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

Abstract

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.

Continuous renal replacement therapy to reduce inflammation in a piglet hemorrhage–reperfusion extracorporeal membrane oxygenation model

“…Additional reviews of institutional experiences with CRRT and ECMO described the technical challenges and complications associated with continuous venovenous hemofiltration (CVVH) and ECMO using objective clinical and/or biochemical markers (9,16). Recently, Paden et al (19), suggested that the combination of CVVH and ECMO does not contribute to development of chronic renal failure but is associated with higher mortality risk than ECMO alone, probably because of the preexisting renal failure rather than the introduction of CVVH. In addition, Santiago et al (20) analyzed the efficacy and safety of the inclusion of CRRT with ECMO in vitro, in a piglet model, as well as in selected pediatric patients.…”

Early Continuous Renal Replacement Therapy in Cardiogenic Shock Patients with Severe Acute Kidney Injury Undergoing Extracorporeal Membrane Oxygenation

“…The prognosis of patients receiving ECMO who require CRRT is especially poor [15,16,17]. Wu et al [13] reported that the latency between hospital admission and dialysis correlated with reduced survival among patients who received acute dialysis during ECMO therapy, especially those who had not undergone coronary artery bypass surgery.…”

Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy

“…Paden et al [11] in his study of 154 patients on ECMO and CRRT showed that renal recovery was seen in 96% of the patients who survived. Similarly, Meyer et al [12] in a series of neonatal and pediatric survivors renal recovery was seen in 14/15 (93%) patients.…”