Acute Kidney Injury and Fluid Overload in Pediatric Extracorporeal Cardio-Pulmonary Resuscitation: A Multicenter Retrospective Cohort Study

Abstract

Acute kidney injury (AKI) and fluid overload (FO) are common complications of extracorporeal membrane oxygenation (ECMO). The purpose of this study was to characterize AKI and FO in children receiving extracorporeal cardiopulmonary resuscitation (eCPR). We performed a multicenter retrospective study of children who received eCPR. AKI was assessed during ECMO and FO defined as <10% [FO−] vs. ≥10% [FO+] evaluated at ECMO initiation and discontinuation. A composite exposure, defined by a four-group discrete phenotypic classification [FO−/AKI−, FO−/AKI+, FO+/AKI−, FO+/AKI+] was also evaluated. Primary outcome was mortality and hospital length of stay (LOS) among survivors. 131 patients (median age 29 days (IQR:9, 242 days); 51% men and 82% with underlying cardiac disease) were included. 45.8% survived hospital discharge. FO+ at ECMO discontinuation, but not AKI was associated with mortality [aOR=2.3; 95% CI: 1.07–4.91]. LOS for FO+ patients was twice as long as FO− patients, irrespective of AKI status [(FO+/AKI+ (60 days; IQR: 49-83) vs. FO−/AKI+ (30 days, IQR: 19–48 days); P = 0.01]. FO+ at ECMO initiation and discontinuation was associated with an adjusted 66% and 50% longer length of stay respectively. Prospective studies that target timing and strategy of fluid management, including its removal in children receiving ECPR are greatly needed.

Fluid balance in pediatric critically ill patients (with and without kidney dysfunction)

“…Gist and coworkers recently reported an analysis on more than 130 children undergoing ECMO indicated as cardiopulmonary resuscitation. They found that the presence of fluid overload at ECMO discontinuation (defined as a cumulative positive FB above 10%), but not AKI was associated with mortality, further reinforcing the concept that excess fluids may be harmful in high-risk children, regardless of clinical phenotype (i.e., AKI positive or AKI negative) [30]. Gorga et al…”

Standard Versus Restrictive Transfusion Strategy for Pediatric Cardiac ECLS Patients: Single Center Retrospective Cohort Study

“…37,38 In pediatric patients receiving Extracorporeal Cardiopulmonary Resuscitation (ECPR), fluid overload was associated not only with mortality, but also with increased LOS in survivors. 39 A recent multicenter cohort study of pediatric ECLS patients found a negative association between survival and the amount of blood components administered in the first 5 days of ECLS. 40 In our study, the implementation of a RTS was associated with less fluid accumulation in the first 48 hours of ECLS support.…”

The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO

“…28,32,33,35,38,39,46 However, one multivariate analysis found that AKI/RRT is no longer a risk factor for mortality when correcting for fluid overload at ECMO discontinuation, suggesting that AKI/RRT might not be associated with worse outcome when fluids can be withdrawn by RRT. 47 The negative impact of RRT on survival is probably not due to the actual RRT itself, but more a reflection of the underlying disease and/or event that lead to renal dysfunction and the concomitant requirement of RRT. 31,34 Neuromonitoring Whilst on V-A ECMO it is important to perform neuromonitoring like near-infrared spectroscopy (NIRS), (amplitude integrated) EEG and routine brain ultrasound in neonates, however this practice is highly variable amongst ECMO programs in Europe.…”

“…28,32,33,35,38,39,46 However, one multivariate analysis found that AKI/RRT is no longer a risk factor for mortality when correcting for fluid overload at ECMO discontinuation, suggesting that AKI/RRT might not be associated with worse outcome when fluids can be withdrawn by RRT. 47 The negative impact of RRT on survival is probably not due to the actual RRT itself, but more a reflection of the underlying disease and/or event that lead to renal dysfunction and the concomitant requirement of RRT. 31,34…”

“…Based on the limited outcomes in non-cardiac patients it might be reasonable to limit ECPR to children with witnessed IHCA, to exclude those with known cerebral damage or no chance to bridge to recovery or Single-ventricle physiology [28][29][30][31] Two-ventricle physiology 28-31 Non-cardiac disease 32,33 Cardiac disease 17,37,38 Acquired heart disease 27 White race 36,39 Higher complexity of CHD 28 Post-cardiac surgery 27 Prematurity 33 Younger age (<12 months) 34 Chromosomal abnormalities 35 Neurologic comorbidity 17 Trauma 36 Obesity 36 Gastro-intestinal comorbidity 27 Technology dependence 27 Cardiac arrest and CPR OHCA IHCA Unwitnessed CA 40 Short duration of CCPR 41 Long duration of CCPR 41 Open-chest compressions 27 CCPR interruptions 42 CA in catheterisation lab 24 CCPR location outside ICU 27 PH >7.17 39 High lactate 27,43 Neck/RCA cannulation 28,38 Acidosis, pH <7.01 28 Hypercarbia 44 Sodium bicarbonate bolus 32 Calcium 45 Blood-primed ECMO circuit 35 During ECPR Time to normal lactate 43 Early diagnosis and management of underlying cause [49][50][51][52] Normalization of lactate 27 AKI/Renal failure 28,32,33,35,38,39,46 RRT 31,34 Fluid overload 47 ECMO duration 30 Neurologic complications 28,31,34,35,…”