Prognostic determinants in extracorporeal membrane oxygenation for respiratory failure in newborns

103

Objective-In a population of neonatal and pediatric patients on extracorporeal membrane oxygenation (ECMO); to describe the incidence and timing of acute kidney injury (AKI) utilizing a consensus AKI definition and investigate the association of AKI with outcomes (length of ECMO and mortality). Design-Multicenter retrospective observational cohort study Setting-Six pediatric ECMO centersPatients-Pediatric patients (age <18 years) on ECMO at six centers during a period of January 1, 2007 to December 31, 2011. Interventions-NoneMeasurements and Main Results-Complete data were analyzed for 832 patients on ECMO. Sixty percent of patients had AKI utilizing the serum creatinine KDIGO criteria (AKI SCr ) and Corresponding Author: Geoffrey M. Fleming, 5112 DOT, 2200 Children's Way, Nashville, TN 37232, Geoffrey.fleming@vanderbilt.edu, Tel: (615) 936-1302. Conflict of Interest: 1) The authors report no conflict of interest with funding support for RedCap 2) Dr Askenazi reports no conflict of interest with funding support as these sources were not used directly in the execution of this study. Conclusion-AKI is present in 60-74% of neonatal-pediatric patients supported on ECMO and is present by 48 hours of ECMO support in 86-93% of cases. AKI has a significant association with increased duration of ECMO support and increased adjusted odds of mortality at hospital discharge. HHS Public AccessAuthor manuscript Pediatr Crit Care Med. Author manuscript; available in PMC 2017 December 01.

Section: Discussionmentioning

confidence: 66%

The Incidence of Acute Kidney Injury and Its Effect on Neonatal and Pediatric Extracorporeal Membrane Oxygenation Outcomes: A Multicenter Report From the Kidney Intervention During Extracorporeal Membrane Oxygenation Study Group

Fleming

Sahay

Zappitelli

et al. 2016

103

“…Weber et al described 135 neonates treated with ECMO for respiratory failure(16). Forty-three patients (32%) had acute renal failure (defined as a serum creatinine greater than 2 mg/dL, or requiring ultrafiltration/dialysis).…”

Section: Discussionmentioning

confidence: 99%

Recovery of renal function and survival after continuous renal replacement therapy during extracorporeal membrane oxygenation*

Paden

Warshaw

Heard

et al. 2011

117

103

Objective To assess the outcome of pediatric patients supported by concomitant extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). Design, Setting, and Patients Acute kidney injury (AKI) is associated with mortality in ECMO patients. CRRT on ECMO provides an efficient and potentially beneficial method of AKI management. Concern that concomitant CRRT use increases the risk of developing anuria and chronic renal failure (CRF) limits its use in some centers. We hypothesized that development of CRF is rare with concurrent ECMO and CRRT. Outcomes of 154 ECMO/CRRT patients cared for over 10 years at a referral pediatric medical center were evaluated. Measurements and Main Results Among 68 ECMO/CRRT survivors (44%), 45 were assigned a pRIFLE score at CRRT initiation. Seventeen patients (38%) met criteria for Risk, 15 (33%) for Injury, and 10 (22%) for Failure. Two Failure patients later met End stage criteria. Of all survivors, 18 (26%) required ongoing RRT (15 CVVH, 2 peritoneal dialysis, 1 intermittent hemodialysis) following ECMO discontinuation. Renal recovery occurred in 65 of 68 (96%) before discharge. One neonatal patient had sepsis-induced renal injury on transfer, but normal creatinine one month later. Two pediatric patients with vasculitis and primary renal disease at presentation (both meeting Failure criteria) developed end-stage renal disease. One received peritoneal dialysis and subsequent renal transplant. The other has diminished function without need for renal replacement therapy. Conclusion In the absence of primary renal disease, CRF did not occur following concurrent use of CRRT with ECMO. Concern for precipitating CRF by using CRRT during ECMO is not substantiated by this large single center experience. Consistent with previous reports, mortality is higher in patients receiving concomitant CRRT and ECMO compared to those receiving ECMO alone. Mortality is similar to patients requiring CRRT who are not on ECMO. Additional studies are warranted to determine the optimal role of CRRT use in ECMO patients.

“…Children treated with ECMO are typically the most critically ill patients in the ICU and are likely to be at high risk for FO. Several single-centre studies in children and neonates treated with ECMO have suggested an association between FO and adverse outcomes, including duration of ECMO and mortality (6, 19–21). Given the consistent finding of the negative effect of FO on outcomes in patients treated with ECMO, FO may represent a clinically important target for interventions (such as CRRT) to improve patient outcomes.…”

Section: Introductionmentioning

confidence: 99%

The Impact of Fluid Overload on Outcomes in Children Treated With Extracorporeal Membrane Oxygenation: A Multicenter Retrospective Cohort Study*

Selewski

Askenazi

Bridges

et al. 2017

Purpose To characterize the epidemiology of fluid overload and its association with mortality and duration of extracorporeal membrane oxygenation (ECMO) in children treated with ECMO. Design Retrospective cohort study. Setting Six tertiary children’s hospital intensive care units. Patients 756 children < 18 years of age treated with ECMO for ≥ 24 hours from January 1, 2007 to December 31, 2011. Results Overall survival to ECMO decannulation and hospital discharge was 74.9% (n=566) and 57.7% (n=436), respectively. Median fluid overload at ECMO initiation was 8.8% (IQR 0.3, 19.2) and it differed between hospital survivors and non-survival, though not between ECMO survivors and non-survivors. Median peak fluid overload on ECMO was 30.9% (IQR 15.4, 54.8). During ECMO, 84.8% had a peak fluid overload ≥ 10%; 67.2% of patients had a peak fluid overload of ≥ 20% and 29% of patients had a peak fluid overload of ≥ 50%. The median peak fluid overload was lower in patients who survived ECMO (27.2% vs. 44.4%, p<0.0001) and survived to hospital discharge (24.8% vs. 43.3%, p<0.0001). After adjusting for acute kidney injury, pH at ECMO initiation, non-renal complications, ECMO mode, support type, centre and patient age, the degree of fluid overload at ECMO initiation (p =0.05) and the peak fluid overload on ECMO (p<0.0001) predicted duration of ECMO in survivors. Multivariable analysis showed that peak fluid overload on ECMO (aOR 1.09, 95% CI 1.04–1.15) predicted mortality on ECMO; fluid overload at ECMO initiation (aOR 1.13, 95% CI 1.05–1.22) and peak fluid overload (aOR 1.18, 95% CI 1.12–1.24) both predicted hospital morality. Conclusions Fluid overload occurs commonly and is independently associated with adverse outcomes including increased mortality and increased duration of ECMO in a broad pediatric ECMO population. These results suggest that fluid overload is a potential target for intervention to improve outcomes in children on ECMO.