes. RESULTS Significantly lower vasopressor doses were required among patients treated with Cytosorb at the initiation and before weaning from ECMO. Furthermore, these patients showed significantly higher urine output before weaning and lower lactate levels during the extracorporeal support. Finally, the mortality rate was lower among the Cytosorb therapy group (22.2% vs 57.1%). CONCLUSION While a decrease in vasopressor doses was already associated with CytoSorb use, this is the first study showing an increase in urinary output and a trend towards better survival among patients on VA ECMO treated with CytoSorb.
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Affiliation(s)
- Daniel Lovrić
- Cardiology Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | - Marijan Pašalić
- Cardiology Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | | | - Karla Kovačić
- Emergency Medicine Institute of Koprivnica-Križevci County, Koprivnica, Croatia
| | - Boško Skorić
- Cardiology Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | - Hrvoje Jurin
- Cardiology Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | - Davor Miličić
- Cardiology Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | - Vedran Premužić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, Zagreb, Croatia
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Penaud V, Duburcq T, Bureau C, Salmon Gandonnière C, Arrestier R, Henri S, Dres M, Jacquier S, Prost ND, Giraud R, Ricard JD, Roux D, Uhel F, Legouis D, Verney C. Kidney Increase Natriuresis but Not Glomerular Filtration Under Veno-venous ECMO, a Retrospective Study. J Intensive Care Med 2024; 39:146-152. [PMID: 37632128 DOI: 10.1177/08850666231195755] [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: 08/27/2023]
Abstract
PURPOSE Acute kidney injury is a frequent complication of acute respiratory distress syndrome (ARDS). We aim to study the evolution of kidney function in patients presenting severe ARDS and requiring veno-venous extracorporeal membrane oxygenation (VV ECMO). METHODS We conducted a multicenter retrospective study, including adult patients requiring VV ECMO for ARDS. The primary outcome was the evolution of the serum creatinine level after VV ECMO initiation. Secondary outcomes were change in urine output, and urine biochemical parameters after VV ECMO initiation. RESULTS One hundred and two patients were included. VV ECMO was initiated after a median of 6 days of mechanical ventilation, mainly for ARDS caused by COVID-19 (73%). Serum creatinine level did not significantly differ after VV ECMO initiation (P = .20). VV ECMO was associated with a significant increase in daily urine output (+6.6 mL/kg/day, [3.8;9.3] P < .001), even after adjustment for potential confounding factors; with an increase in natriuresis. The increase in urine output under VV ECMO was associated with a reduced risk of receiving kidney replacement therapy (OR 0.4 [0.2;0.8], P = .026). CONCLUSIONS VV ECMO initiation in severe ARDS is associated with an increase in daily urine output and natriuresis, without change in glomerular filtration rate.
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Affiliation(s)
- Victor Penaud
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
| | | | - Côme Bureau
- Médecine Intensive et Réanimation - R3S, AP-HP, Hôpital Pitié-Salpêtrière, Paris Sorbonne Université, Paris, France
- Sorbonne Université, INSERM_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Charlotte Salmon Gandonnière
- Université François Rabelais, CHRU de Tours, Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-TriggerSep Research Network, Tours, France
| | - Romain Arrestier
- Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, Université Paris Est Créteil, Créteil, France
| | - Samuel Henri
- Médecine Intensive Réanimation, CHU Lille, Lille, France
| | - Martin Dres
- Médecine Intensive et Réanimation - R3S, AP-HP, Hôpital Pitié-Salpêtrière, Paris Sorbonne Université, Paris, France
- Sorbonne Université, INSERM_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Sophie Jacquier
- Université François Rabelais, CHRU de Tours, Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-TriggerSep Research Network, Tours, France
| | - Nicolas De Prost
- Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, Université Paris Est Créteil, Créteil, France
| | - Raphael Giraud
- Département de Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
| | - Jean-Damien Ricard
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
- Université Paris Cité, UMR1137 IAME, INSERM, Paris, France
| | - Damien Roux
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
- Université Paris Cité, INSERM UMR-S1151, CNRS UMR-S8253, Institut Necker-Enfants Malades, Paris, France
| | - Fabrice Uhel
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
- Université Paris Cité, INSERM UMR-S1151, CNRS UMR-S8253, Institut Necker-Enfants Malades, Paris, France
| | - David Legouis
- Département de Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
- Département de physiologie cellulaire, Faculté de Médecine, Université de Genève, Genève, Suisse
| | - Charles Verney
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
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Surjit A, Prasannan B, Abraham J, Balagopal A, Unni VN. Acute Kidney Injury in Patients Undergoing Extracorporeal Membrane Oxygenation: A Retrospective Cohort Study. Indian J Crit Care Med 2024; 28:26-29. [PMID: 38510762 PMCID: PMC10949276 DOI: 10.5005/jp-journals-10071-24612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/06/2023] [Indexed: 03/22/2024] Open
Abstract
Aims and background Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal therapy to support oxygenation of patients with severe cardiac or respiratory failure. Studies have shown that acute kidney injury (AKI) can worsen the outcome in these patients. This study aims to assess the incidence and outcome of AKI in patients on ECMO support. Materials and methods This retrospective study included 64 patients who underwent ECMO for more than 24 hours. Patients who died within 48 hours of initiation of ECMO and patients with end-stage renal disease (ESRD) on maintenance hemodialysis were excluded. Acute kidney injury was diagnosed and categorized according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Results Of the 64 patients studied, 38 patients (59.38%) developed AKI and 17 patients (44.73%) among them developed AKI within 24 hours of initiation of ECMO. Age, Acute Physiology and Chronic Health Evaluation (APACHE-II) score, hypertension, use of nephrotoxic agents, inotropic support, and poor cardiac function were the risk factors associated with the development of AKI. Diabetes mellitus, type of ECMO used, and duration of ECMO were not found to be risk factors for AKI. Renal replacement therapy was initiated in 31 patients (81.58%). The overall mortality in the whole group was 67.19%, while it was 81.58% among the patients with AKI. Conclusion Acute kidney injury was found to be an independent risk factor for mortality in patients on ECMO. Early identification of the risk factors for AKI and management may help to improve the survival rate. Clinical significance The occurrence of AKI among patients on ECMO support increases the risk of mortality significantly. Hence, measures to prevent AKI, as well as early detection and appropriate management of AKI, would improve patient outcomes. How to cite this article Surjit A, Prasannan B, Abraham J, Balagopal A, Unni VA. Acute Kidney Injury in Patients Undergoing Extracorporeal Membrane Oxygenation: A Retrospective Cohort Study. Indian J Crit Care Med 2024;28(1):26-29.
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Affiliation(s)
- Aswin Surjit
- Department of Internal Medicine, Aster Medcity, Kochi, Kerala, India
| | - Bipi Prasannan
- Department of Nephrology, Aster Medcity, Kochi, Kerala, India
| | - Jobin Abraham
- Department of Critical Care, Aster Medcity, Kochi, Kerala, India
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Sitbon A, Coutrot M, Montero S, Chommeloux J, Lebreton G, Huang F, Frapard T, Assouline B, Pineton De Chambrun M, Hekimian G, Luyt CE, Combes A, Schmidt M. Early renal recovery after acute kidney injury in patients on venoarterial extracorporeal membrane oxygenation: A retrospective study. J Crit Care 2023; 78:154368. [PMID: 37540960 DOI: 10.1016/j.jcrc.2023.154368] [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: 04/05/2023] [Revised: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 08/06/2023]
Abstract
PURPOSE The impact of VA-ECMO on early renal recovery (within 7 days after ECMO onset) in patients with pre-ECMO acute kidney injury and cardiogenic shock is unknown. MATERIAL AND METHODS This retrospective single-center study included adult patients with cardiogenic shock rescued by VA-ECMO and severe AKI occurring before ECMO implantation (pre-ECMO AKI). Patients with early renal recovery (defined as at least a 50% decrease in peak serum creatinine or weaning from renal replacement therapy) were compared to patients without early renal recovery. RESULTS During 7 years, 145 patients with severe pre-ECMO AKI were included. Eighty-two patients had no early renal recovery whereas 63 had early renal recovery within 7 days after VA-ECMO onset. The median time to early renal recovery was 4 (3,6) days. Nephrotoxic antibiotics (HR = 0.35 [95% CI, 0.21-0.59], p < 0.001), median fluid balance during the first 7 days of VA-ECMO (HR = 0.77 [95% CI, 0.64-0.93], p = 0.008), pre-ECMO AKI stage 3 (HR = 0.36 [95% CI, 0.20-0.64], p < 0.001) and median vasoactive-inotropic score (HR = 0.99 [95% CI, 0.98,1.00], p = 0.035) were independently associated with no early renal recovery. CONCLUSIONS Only 43% of patients with severe pre-ECMO AKI had early renal recovery after VA-ECMO initiation.
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Affiliation(s)
- Alexandre Sitbon
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France
| | - Maxime Coutrot
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France
| | - Santiago Montero
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, 08916 Badalona, Spain
| | - Juliette Chommeloux
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Thoracic and Cardiovascular Department, 75651 Paris Cedex 13, France
| | - Florent Huang
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France
| | - Thomas Frapard
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France
| | - Benjamin Assouline
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France
| | - Marc Pineton De Chambrun
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France
| | - Guillaume Hekimian
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France
| | - Charles Edouard Luyt
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France
| | - Alain Combes
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France
| | - Matthieu Schmidt
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France.
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10
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Siriwardena M, Breeding J, Gopalakrishnan M, Jansz P, Granger EK, Jackson A, MacDonald PS, Lowe D, Buscher H, Nair P. Pulse pressure within the first 2 days of veno-arterial extracorporeal membrane oxygenation is predictive of death prior to hospital discharge, renal dysfunction requiring dialysis and pulmonary oedema. Perfusion 2023; 38:1568-1576. [PMID: 36036658 DOI: 10.1177/02676591221115935] [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: 11/16/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) flows are titrated to achieve adequate perfusion while attempting to ideally maintain arterial pulse pressure (PP). We assessed risk in patients with low PP defined as <10 mmHg within the first 2 days of support. METHODS Demographics, haemodynamics, echocardiographic and radiological findings were recorded retrospectively in cases conducted between 2014 and 2016. Outcomes were hospital mortality, requirement for renal replacement therapy (RRT) and severe pulmonary oedema (PO). RESULTS Of 101 patients, 66.3% were male, mean age was 56 (range 18-71 years), mean duration of support was 6.3 days ± 4.1 days, 37.6% died prior to hospital discharge, 39.6% needed RRT and 11.9% had severe PO. Areas under the receiver operating curves of PP at 48 h for hospital mortality, RRT and severe PO were (respectively): 0.69 (95% CI 0.58-0.80, p = .001), 0.64 (95% CI 0.50-0.77, p = .044), 0.69 (95% CI 0.55-0.82, p = .009). The odds ratio for mortality, RRT, severe PO for those with low PP were (respectively) 2.8 (95% CI 1.01-7.5, p = .04), 3.1 (95% CI 1.11-8.40, p = .026), 7.6 (95% CI 2.06-27.89, p = .001). Central venous pressure, mean arterial pressure were not predictive. CONCLUSION PP during the first 2 days of support is predictive of clinically important outcomes in patients supported with VA-ECMO.
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Affiliation(s)
- Maithri Siriwardena
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Jeff Breeding
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Mani Gopalakrishnan
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Paul Jansz
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Emily K Granger
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Andrew Jackson
- Department of Cardiac Anaesthesia, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Peter S MacDonald
- Cardiac Failure and Transplantation, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - David Lowe
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Hergen Buscher
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Centre of Applied Medical Research, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
| | - Priya Nair
- Department of Intensive Care, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia
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11
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Teixeira JP, Larson LM, Schmid KM, Azevedo K, Kraai E. Extracorporeal cardiopulmonary resuscitation. Int Anesthesiol Clin 2023; 61:22-34. [PMID: 37589133 DOI: 10.1097/aia.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- J Pedro Teixeira
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Lance M Larson
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Kristin M Schmid
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Keith Azevedo
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Erik Kraai
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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12
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Palacios CRF, Hoxhaj R, Thigpen C, Jacob J, Bhatnagar A, Saberi A. Outcomes of patients with COVID-19 requiring extracorporeal membrane oxygenation and continuous renal replacement therapy in the United States. Acute Crit Care 2023; 38:308-314. [PMID: 37652860 PMCID: PMC10497892 DOI: 10.4266/acc.2023.00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/25/2023] [Accepted: 06/22/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) infection is associated with significant morbidity and mortality. Some patients develop severe acute respiratory distress syndrome and kidney failure requiring the combination of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). METHODS Retrospective cohort study of 127 consecutive patients requiring combined ECMO and CRRT support in intensive care units at an ECMO center in Marietta, GA, United States. RESULTS Sixty and 67 patients with and without COVID-19, respectively, required ECMO-CRRT support. After adjusting for confounding variables, patients with COVID-19 had increased mortality at 30 days (hazard ratio [HR], 5.19; 95% confidence interval [CI], 2.51-10.7; P<0.001) and 90 days (HR, 6.23; 95% CI, 2.60-14.9; P<0.001). CONCLUSIONS In this retrospective study, patients with COVID-19 who required ECMO-CRRT had increased mortality when compared to patients without COVID-19.
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Affiliation(s)
| | - Rudiona Hoxhaj
- Internal Medicine, WellStar Health System, Marietta, GA, USA
| | - Catlyn Thigpen
- Internal Medicine, WellStar Health System, Marietta, GA, USA
| | - Jeffrey Jacob
- Internal Medicine, WellStar Health System, Marietta, GA, USA
| | - Atul Bhatnagar
- Critical Care Medicine, WellStar Health System, Marietta, GA, USA
| | - Asif Saberi
- Critical Care Medicine, WellStar Health System, Marietta, GA, USA
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13
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Tarzia V, Bagozzi L, Ponzoni M, Pradegan N, Banchelli F, Bortolussi G, Bellanti E, Bianco R, Zanella F, Bottio T, Gregori D, Gerosa G. Prognosticating Mortality of Primary Cardiogenic Shock Requiring Extracorporeal Life Support: The RESCUE Score. Curr Probl Cardiol 2023; 48:101554. [PMID: 36529235 DOI: 10.1016/j.cpcardiol.2022.101554] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
We aimed to identify prognostic laboratory markers during extracorporeal life support (ECLS) in patients with primary refractory cardiogenic shock (RCS) and to create a preliminary specific mortality score. All 208 consecutive subjects admitted for primary RCS and treated with ECLS between January-2009 and December-2018 were retrospectively analyzed. Multivariate regression analysis on laboratory markers during the first nine days of ECLS was used to develop a "Refractory End-stage Shock CUred with Ecls" (RESCUE) score. Serum creatinine (OR = 3.72, 95%CI: 2.01-6.88), direct bilirubin (OR = 1.40, 95%CI: 1.05-1.8), and platelet count (OR = 0.62, 95%CI: 0.42-0.94) were independent predictors of in-hospital mortality and were included in the score. The mean AUC was 0.763 (95%CI: 0.698-0.828) in the development cohort and 0.729 (95%CI: 0.664-0.794) in the bootstrap internal validation cohort. The RESCUE score represents a novel promising instrument to predict early mortality during the first critical days of ECLS and to help in properly guiding the therapeutic decision-making process.
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Affiliation(s)
- Vincenzo Tarzia
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy.
| | - Lorenzo Bagozzi
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Matteo Ponzoni
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Nicola Pradegan
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Federico Banchelli
- Statistics Unit, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Giacomo Bortolussi
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Ermanno Bellanti
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Roberto Bianco
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Fabio Zanella
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Tomaso Bottio
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
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14
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Flinspach AN, Raimann FJ, Bauer F, Zacharowski K, Ippolito A, Booke H. Therapy and Outcome of Prolonged Veno-Venous ECMO Therapy of Critically Ill ARDS Patients. J Clin Med 2023; 12:2499. [PMID: 37048583 PMCID: PMC10094941 DOI: 10.3390/jcm12072499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/06/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) therapy has become increasingly used and established in many hospitals as a routine treatment. With ECMO-therapy being a resource-demanding procedure, it is of interest whether a more prolonged VV-ECMO treatment would hold sufficient therapeutic success. Our retrospective study included all VV-ECMO runs from 1 January 2020 to 31 June 2022. We divided all runs into four groups (<14 days, 14-27, 28-49, 50+) of different durations and looked for differences overall in hospital survival. Additionally, corresponding treatments and therapeutic modalities, as well as laboratory results, were analyzed. We included 117 patients. Of those, 97 (82.9%) received a VV-ECMO treatment longer than two weeks. We did not find a significant association between ECMO duration (p = 0.15) and increased mortality though a significant correlation between the patients' age and their probability of survival (p = 0.02). Notably, we found significantly lower interleukin-6 levels with an increase in therapy duration (p < 0.01). Our findings show no association between the duration of ECMO therapy and mortality. Thus, the treatment duration alone may not be used for making assumptions about the prospect of survival. However, attention is also increasingly focused on long-term outcomes, such as post-intensive care syndrome with severe impairments.
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Affiliation(s)
- Armin N Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Florian J Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Frederike Bauer
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Angelo Ippolito
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Hendrik Booke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Albert-Schweitzer-Straße 33, 48149 Muenster, Germany
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15
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Shin M, Han JJ, Cohen WG, Iyengar A, Helmers MR, Kelly JJ, Patrick WL, Wang X, Cevasco M. Higher Rates of Dialysis and Subsequent Mortality in the New Allocation Era for Heart Transplants. Ann Thorac Surg 2023; 115:502-509. [PMID: 35926639 DOI: 10.1016/j.athoracsur.2022.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/30/2022] [Accepted: 07/19/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2018, a United Network for Organ Sharing (UNOS) policy change increased prioritization of patients bridged with temporary mechanical circulatory support devices, such as venoarterial ECMO, for cardiac transplantation. Considering increased waitlist acuity, we sought to characterize whether this was associated with an increased risk for development of postoperative acute renal failure requiring dialysis (AKI-D) and risk of death after transplantation. METHODS Dialysis-naive adults receiving single-organ heart transplant between November 2009 and February 2020 were stratified by receipt of AKI-D. Era 1 and era 2 were defined by the periods of UNOS allocation before and after policy change, respectively. Multivariable logistic regression was performed to determine risk factors for AKI-D. Rates of AKI-D were compared by propensity score-matched cohorts. Survival was compared by Kaplan-Meier analysis. RESULTS A total of 20 698 patients were included. Venoarterial ECMO use significantly increased in era 2 (5.6% vs 0.58%; P < .01). Overall prevalence of AKI-D was greater in era 2 (13.5% vs 10.2%; P < .01). Use of preoperative ECMO, intra-aortic balloon pump, and ventilators and longer ischemia times were identified as independent risk factors for development of AKI-D. Five- and 10-year survival rates were significantly decreased for patients with AKI-D. There was no short-term survival difference of patients with AKI-D between era 2 and the more contemporary era 1. CONCLUSIONS Patients in whom AKI-D develops after transplantation have significantly worse short- and long-term outcomes. Preoperative use of ECMO, preoperative ventilator support, and longer ischemia times are risk factors for development of AKI-D, and their prevalence has increased since the allocation policy change.
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Affiliation(s)
- Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William G Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xingmei Wang
- Biostatistics Analysis Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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16
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Roberts SH, Goodwin ML, Bobba CM, Al-Qudsi O, Satyapriya SV, Tripathi RS, Papadimos TJ, Whitson BA. Continuous renal replacement therapy and extracorporeal membrane oxygenation: implications in the COVID-19 era. Perfusion 2023; 38:18-27. [PMID: 34494489 DOI: 10.1177/02676591211042561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The novel severe acute respiratory syndrome coronavirus 2, SARS-CoV-2 (coronavirus Disease 19 (COVID-19)) was identified as the causative agent of viral pneumonias in Wuhan, China in December 2019, and has emerged as a pandemic causing acute respiratory distress syndrome (ARDS) and multiple organ dysfunction. Interim guidance by the World Health Organization states that extracorporeal membrane oxygenation (ECMO) should be considered as a rescue therapy in COVID-19-related ARDS. International registries tracking ECMO in COVID-19 patients reveal a 21%-70% incidence of acute renal injury requiring renal replacement therapy (RRT) during ECMO support. The indications for initiating RRT in patients on ECMO are similar to those for patients not requiring ECMO. RRT can be administered during ECMO via a temporary dialysis catheter, placement of a circuit in-line hemofilter, or direct connection of continuous RRT in-line with the ECMO circuit. Here we review methods for RRT during ECMO, RRT initiation and timing during ECMO, anticoagulation strategies, and novel cytokine filtration approaches to minimize COVID-19's pathophysiological impact.
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Affiliation(s)
- Sophia H Roberts
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
| | - Matthew L Goodwin
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Christopher M Bobba
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
| | - Omar Al-Qudsi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - S Veena Satyapriya
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ravi S Tripathi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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17
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Kanchi M, Bangal K, PVS P, Patangi SO. Extracorporeal Membrane Oxygenation (ECMO) for Pulmonary and/or Cardiopulmonary Support-a Brief Review and Our Experience. Indian J Surg 2022; 85:1-10. [PMID: 36533272 PMCID: PMC9734967 DOI: 10.1007/s12262-022-03620-z] [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: 11/16/2021] [Accepted: 11/12/2022] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a modality utilized for partially or completely supporting the cardiac and/or pulmonary function. There are multiple vascular access techniques depending upon the necessity and the mode of ECMO used. ECMO has evolved over the years as an integral part of the cardiac care discipline. Historically, this lifesaving modality began as an extension of cardiopulmonary bypass and was associated with adverse outcomes. Currently, ECMO has evolved as an accepted and viable solution to patients with severe cardiac/respiratory/cardiorespiratory failure that is refractory to conservative management. The outcomes of patients on ECMO are dependent on multiple factors originating from demographic and pathophysiological status of patients as well as the control of homeostasis during ECMO within the acceptable range. Various studies have been published by many practitioners over past decades since the dawn of ECMO era. A brief review of such experience is summated, and a conclusion is derived about the clinical course of the patients on ECMO, while adding the author's experience about the same in a tertiary care large-volume center.
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Affiliation(s)
- Muralidhar Kanchi
- Dept of Cardiac Anaesthesiology, Narayana Institute of Cardiac Sciences, Narayana Hrudayalaya, Narayana Health City, Bangalore, 560099 Karnataka India
- University of Minnesota, Minneapolis, USA
- Narayana Hrudayalaya Institute of Allied Health Sciences, #258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore, 560099 Karnataka India
| | - Kedar Bangal
- Dept of Cardiac Anaesthesiology, Narayana Institute of Cardiac Sciences, Narayana Hrudayalaya, Narayana Health City, Bangalore, 560099 Karnataka India
| | - Prakash PVS
- Perfusion Department, Narayana Institute of Cardiac Sciences, Narayana Hrudayalaya, Narayana Health City, Bangalore, 560099 Karnataka India
| | - Sanjay Orathi Patangi
- Cardiac Critical Care Services, Narayana Institute of Cardiac Sciences, Narayana Hrudayalaya, Narayana Health City, Bangalore, 560099 Karnataka India
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18
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Analgosedation in Critically Ill Adults Receiving Extracorporeal Membrane Oxygenation Support. ASAIO J 2022; 68:1419-1427. [PMID: 35593878 PMCID: PMC9675878 DOI: 10.1097/mat.0000000000001758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an increasingly utilized intervention for cardiopulmonary failure. Analgosedation during ECMO support is essential to ensure adequate pain and agitation control and ventilator synchrony, optimize ECMO support, facilitate patient assessment, and minimize adverse events. Although the principles of analgosedation are likely similar for all critically ill patients, ECMO circuitry alters medication pharmacodynamics and pharmacokinetics. The lack of clinical guidelines for analgosedation during ECMO, especially at times of medication shortage, can affect patient management. Here, we review pharmacological considerations, protocols, and special considerations for analgosedation in critically ill adults receiving ECMO support.
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19
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Lumlertgul N, Wright R, Hutson G, Milicevic JK, Vlachopanos G, Lee KCH, Pirondini L, Gregson J, Sanderson B, Leach R, Camporota L, Barrett NA, Ostermann M. Long-term outcomes in patients who received veno-venous extracorporeal membrane oxygenation and renal replacement therapy: a retrospective cohort study. Ann Intensive Care 2022; 12:70. [PMID: 35870022 PMCID: PMC9308118 DOI: 10.1186/s13613-022-01046-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background Acute kidney injury (AKI) is a frequent complication in patients with severe respiratory failure receiving extracorporeal membrane oxygenation (ECMO). However, little is known of long-term kidney function in ECMO survivors. We aimed to assess the long-term mortality and kidney outcomes in adult patients treated with veno-venous ECMO (VV-ECMO). Methods This was a single-centre retrospective study of adult patients (≥ 18 years old) who were treated with VV-ECMO at a commissioned ECMO centre in the UK between 1st September 2010, and 30th November 2016. AKI was defined and staged using the serum creatinine and urine output criteria of the Kidney Diseases: Improving Global Outcomes (KDIGO) classification. The primary outcome was 1-year mortality. Secondary outcomes were long-term mortality (up to March 2020), 1-year incidence of end-stage kidney disease (ESKD) or chronic kidney disease (CKD) among AKI patients who received renal replacement therapy (AKI-RRT), AKI patients who did not receive RRT (AKI-no RRT) and patients without AKI (non-AKI). Results A total of 300 patients [57% male; median age 44.5; interquartile range (IQR) 34–54] were included in the final analysis. Past medical histories included diabetes (12%), hypertension (17%), and CKD (2.3%). The main cause of severe respiratory failure was pulmonary infection (72%). AKI occurred in 230 patients (76.7%) and 59.3% received renal replacement therapy (RRT). One-year mortality was 32% in AKI-RRT patients vs. 21.4% in non-AKI patients (p = 0.014). The median follow-up time was 4.35 years. Patients who received RRT had a higher risk of 1-year mortality than those who did not receive RRT (adjusted HR 1.80, 95% CI 1.06, 3.06; p = 0.029). ESKD occurred in 3 patients, all of whom were in the AKI-RRT group. At 1-year, 41.2% of survivors had serum creatinine results available. Among these, CKD was prevalent in 33.3% of AKI-RRT patients vs. 4.3% in non-AKI patients (p = 0.004). Conclusions VV-EMCO patients with AKI-RRT had high long-term mortality. Monitoring of kidney function after hospital discharge was poor. In patients with follow-up creatinine results available, the CKD prevalence was high at 1 year, especially in AKI-RRT patients. More awareness about this serious long-term complication and appropriate follow-up interventions are required. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01046-0.
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20
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Evaluation of Bivalirudin Dosing in Pediatric Extracorporeal Membrane Oxygenation with Renal Insufficiency or Renal Replacement Therapy. ASAIO J 2022; 68:e196-e203. [PMID: 36229032 DOI: 10.1097/mat.0000000000001818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Bivalirudin offers several important advantages of relevance to the management of extracorporeal membrane oxygenation (ECMO) patients. This multicenter retrospective analysis evaluated the bivalirudin dosing in pediatric ECMO and correlated these doses with the severity of renal dysfunction. A total of 75 patients were included in this analyses: estimated glomerular filtration rate (eGFR) > 60 ml/min/1.73 m 2 (n = 29), eGFR 30-60 (n = 18), eGFR < 30 (n = 28), and of those 23 were on renal replacement therapy (RRT). The initial bivalirudin dose used to reach therapeutic anticoagulation in patients with eGFR > 60 was significantly higher than the dose required in those with renal impairment (0.25 mg/kg/hr in patients with eGFR > 60 and 0.19 mg/kg/hr in patients on RRT, 0.18 mg/kg/hr in patients with eGFR 30-60 and 0.13 mg/kg/hr in patients with eGFR < 30 with no RRT). Progressive dose escalations (two to threefold increase) were required to maintain therapeutic range over the initial 4 days of ECMO that coincided with improving renal creatinine clearance during that same time period. Establishing an initial starting dose of bivalirudin contingent upon eGFR is essential for the rapid achievement of target anticoagulation intensity. Further dose adjustments guided by laboratory monitoring is necessary given the dynamic changes in creatinine clearance following ECMO initiation.
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21
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Rosen RJ, Stevens JS, Canetta PA, Siddall E. Polyuria due to Pressure Natriuresis in Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:e124-e127. [PMID: 34593678 DOI: 10.1097/mat.0000000000001594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We report a case of a 40-year-old woman who developed profound polyuria (>25 L urine output) immediately after initiation of venoarterial (VA) extracorporeal membrane oxygenation (ECMO). Investigations into the cause determined the polyuria was due to marked natriuresis (>85 g of sodium excreted in 1 day). This natriuresis persisted despite low cardiac filling pressures and high-negative ECMO venous pressures, suggesting clinical hypovolemia due to pressure natriuresis from locally high pressures at the renal artery due to arterial ECMO inflow. As ECMO flows were decreased, polyuria and natriuresis resolved. To our knowledge, this is the first description of VA-ECMO-associated salt wasting.
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Affiliation(s)
- Raphael J Rosen
- From the Department of Medicine, Division of Nephrology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
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22
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Reaz S, Loyaga-Rendon R, Dickinson MG, Lee S, Fitch SJ, Marco G, Boeve T, Langholz DE, Kelty C, Shrestha NM, Leacche M, Jovinge S. Risk of Developing Acute Kidney Injury on the VA ECLS Circuit in Patients with Acute Decompensated Heart Failure. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1750191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Aims Venoarterial extracorporeal life support (VA ECLS) is a life-saving treatment with a high risk of mortality. Appropriate patient selection is critical for optimal patient outcomes. Acute kidney injury (AKI) is a common risk among VA ECLS patients, and more information is needed to understand how AKI affects the mortality risk of these patients. To do this, we examined acute decompensated heart failure (ADHF) patients supported by VA ECLS and compared their risk of developing AKI to a background population. VA ECLS has become an increasingly important tool to bridge or recover patients with severe ADHF as the primary indication of VA ECLS.
Methods and Results All VA ECLS patients from a single center were included. ADHF patients supported by VA ECLS were compared with the remaining VA ECLS cohort. CATEGORICAL comparisons were made between groups using chi-squared and Fisher's exact tests. A survival analysis was conducted to determine freedom from AKI between the two groups. Predictor variables were tested by multiple logistic regression. Of the 255 patients included in this study, 110 had ADHF as their primary indication for VA ECLS and 145 patients had other VA ECLS indications. The survival analysis showed that patients with ADHF had a decreased risk of developing AKI on the VA ECLS circuit. Multiple logistic regression revealed no predictors in AKI development between groups and no difference in 30-day mortality was observed.
Conclusion Patients supported by VA ECLS are at high risk of mortality and complications. This research demonstrated that medically complex ADHF patients had less chance of developing AKI when compared with other patients supported by VA ECLS. Future research is needed to investigate potential protective mechanisms of VA ECLS support.
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Affiliation(s)
- Shams Reaz
- Human College of Medicine, Michigan State University, Grand Rapids, Michigan, United States
- Internal Medicine, Metro Health- University of Michigan, Grand Rapids, Michigan, United States
| | - Renzo Loyaga-Rendon
- Fredrik Meijer Heart- and Vascular Institute/Spectrum Health Grand Rapids, Michigan, United States
| | - Michael G. Dickinson
- Fredrik Meijer Heart- and Vascular Institute/Spectrum Health Grand Rapids, Michigan, United States
| | - Sangjin Lee
- Fredrik Meijer Heart- and Vascular Institute/Spectrum Health Grand Rapids, Michigan, United States
| | - Stephen J. Fitch
- Fredrik Meijer Heart- and Vascular Institute/Spectrum Health Grand Rapids, Michigan, United States
| | - Greg Marco
- Fredrik Meijer Heart- and Vascular Institute/Spectrum Health Grand Rapids, Michigan, United States
| | - Theodore Boeve
- Fredrik Meijer Heart- and Vascular Institute/Spectrum Health Grand Rapids, Michigan, United States
| | - David E. Langholz
- Fredrik Meijer Heart- and Vascular Institute/Spectrum Health Grand Rapids, Michigan, United States
| | - Catherine Kelty
- DeVos CardioVascular Research Program, Grand Rapids, Michigan, United States
| | | | - Marzia Leacche
- Fredrik Meijer Heart- and Vascular Institute/Spectrum Health Grand Rapids, Michigan, United States
| | - Stefan Jovinge
- Human College of Medicine, Michigan State University, Grand Rapids, Michigan, United States
- Fredrik Meijer Heart- and Vascular Institute/Spectrum Health Grand Rapids, Michigan, United States
- DeVos CardioVascular Research Program, Grand Rapids, Michigan, United States
- Van Andel Research Institute/Spectrum Health, Grand Rapids, Michigan, United States
- Cardiovascular Institute Stanford University Palo Alto, California, United States
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23
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Bridges BC, Dhar A, Ramanathan K, Steflik HJ, Schmidt M, Shekar K. Extracorporeal Life Support Organization Guidelines for Fluid Overload, Acute Kidney Injury, and Electrolyte Management. ASAIO J 2022; 68:611-618. [PMID: 35348527 DOI: 10.1097/mat.0000000000001702] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
DISCLAIMER This guideline for extracorporeal membrane oxygenation (ECMO) fluid and electrolyte management for all patient populations is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS/ECMO, but these are not necessarily consensus recommendations. The aim of clinical guidelines is to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but Extracorporeal Life Support Organization (ELSO) is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Brian C Bridges
- From the Division of Pediatric Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Archana Dhar
- Department of Pediatrics, UT Southwestern Medical School, Dallas, Texas
| | - Kollengode Ramanathan
- Department of Cardiothoracic Intensive Care Unit, National University Hospital, Singapore
| | - Heidi J Steflik
- Division of Neonatal Perinatal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Matthieu Schmidt
- Department of Intensive Care Medicine at Sorbonne University, Paris, France
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
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24
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Ganguli A, Farooq S, Desai N, Adhikari S, Shah V, Sherman MJ, Veis JH, Moore J. A Novel Predictive Model for Hospital Survival in Patients who are Critically Ill with Dialysis-Dependent AKI: A Retrospective Single-Center Exploratory Study. KIDNEY360 2022; 3:636-646. [PMID: 35721620 PMCID: PMC9136904 DOI: 10.34067/kid.0007272021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/24/2022] [Indexed: 04/20/2023]
Abstract
BACKGROUND Mortality of patients who are critically ill with AKI initiated on RRT is very high. Identifying modifiable and unmodifiable clinical variables at dialysis start that are associated with hospital survival can help, not only in prognostication, but also in clinical triaging. METHODS A retrospective observational study was conducted on patients with AKI-D who were initiated on RRT in the medical and surgical intensive care units (ICUs) of a high-acuity academic medical center from January 2010 through December 2015. We excluded patients with suspected poisoning, ESKD, stage 5 CKD not on dialysis, or patients with AKI-D initiated on RRT outside of the ICU setting. The primary outcome was in-hospital mortality. RESULTS Of the 416 patients who were critically ill with AKI-D admitted to the medical (38%), surgical (41%), and cardiac (21%) ICUs, with nearly 75% on artificial organ support, the mean age 62.1±14.8 years, mean SOFA score was 11.8±4.3, dialysis was initiated using continuous RRT in 261 (63%) and intermittent hemodialysis in 155 (37%) patients. Incidence of survival to hospital discharge was 48%. Using multivariable logistic regression with stepwise backward elimination, a prognostic model was created that included the variables age, CKD, COPD, admission, and within 24 hours of the start SOFA score, refractory hyperkalemia and uremic encephalopathy as dialysis indications, BUN >100 mg/dl, serum creatinine, serum lactate, serum albumin, CRRT as initial modality, severe volume overload, and abdominal surgery. The model exhibited good calibration (goodness of fit test, P=0.83) and excellent discrimination (optimism-corrected C statistic 0.93). CONCLUSIONS In this single-center, diverse, critically ill AKI-D population, a novel prognostic model that combined widely used ICU scores, clinical and biochemical data at dialysis start, and dialysis indication and modality, robustly predicted short-term survival. External validation is needed to prove the generalizability of the study findings.
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Affiliation(s)
- Anirban Ganguli
- Division of Nephrology, Georgetown University/Medstar Washington Hospital Center, Washington, DC
| | - Saad Farooq
- Division of Nephrology, Georgetown University/Medstar Washington Hospital Center, Washington, DC
| | - Neerja Desai
- Division of Nephrology, Georgetown University/Medstar Washington Hospital Center, Washington, DC
| | - Shreedhar Adhikari
- Division of Renal-Electrolyte, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vatsal Shah
- Division of Nephrology, Georgetown University/Medstar Washington Hospital Center, Washington, DC
| | - Michael J. Sherman
- Division of Nephrology, Georgetown University/Medstar Washington Hospital Center, Washington, DC
| | - Judith H. Veis
- Division of Nephrology, Georgetown University/Medstar Washington Hospital Center, Washington, DC
| | - Jack Moore
- Division of Nephrology, Georgetown University/Medstar Washington Hospital Center, Washington, DC
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25
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Frick AE, Gan CT, Vos R, Schwarz S, Kraft F, Kifjak D, Neyrinck AP, Van Raemdonck DE, Klepetko W, Jaksch P, Verschuuren EAM, Hoetzenecker K. Lung transplantation for acute respiratory distress syndrome: A multicenter experience. Am J Transplant 2022; 22:144-153. [PMID: 34254423 PMCID: PMC8441742 DOI: 10.1111/ajt.16759] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 01/25/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a rapidly progressive lung disease with a high mortality rate. Although lung transplantation (LTx) is a well-established treatment for a variety of chronic pulmonary diseases, LTx for acute lung failure (due to ARDS) remains controversial. We reviewed posttransplant outcome of ARDS patients from three high-volume European transplant centers. Demographics and clinical data were collected and analyzed. Viral infection was the main reason for ARDS (n = 7/13, 53.8%). All patients were admitted to ICU and required mechanical ventilation, 11/13 were supported with ECMO at the time of listing. They were granted a median LAS of 76 (IQR 50-85) and waited for a median of 3 days (IQR 1.5-14). Postoperatively, median length of mechanical ventilation was 33 days (IQR 17-52.5), median length of ICU and hospital stay were 39 days (IQR 19.5-58.5) and 54 days (IQR 43.5-127). Prolongation of peripheral postoperative ECMO was required in 7/13 (53.8%) patients with a median duration of 2 days (IQR 2-7). 30-day mortality was 7.7%, 1 and 5-year survival rates were calculated as 71.6% and 54.2%, respectively. Given the lack of alternative treatment options, the herein presented results support the concept of offering live-saving LTx to carefully selected ARDS patients.
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Affiliation(s)
- Anna E. Frick
- Department of Thoracic SurgeryMedical University of ViennaViennaAustria,Department of Cardiovascular SciencesKU LeuvenLeuvenBelgium
| | - Christiaan T. Gan
- Department of Pulmonary DiseasesUniversity Medical Centre GroningenGroningenThe Netherlands
| | - Robin Vos
- BREATHELeuven Lung Transplant UnitDepartment of Chronic Diseases, Metabolism and Ageing (Chromed)KU LeuvenLeuvenBelgium,Department of Respiratory DiseasesUniversity Hospitals LeuvenLeuvenBelgium
| | - Stefan Schwarz
- Department of Thoracic SurgeryMedical University of ViennaViennaAustria
| | - Felix Kraft
- Department of Anaesthesia, General Intensive Care and Pain ManagementMedical University of ViennaViennaAustria
| | - Daria Kifjak
- Department of Biomedical Imaging and Image‐guided TherapyMedical University of ViennaViennaAustria
| | | | - Dirk E. Van Raemdonck
- BREATHELeuven Lung Transplant UnitDepartment of Chronic Diseases, Metabolism and Ageing (Chromed)KU LeuvenLeuvenBelgium,Department of Thoracic SurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | - Walter Klepetko
- Department of Thoracic SurgeryMedical University of ViennaViennaAustria
| | - Peter Jaksch
- Department of Thoracic SurgeryMedical University of ViennaViennaAustria
| | - Erik A. M. Verschuuren
- Department of Pulmonary DiseasesUniversity Medical Centre GroningenGroningenThe Netherlands
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26
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Sakhuja A, McCarthy P, Hayanga JA, Turley S, Smith G, Kellum JA. Acute Kidney Injury in Extracorporeal Membrane Oxygenation Patients: National Analysis of Impact of Age. Blood Purif 2022; 51:567-576. [PMID: 34515054 PMCID: PMC8898984 DOI: 10.1159/000518346] [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] [Received: 09/23/2020] [Accepted: 07/06/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The aim of this study was to determine epidemiology and outcomes of acute kidney injury (AKI) in patients on extracorporeal membrane oxygenation (ECMO) and to assess if age modifies the effect of AKI on mortality. METHODS Using National (Nationwide) Inpatient Sample Database for hospitalizations in the USA from 2003 to 2014, we identified adult patients on ECMO support. Using International Classification of Diseases 9th Revision, we assessed the rates of AKI and AKI requiring dialysis (AKI-D) among them and associated survival. We used a multivariable logistic regression to identify risk factors of and differential effect of age on mortality from AKI. RESULTS AKI was seen in 63.9% of 17,942 ECMO hospitalizations: 21.9% of those with AKI required dialysis. The percentage of those with AKI increased steadily. Mortality was higher in those with AKI, with highest in those with AKI-D (70.8% vs. 61.7%; p < 0.001). While both age and AKI were independent predictors of mortality, age was neither a risk factor for AKI nor did it modify the effect of AKI on mortality. CONCLUSIONS AKI is common and is increasing among patients on ECMO support. Patients on ECMO have high mortality and AKI is an independent predictor of mortality. Though age is also an independent predictor of mortality in patients on ECMO, it is neither a predictor of AKI nor does not modify the relationship between AKI and mortality.
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Affiliation(s)
- Ankit Sakhuja
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Paul McCarthy
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV
| | - Jeremiah A Hayanga
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV
| | - Steven Turley
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV
| | - Gordon Smith
- Department of Epidemiology, School of Public Health, West Virginia University, Morgantown, WV
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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27
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Levin B, Ortoleva J, Tagliavia A, Colon K, Crowley J, Shelton K, Dalia AA. 1-year Survival for Adult Venoarterial Extracorporeal Membrane Oxygenation Patients Requiring Renal Replacement Therapy. J Cardiothorac Vasc Anesth 2021; 36:1942-1948. [DOI: 10.1053/j.jvca.2021.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 11/11/2022]
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28
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Foti L, Villa G, Romagnoli S, Ricci Z. Acute Kidney Injury and Extracorporeal Membrane Oxygenation: Review on Multiple Organ Support Options. Int J Nephrol Renovasc Dis 2021; 14:321-329. [PMID: 34413667 PMCID: PMC8370847 DOI: 10.2147/ijnrd.s292893] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/03/2021] [Indexed: 12/01/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a temporary life support system used to assist patients with life-threatening severe cardiac and/or respiratory insufficiency. Patients requiring ECMO can be considered the sickest patients admitted to the intensive care unit (ICU). Acute kidney injury (AKI) represents a frequent complication during ECMO, affecting up to 70% of patients, with multifactorial pathophysiology and an independent risk factor for mortality. Severe AKI requiring Continuous Renal Replacement Therapy (CRRT) occurs in 20% of ECMO patients, but multiple indications and different timing may imply a significantly higher application rate in different centers. CRRT can be run in parallel to ECMO through different vascular access, or it can be conducted in series by connecting the circuits. Anticoagulation of ECMO is typically managed with systemic heparin, but several approaches can be applied for the CRRT circuit, from no anticoagulation to the addition of intra-filter heparin or regional citrate anticoagulation. The combination of CRRT and ECMO can be considered a form of multiple organ support therapy, but this approach still requires optimization in timing, set-up, anticoagulation, prescription and delivery. The aim of this report is to review the pathophysiology of AKI, the CRRT delivery, anticoagulation strategies and outcomes of patients with AKI treated with ECMO.
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Affiliation(s)
- Lorenzo Foti
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.,Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
| | - Gianluca Villa
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.,Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
| | - Stefano Romagnoli
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.,Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
| | - Zaccaria Ricci
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.,Pediatric Intensive Care Unit, Meyer Children's University Hospital, Florence, Italy
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29
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Akoumianaki E, Jonkman A, Sklar MC, Georgopoulos D, Brochard L. A rational approach on the use of extracorporeal membrane oxygenation in severe hypoxemia: advanced technology is not a panacea. Ann Intensive Care 2021; 11:107. [PMID: 34250563 PMCID: PMC8273031 DOI: 10.1186/s13613-021-00897-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/30/2021] [Indexed: 12/16/2022] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (ECMO) is a helpful intervention in patients with severe refractory hypoxemia either because mechanical ventilation cannot ensure adequate oxygenation or because lung protective ventilation is not feasible. Since ECMO is a highly invasive procedure with several, potentially devastating complications and its implementation is complex and expensive, simpler and less invasive therapeutic options should be first exploited. Low tidal volume and driving pressure ventilation, prone position, neuromuscular blocking agents and individualized ventilation based on transpulmonary pressure measurements have been demonstrated to successfully treat the vast majority of mechanically ventilated patients with severe hypoxemia. Veno-venous ECMO has a place in the small portion of severely hypoxemic patients in whom these strategies fail. A combined analysis of recent ARDS trials revealed that ECMO was used in only 2.15% of patients (n = 145/6736). Nevertheless, ECMO use has sharply increased in the last decade, raising questions regarding its thoughtful use. Such a policy could be harmful both for patients as well as for the ECMO technique itself. This narrative review attempts to describe together the practical approaches that can be offered to the sickest patients before going to ECMO, as well as the rationale and the limitations of ECMO. The benefit and the drawbacks associated with ECMO use along with a direct comparison with less invasive therapeutic strategies will be analyzed.
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Affiliation(s)
- Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Annemijn Jonkman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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30
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Cheng V, Abdul-Aziz MH, Roberts JA. Applying Antimicrobial Pharmacokinetic Principles for Complex Patients: Critically Ill Adult Patients Receiving Extracorporeal Membrane Oxygenation and Renal Replacement Therapy. Curr Infect Dis Rep 2021. [DOI: 10.1007/s11908-021-00757-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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31
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Song H, Yuan Z, Peng Y, Luo G. Extracorporeal membrane oxygenation combined with continuous renal replacement therapy for the treatment of severe burns: current status and challenges. BURNS & TRAUMA 2021; 9:tkab017. [PMID: 34212063 PMCID: PMC8240511 DOI: 10.1093/burnst/tkab017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/26/2021] [Indexed: 11/25/2022]
Abstract
Severe burns often cause various systemic complications and multiple organ dysfunction syndrome, which is the main cause of death. The lungs and kidneys are vulnerable organs in patients with multiple organ dysfunction syndrome after burns. Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) have been gradually applied in clinical practice and are beneficial for severe burn patients with refractory respiratory failure or renal dysfunction. However, the literature on ECMO combined with CRRT for the treatment of severe burns is limited. Here, we focus on the current status of ECMO combined with CRRT for the treatment of severe burns and the associated challenges, including the timing of treatment, nutrition support, heparinization and wound management, catheter-related infection and drug dosing in CRRT. With the advancement of medical technology, ECMO combined with CRRT will be further optimized to improve the outcomes of patients with severe burns.
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Affiliation(s)
- Huapei Song
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Chongqing 400038, China
| | - Zhiqiang Yuan
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Chongqing 400038, China
| | - Yizhi Peng
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Chongqing 400038, China
| | - Gaoxing Luo
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Chongqing 400038, China
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32
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Beeckmans H, Bos S, Vos R. Selection Criteria for Lung Transplantation: Controversies and New Developments. Semin Respir Crit Care Med 2021; 42:329-345. [PMID: 34030197 DOI: 10.1055/s-0041-1728756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Lung transplantation is an accepted therapeutic option for end-stage lung diseases. The imbalance between limited availability and vast need of donor organs necessitates careful selection of recipient candidates, ensuring the best possible utilization of the scarce resource of organs. Nonetheless, possible lung transplant candidates who could experience a meaningful improvement in survival and quality of life should not be excluded solely based on the complexity of their case. In this review, controversial issues or difficult limitations for lung transplantation, and new developments in recipient selection criteria, are discussed, which may help broaden recipient eligibility for lung transplantation without compromising long-term outcomes.
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Affiliation(s)
- Hanne Beeckmans
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Saskia Bos
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Robin Vos
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), BREATHE, Leuven, Belgium
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33
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Hiramatsu T, Shimizu S, Koga H. Prognostic factors in patients treated with extracorporeal membrane oxygenation and continuous renal replacement therapy. Perfusion 2021; 37:570-574. [PMID: 33870783 DOI: 10.1177/02676591211011039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) and Continuous renal replacement therapy (CRRT) are treatments for critically ill patients with respiratory failure and acute kidney injury. However, no reliable factors have been identified to predict survival in patients treated with both ECMO and CRRT. The aim of this study was to identify prognostic factors for discharging intensive care unit (ICU) patients who required CRRT during ECMO. METHODS We retrospectively analyzed data from patients who required CRRT in addition to the ECMO, between April 2015 and March 2018. The patients were divided into two groups: patients who survived and patients who died during ICU hospitalization. We determined their demographic and clinical characteristics, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, Simplified Acute Physiology Score II (SAPS II) scores, and sequential organ failure assessment (SOFA) scores. Further, we assessed whether these characteristics differed between individuals who did or did not survive the ICU hospitalization. RESULTS We found that the APACHE II and SAPS II scores differed significantly between both ECMO and CRRT treated patients who did or did not survive hospitalization. Further, intracranial hemorrhage during ECMO and CRRT therapy was associated with lower survival rate. CONCLUSIONS Using APACHE II and SAPS II scores might be helpful in making treatment decisions for patients treated with ECMO and CRRT. Intracranial hemorrhage could be a poor prognostic factor. Our findings indicate the potential utility of APACHE II and SAPS II scores to predict mortality in patients treated with both ECMO and CRRT.
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Affiliation(s)
- Toshiki Hiramatsu
- Department of Critical Care Medicine, ASO Iizuka Hospital, Iizuka city, Fukuoka, Japan
| | - Shigemitsu Shimizu
- Department of Clinical Engineering, ASO Iizuka Hospital, Iizuka city, Fukuoka, Japan
| | - Hidenobu Koga
- Clinical Research Support Office, ASO Iizuka Hospital, Iizuka city, Fukuoka, Japan
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Selewski DT, Wille KM. Continuous renal replacement therapy in patients treated with extracorporeal membrane oxygenation. Semin Dial 2021; 34:537-549. [PMID: 33765346 PMCID: PMC8250911 DOI: 10.1111/sdi.12965] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life‐saving therapy utilized for patients with severe life‐threatening cardiorespiratory failure. Patients treated with ECMO are among the most severely ill encountered in critical care and are at high‐risk of developing multiple organ dysfunction, including acute kidney injury (AKI) and fluid overload. Continuous renal replacement therapy (CRRT) is increasingly utilized inpatients on ECMO to manage AKI and treat fluid overload. The indications for renal replacement therapy for patients on ECMO are similar to those of other critically ill populations; however, there is wide practice variation in how renal supportive therapies are utilized during ECMO. For patients requiring both CRRT and ECMO, CRRT may be connected directly to the ECMO circuit, or CRRT and ECMO may be performed independently. This review will summarize current knowledge of the epidemiology of AKI, indications and timing of CRRT, delivery of CRRT, and the outcomes of patients requiring CRRT with ECMO.
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Affiliation(s)
- David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Keith M Wille
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Mou Z, Guan T, Chen L. Risk Factors of Acute Kidney Injury in ECMO Patients: A Systematic Review and Meta-Analysis. J Intensive Care Med 2021; 37:267-277. [PMID: 33761767 DOI: 10.1177/08850666211003485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Acute kidney injury (AKI) is one of the most common complications in patients receiving extracorporeal membrane oxygenation (ECMO), but there is no systematic analysis regarding its risk factors. This meta-analysis aims to determine the risk factors of AKI in adult patients with ECMO treatment. METHODS Two authors independently carried out a systemic literature search using PubMed, Web of Science, and Embase until April 20, 2020 (inclusive) to enroll 12 studies reporting the necessary clinical characteristics. The Gender (male), age, APACHE II score, SOFA score, cancer, diabetes mellitus (DM), intra-aortic balloon pump (IABP), postcardiotomy, and ECMO supporting duration were pooled for further analysis by STATA. RESULTS Adult patients receiving ECMO who develop AKI and severe AKI incidents are usually older or have a higher APACHE II scores; in addition, severe AKI is related to higher SOFA scores, DM, and longer duration of ECMO support. CONCLUSIONS Patients with these clinical characteristics should be paid more attention during ECMO. There remains a need for additional studies to validate these conclusions and to detect additional AKI risk factors for ECMO patients.
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Affiliation(s)
- Zhixiang Mou
- Department of Nephrology, 66366Zhongshan Hospital Xiamen University, Xiamen, China
| | - Tianjun Guan
- Department of Nephrology, 66366Zhongshan Hospital Xiamen University, Xiamen, China
| | - Lan Chen
- Department of Nephrology, 66366Zhongshan Hospital Xiamen University, Xiamen, China
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Extracorporeal Gas Exchange for Acute Respiratory Distress Syndrome: Open Questions, Controversies and Future Directions. MEMBRANES 2021; 11:membranes11030172. [PMID: 33670987 PMCID: PMC7997339 DOI: 10.3390/membranes11030172] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.
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Breathing Life Back Into the Kidney—Continuous Renal Replacement Therapy and Veno-Venous Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:208-212. [DOI: 10.1097/mat.0000000000001210] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Mitra S, Ling RR, Tan CS, Shekar K, MacLaren G, Ramanathan K. Concurrent Use of Renal Replacement Therapy during Extracorporeal Membrane Oxygenation Support: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10020241. [PMID: 33440805 PMCID: PMC7827381 DOI: 10.3390/jcm10020241] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 12/21/2022] Open
Abstract
Patients supported with extracorporeal membrane oxygenation (ECMO) often receive renal replacement therapy (RRT). We conducted this systematic review and meta-analysis (between January 2000 and September 2020) to assess outcomes in patients who received RRT on ECMO. Random-effects meta-analyses were performed using R 3.6.1 and certainty of evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The primary outcome was pooled mortality. The duration of ECMO support and ICU/hospital lengths of stay were also investigated. Meta-regression analyses identified factors associated with mortality. A total of 5896 adult patients (from 24 observational studies and 1 randomised controlled trial) were included in this review. Overall pooled mortality due to concurrent use of RRT while on ECMO from observational studies was 63.0% (95% CI: 56.0–69.6%). In patients receiving RRT, mortality decreased by 20% in the last five years; the mean duration of ECMO support and ICU and hospital lengths of stay were 9.33 days (95% CI: 7.74–10.92), 15.76 days (95% CI: 12.83–18.69) and 28.47 days (95% CI: 22.13–34.81), respectively, with an 81% increased risk of death (RR: 1.81, 95% CI: 1.56–2.08, p < 0.001). RRT on ECMO was associated with higher mortality rates and a longer ICU/hospital stay compared to those without RRT. Future research should focus on minimizing renal dysfunction in ECMO patients and define the optimal timing of RRT initiation.
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Affiliation(s)
- Saikat Mitra
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119228, Singapore; (G.M.); (K.R.)
- Correspondence:
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119077, Singapore;
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD 4032, Australia;
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119228, Singapore; (G.M.); (K.R.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119228, Singapore; (G.M.); (K.R.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
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Ayers B, Bjelic M, Kumar N, Wood K, Barrus B, Prasad S, Gosev I. Long-term renal function after venoarterial extracorporeal membrane oxygenation. J Card Surg 2021; 36:815-820. [PMID: 33416196 DOI: 10.1111/jocs.15277] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/06/2020] [Accepted: 12/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a life-supporting therapy has increased exponentially over the last decade. As more patients receive and survive ECMO, there are a number of unanswered clinical questions about their long-term prognosis and organ function including the need for long-term dialysis. METHODS We aimed to utilize over 208 patient-years of follow-up data from our large institutional cohort of VA-ECMO patients to determine the incidence of requiring VA-ECMO support on the need for renal replacement therapy after discharge (LT-dialysis). This retrospective review included all adult VA-ECMO patients at our institution from January 2014 to October 2018 (N = 283). RESULTS Out of the 99 (35%) survivors, 88 (89%) did not require LT-dialysis of any duration after discharge from the index hospitalization. Patients who required VA-ECMO for decompensated cardiogenic shock were more likely to need LT-dialysis (p = .034), and those who required renal replacement therapy during VA-ECMO (N = 27) also had a higher incidence of LT-dialysis (33%). CONCLUSION Overall, these data suggest there is a low incidence of long-term dialysis dependence among survivors of VA-ECMO support. Worries about the potential long-term detrimental effect of VA-ECMO should not preclude patients from receiving this life-saving support.
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Affiliation(s)
- Brian Ayers
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Milica Bjelic
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Neil Kumar
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Katherine Wood
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Bryan Barrus
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Sunil Prasad
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Igor Gosev
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Gu M, Mei XL, Zhao YN. A review on extracorporeal membrane oxygenation and kidney injury. J Biochem Mol Toxicol 2020; 35:e22679. [PMID: 33325616 DOI: 10.1002/jbt.22679] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/04/2020] [Accepted: 11/26/2020] [Indexed: 12/17/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is inevitable external life support in case of cardiac and respiratory failure since the 1970s. Acute kidney injury (AKI) and the requirement of renal replacement therapy (RRT) is a potential risk among these patients. This review aims to give an overview of the risk of AKI, RRT, and associated mortality among the patients who received ECMO for any of its indications. PubMed database was searched to find the relevant literature and the reference list of included studies was also searched for additional studies. The incidence of AKI ranged from 30% to 78% and RRT from 47% to 60% in ECMO patients. The pathophysiology of AKI in ECMO is multifactorial, and includes ischaemia, RBCs breakdown, comorbidity, conversion of zymogen form of pro-inflammatory mediators, structural alteration of the kidney, coadministration of nephrotoxic drugs, coagulation abnormality, and oxidative stress. ECMO was associated with the higher incidence of renal abnormalities, AKI, requirement of RRT, and associated mortality. Patients who underwent RRT had improved renal function and reduced overall mortality compared to the non-RRT group among the ECMO patients. Currently, there is no consensus evidence to support the superior use of the inline hemofilter system over continuous renal replacement therapy among patients who had AKI during ECMO.
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Affiliation(s)
- Ming Gu
- Department of Emergency and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Xiang-Lin Mei
- Department of Pathology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Ya-Nan Zhao
- Neurology Department, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
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Jenks C, Raman L, Dhar A. Review of acute kidney injury and continuous renal replacement therapy in pediatric extracorporeal membrane oxygenation. Indian J Thorac Cardiovasc Surg 2020; 37:254-260. [PMID: 33967449 DOI: 10.1007/s12055-020-01071-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 10/22/2022] Open
Abstract
Purpose To review the relevant literature of acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) as it relates to pediatric extracorporeal membrane oxygenation (ECMO). Methods Available online relevant literature. Results ECMO is a therapeutic modality utilized to support patients with refractory respiratory and/or cardiac failure. AKI and fluid overload (FO) are frequently observed in this patient population. There are multiple modalities that can be utilized for AKI and FO which include the following: diuretics, in-line hemofiltration, and CRRT. There are multiple considerations when using CRRT with ECMO including access, CRRT flows, hemolysis, anticoagulation, and CRRT termination. Conclusion While each ECMO center has its own set of equipment, experiences, and practices, it is imperative that the international ECMO community continues to work together to provide an evidence-based approach to address the morbidity and mortality associated with AKI and FO.
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Affiliation(s)
- Christopher Jenks
- Blair E Batson Children's Hospital, Department of Pediatrics, Section of Critical Care, University of Mississippi Medical Center, Jackson, MS USA
| | - Lakshmi Raman
- Children's of Dallas, Department of Pediatrics, Section of Critical Care, University of Texas Southwestern Medical Center, Dallas, TX USA.,Children's Health, Dallas, TX USA
| | - Archana Dhar
- Children's of Dallas, Department of Pediatrics, Section of Critical Care, University of Texas Southwestern Medical Center, Dallas, TX USA.,Children's Health, Dallas, TX USA
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Giani M, Scaravilli V, Stefanini F, Valsecchi G, Rona R, Grasselli G, Bellani G, Pesenti AM, Foti G. Continuous Renal Replacement Therapy in Venovenous Extracorporeal Membrane Oxygenation: A Retrospective Study on Regional Citrate Anticoagulation. ASAIO J 2020; 66:332-338. [PMID: 31045918 DOI: 10.1097/mat.0000000000001003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Systemic infusion of unfractionated heparin (UFH) is the standard anticoagulation technique for continuous renal replacement therapy (CRRT) during extracorporeal membrane oxygenation (ECMO), but often fails to avoid CRRT circuit clotting. The aim of this study was to assess, in patients undergoing CRRT during venovenous ECMO (vv-ECMO), the efficacy and safety of adding regional citrate anticoagulation (RCA) for CRRT circuit anticoagulation (RCA + UFH group) compared with the sole systemic heparin anticoagulation (UFH group). We performed a retrospective chart review (2009-2018) of patients treated with CRRT during ECMO. We evaluated filter life span, rate of CRRT circuit clotting, and coagulation parameters. The incidence of citrate anticoagulation-related complications was recorded. Forty-eight consecutive adult patients underwent CRRT during vv-ECMO in the study period. The incidence of CRRT circuit clotting was lower in the RCA + UFH group (11% vs. 38% in the UFH group, p < 0.001). Log-rank survival analysis demonstrated longer circuit lifetime for RCA + UFH group. No complication ascribable to citrate anticoagulation was recorded. Regional citrate anticoagulation resulted a feasible, safe, and effective technique as additional anticoagulation for CRRT circuits during ECMO. Compared with systemic heparinization only, this technique allowed to reduce the rate of CRRT circuit clotting.
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Affiliation(s)
- Marco Giani
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Vittorio Scaravilli
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Flavia Stefanini
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Gabriele Valsecchi
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Roberto Rona
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Giacomo Grasselli
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy.,Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - Giacomo Bellani
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy.,Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Antonio M Pesenti
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.,Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - Giuseppe Foti
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy.,Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
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Austin D, McCanny P, Aneman A. Post-operative renal failure management in mechanical circulatory support patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:833. [PMID: 32793678 PMCID: PMC7396231 DOI: 10.21037/atm-20-1172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) occurs commonly in patients requiring mechanical circulatory support (MCS) after cardiothoracic surgery. The prognostic implications of AKI in this patient group relate closely to the pathophysiology and risk factors associated with the underlying disease; pre-operative, intra-operative, and post-operative variables; hemodynamic factors; and type of support device used. General approaches to AKI management, including prevention strategies, medical management, and hemodynamic support, are also applicable in patients requiring MCS. Approaches to renal replacement therapy vary depend on patient factors, device-specific factors, and local preferences and experience. In this invited narrative review, we discuss the pathophysiology, risk factors, and prognostic implications of AKI in post-operative adult patients following institution of MCS. Management strategies for AKI are presented with a focus on those supported with either extracorporeal membrane oxygenation or a ventricular assist device.
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Affiliation(s)
- Danielle Austin
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Peter McCanny
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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Vigneshwar NG, Kohtz PD, Lucas MT, Bronsert M, J Weyant M, F Masood M, Itoh A, Rove JY, Reece TB, Cleveland JC, Pal JD, Fullerton DA, Aftab M. Clinical predictors of in-hospital mortality in venoarterial extracorporeal membrane oxygenation. J Card Surg 2020; 35:2512-2521. [PMID: 32789912 DOI: 10.1111/jocs.14758] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is utilized as a life-saving procedure and bridge to myocardial recovery for patients in refractory cardiogenic shock. Despite technical advancements, VA-ECMO retains high mortality. This study aims to identify the clinical predictors of in-hospital mortality after VA-ECMO to improve risk stratification for this tenuous patient population. METHODS The REgistry for Cardiogenic Shock: Utility and Efficacy of Device Therapy database is a multicenter, observational registry of ECMO patients. From 2013 to 2018, 789 patients underwent VA-ECMO. Bivariate analysis was performed on more than 300 variables regarding their association with in-hospital mortality. Logistic regression analyses were performed with variables chosen based upon clinical and statistical significance in the bivariate analysis. Tests were considered significant at a two-sided P < .05. RESULTS Although 63.5% patients were successfully weaned from VA-ECMO, in-hospital mortality was 57.9%. Nonsurvivors were older (P < .0001), had higher body mass index (P = .01), higher rates of hypertension (P = .02), coronary artery disease (P = .02), chronic obstructive pulmonary disease (P = .02), chronic liver disease (P = .008), percutaneous coronary intervention (P = .02), and surgical revascularization (P = .02). Multivariate predictors for in-hospital mortality include older age (odds ratio [OR], 1.019; P = .007), cardiac arrest (OR, 2.76; P = .006), chronic liver disease (OR, 8.87; P = .04), elevated total bilirubin (OR, 1.093; P < .0001), and the presence of a left ventricular vent (OR, 2.018; P = .03). Pre-ECMO sinus rhythm was protective (OR, 0.374; P = .006). CONCLUSIONS In a large study of recent VA-ECMO patients, in-hospital mortality remains significant, but acceptable given the severe pathology manifested in this population. Identification of pre-ECMO predictors of mortality helps stratify high-risk patients when deciding on ECMO placement, prolonged support, and prognosis.
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Affiliation(s)
- Navin G Vigneshwar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Patrick D Kohtz
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Mark T Lucas
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Michael Bronsert
- Colorado Health Outcomes Program, School of Medicine, University of Colorado, Aurora, Colorado
| | - Michael J Weyant
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Muhammad F Masood
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Akinobu Itoh
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Thomas B Reece
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Jay D Pal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - David A Fullerton
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Muhammad Aftab
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
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Arens J, Grottke O, Haverich A, Maier LS, Schmitz-Rode T, Steinseifer U, Wendel H, Rossaint R. Toward a Long-Term Artificial Lung. ASAIO J 2020; 66:847-854. [PMID: 32740342 PMCID: PMC7386861 DOI: 10.1097/mat.0000000000001139] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Only a very small portion of end-stage organ failures can be treated by transplantation because of the shortage of donor organs. Although artificial long-term organ support such as ventricular assist devices provide therapeutic options serving as a bridge-to-transplantation or destination therapy for end-stage heart failure, suitable long-term artificial lung systems are still at an early stage of development. Although a short-term use of an extracorporeal lung support is feasible today, the currently available technical solutions do not permit the long-term use of lung replacement systems in terms of an implantable artificial lung. This is currently limited by a variety of factors: biocompatibility problems lead to clot formation within the system, especially in areas with unphysiological flow conditions. In addition, proteins, cells, and fibrin are deposited on the membranes, decreasing gas exchange performance and thus, limiting long-term use. Coordinated basic and translational scientific research to solve these problems is therefore necessary to enable the long-term use and implantation of an artificial lung. Strategies for improving the biocompatibility of foreign surfaces, for new anticoagulation regimes, for optimization of gas and blood flow, and for miniaturization of these systems must be found. These strategies must be validated by in vitro and in vivo tests, which remain to be developed. In addition, the influence of long-term support on the pathophysiology must be considered. These challenges require well-connected interdisciplinary teams from the natural and material sciences, engineering, and medicine, which take the necessary steps toward the development of an artificial implantable lung.
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Affiliation(s)
- Jutta Arens
- From the Chair in Engineering Organ Support Technologies, Department of Biomechanical Engineering, Faculty of Engineering Technologies, University of Twente, Enschede, The Netherlands
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty
| | - Oliver Grottke
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Axel Haverich
- Thoracic, Cardiac and Vascular Surgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Lars S. Maier
- Internal Medicine II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty
| | - H.P. Wendel
- Thoracic, Cardiac and Vascular Surgery, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
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46
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Greer M, Welte T. Chronic Obstructive Pulmonary Disease and Lung Transplantation. Semin Respir Crit Care Med 2020; 41:862-873. [PMID: 32726838 DOI: 10.1055/s-0040-1714250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Lung transplantation (LTx) has been a viable option for patients with end-stage chronic obstructive pulmonary disease (COPD), with more than 20,000 procedures performed worldwide. Survival after LTx lags behind most other forms of solid-organ transplantation, with median survival for COPD recipients being a sobering 6.0 years. Given the limited supply of suitable donor organs, not all patients with end-stage COPD are candidates for LTx. We discuss appropriate criteria for accepting patients for LTx, as well as contraindications and exclusionary criteria. In the first year post-LTx, infection and graft failure are the leading causes of death. Beyond this chronic graft rejection-currently referred to as chronic lung allograft dysfunction-represents the leading cause of death at all time points, with infection and over time malignancy also limiting survival. Referral of COPD patients to a lung transplant center should be considered in the presence of progressing disease despite maximal medical therapy. As a rule of thumb, a forced expiratory volume in 1 second < 25% predicted in the absence of exacerbation, hypoxia (PaO2 < 60 mm Hg/8 kPa), and/or hypercapnia (PaCO2 > 50 mm Hg/6.6 kPa) and satisfactory general clinical condition should be considered the basic prerequisites for timely referral. We also discuss salient issues post-LTx and factors that impact posttransplant survival and morbidity such as infections, malignancy, renal insufficiency, and complications associated with long-term immunosuppression.
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Affiliation(s)
- Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Centre for Lung Research (DZL), Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Centre for Lung Research (DZL), Hannover, Germany
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47
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Schaubroeck HA, Gevaert S, Bagshaw SM, Kellum JA, Hoste EA. Acute cardiorenal syndrome in acute heart failure: focus on renal replacement therapy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:802-811. [PMID: 32597679 DOI: 10.1177/2048872620936371] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Almost half of hospitalised patients with acute heart failure develop acute cardiorenal syndrome. Treatment consists of optimisation of fluid status and haemodynamics, targeted therapy for the underlying cardiac disease, optimisation of heart failure treatment and preventive measures such as avoidance of nephrotoxic agents. Renal replacement therapy may be temporarily needed to support kidney function, mostly in case of diuretic resistant fluid overload or severe metabolic derangement. The best timing to initiate renal replacement therapy and the best modality in acute heart failure are still under debate. Several modalities are available such as intermittent and continuous renal replacement therapy as well as hybrid techniques, based on two main principles: haemofiltration and haemodialysis. Although continuous techniques have been associated with less haemodynamic instability and a greater chance of renal recovery, cohort data are conflicting and randomised controlled trials have not shown a difference in recovery or mortality. In the presence of diuretic resistance, isolated ultrafiltration with individualisation of ultrafiltration rates is a valid option for decongestion in acute heart failure patients. Practical tools to optimise the use of renal replacement therapy in acute heart failure-related acute cardiorenal syndrome were discussed.
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Affiliation(s)
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Belgium
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Canada
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, USA
| | - Eric Aj Hoste
- Intensive Care Unit, Ghent University Hospital, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
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48
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Gunning S, Kutuby F, Rose R, Trevino S, Song T, Koyner JL. Fluid Overload and Mortality in Patients with Severe Acute Kidney Injury and Extracorporeal Membrane Oxygenation. KIDNEY360 2020; 1:232-240. [PMID: 35372918 PMCID: PMC8809269 DOI: 10.34067/kid.0000402019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/03/2020] [Indexed: 11/27/2022]
Abstract
Background Volume overload is increasingly being understood as an independent risk factor for increased mortality in the setting of AKI and critical illness, but little is known about its effect in the setting of extracorporeal membrane oxygenation (ECMO). We sought to evaluate the incidence of AKI and volume overload and their effect on all-cause mortality in adults after ECMO cannulation. Methods We identified all adult patients who underwent ECMO cannulation at the University of Chicago between January 2015 and March 2017. We evaluated the incidence of KDIGO-defined AKI, RRT, and volume overload. Volume overload was defined as achieving a positive fluid balance of 10% above admission weight over the first 72 hours after ECMO cannulation. The primary outcome collected was 90 day all-cause mortality. Secondary outcomes included 30-day mortality, duration of ECMO and RRT therapy, length of stay, and dialysis independence at 90 days. Results There were 98 eligible patients, 83 of whom developed AKI (85%); 48 (49%) required RRT and 19 (19%) developed volume overload at 72 hours. Patients with volume overload had increased risk of death at 90 days compared with those without volume overload (HR, 2.3; 95% CI, 1.3 to 4.2; P=0.004). Patients with AKI-D had increased risk of death at 90 days compared with those without AKI-D (HR, 2.2; 95% CI, 1.3 to 3.8; P=0.004). Volume overload remained an independent predictor of 90-day mortality when adjusting for RRT, APACHE score, weight (kg), diabetes, and heart failure (HR, 2.9; 95% CI, 1.4 to 6.0; P=0.003). Conclusions Volume overload and AKI are common and have significant prognostic value in patients treated with ECMO. Initiating RRT may help to control the deleterious effects of volume overload and improve mortality.
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Affiliation(s)
- Samantha Gunning
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Fouad Kutuby
- Department of Medicine, University of Tennessee Health Science Center, Knoxville, Tennessee; and
| | - Rebecca Rose
- Section of Cardiac Surgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Sharon Trevino
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Tae Song
- Section of Cardiac Surgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Jay L. Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
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49
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Joannidis M, Forni LG, Klein SJ, Honore PM, Kashani K, Ostermann M, Prowle J, Bagshaw SM, Cantaluppi V, Darmon M, Ding X, Fuhrmann V, Hoste E, Husain-Syed F, Lubnow M, Maggiorini M, Meersch M, Murray PT, Ricci Z, Singbartl K, Staudinger T, Welte T, Ronco C, Kellum JA. Lung-kidney interactions in critically ill patients: consensus report of the Acute Disease Quality Initiative (ADQI) 21 Workgroup. Intensive Care Med 2020; 46:654-672. [PMID: 31820034 PMCID: PMC7103017 DOI: 10.1007/s00134-019-05869-7] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Multi-organ dysfunction in critical illness is common and frequently involves the lungs and kidneys, often requiring organ support such as invasive mechanical ventilation (IMV), renal replacement therapy (RRT) and/or extracorporeal membrane oxygenation (ECMO). METHODS A consensus conference on the spectrum of lung-kidney interactions in critical illness was held under the auspices of the Acute Disease Quality Initiative (ADQI) in Innsbruck, Austria, in June 2018. Through review and critical appraisal of the available evidence, the current state of research, and both clinical and research recommendations were described on the following topics: epidemiology, pathophysiology and strategies to mitigate pulmonary dysfunction among patients with acute kidney injury and/or kidney dysfunction among patients with acute respiratory failure/acute respiratory distress syndrome. Furthermore, emphasis was put on patients receiving organ support (RRT, IMV and/or ECMO) and its impact on lung and kidney function. CONCLUSION The ADQI 21 conference found significant knowledge gaps about organ crosstalk between lung and kidney and its relevance for critically ill patients. Lung protective ventilation, conservative fluid management and early recognition and treatment of pulmonary infections were the only clinical recommendations with higher quality of evidence. Recommendations for research were formulated, targeting lung-kidney interactions to improve care processes and outcomes in critical illness.
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Affiliation(s)
- Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sebastian J Klein
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
- Doctoral College Medical Law and Healthcare, Faculty of Law, University Innsbruck, Innsbruck, Austria
| | - Patrick M Honore
- Department of Intensive Care Medicine, CHU Brugmann University Hospital, Brussels, Belgium
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - John Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Vincenzo Cantaluppi
- Nephrology, Dialysis and Kidney Transplantation Unit, Department of Translational Medicine, University of Eastern Piedmont "A. Avogadro", Maggiore della Carità University Hospital, Novara, Italy
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
- Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai Key Laboratory of Kidney and Blood Purification, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medicine B, University Muenster, Muenster, Germany
| | - Eric Hoste
- ICU, Ghent University Hospital, Ghent, Belgium
- Research Fund-Flanders (FWO), Brussels, Belgium
| | - Faeq Husain-Syed
- Division of Nephrology, Pulmonology and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Giessen, Germany
| | - Matthias Lubnow
- Department of Cardiology, Pulmonary and Critical Care Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Marco Maggiorini
- Medical Intensive Care Unit, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Patrick T Murray
- School of Medicine, University College Dublin, Dublin, Ireland
- UCD Catherine McAuley Education and Research Centre, Dublin, Ireland
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Paediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
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50
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Zayton TM, El-Reweny EM, Tammam HM, Gharbeya KM. Predicting successful weaning in patients treated with venovenous extracorporeal membrane oxygenation. ALEXANDRIA JOURNAL OF MEDICINE 2020. [DOI: 10.1080/20905068.2020.1728881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Tayseer M. Zayton
- Department of Critical Care Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ehab M. El-Reweny
- Department of Critical Care Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Haitham M. Tammam
- Department of Critical Care Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Kareem M. Gharbeya
- Department of Critical Care Medicine, Alexandria Armed Forces Hospital, Alexandria, Egypt
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