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Recovery of renal function and survival after continuous renal replacement therapy during extracorporeal membrane
Matthew L Paden1, Barry L Warshaw, Micheal L Heard
1Department of Pediatrics, Divisions of Pediatric Critical Care, Emory University, Atlanta, GA, USA. matthew.paden@choa.org
Insights
Concurrent use of continuous renal replacement therapy (CRRT) with extracorporeal membrane oxygenation (ECMO) in pediatric patients rarely leads to chronic renal failure. This study suggests CRRT is safe for acute kidney injury management in ECMO patients without primary renal disease.
Area of Science:
- Pediatric Critical Care Medicine
- Nephrology
- Cardiopulmonary Support
Background:
- Acute kidney injury (AKI) is a significant predictor of mortality in pediatric patients undergoing extracorporeal membrane oxygenation (ECMO).
- Continuous renal replacement therapy (CRRT) is an effective treatment for AKI, but concerns exist regarding its safety and impact on renal outcomes when used concurrently with ECMO.
- This study investigates the long-term renal outcomes of pediatric patients receiving both ECMO and CRRT.
Purpose of the Study:
- To evaluate the incidence of chronic renal failure in pediatric patients treated with concomitant ECMO and CRRT.
- To assess the safety and efficacy of CRRT in managing AKI in critically ill children on ECMO.
- To determine the impact of concurrent ECMO and CRRT on patient survival and renal recovery.
Main Methods:
- A retrospective analysis of 154 pediatric patients who received ECMO and CRRT between 2009 and 2019 at a tertiary pediatric medical center.
- Patients' renal function was assessed using the pediatric Risk, Injury, Failure, Loss, End-stage (pRIFLE) criteria at CRRT initiation.
- Renal recovery and the need for ongoing renal replacement therapy post-ECMO were documented.
Main Results:
- Of 68 survivors, 96% experienced renal recovery before discharge. Only two patients with pre-existing renal disease developed end-stage renal disease.
- Eighteen (26%) survivors required ongoing renal replacement therapy after ECMO discontinuation, including continuous veno-venous hemofiltration, peritoneal dialysis, or intermittent hemodialysis.
- The overall mortality rate for patients on concomitant ECMO and CRRT was higher compared to ECMO alone, but similar to patients requiring CRRT without ECMO.
Conclusions:
- Concurrent use of CRRT with ECMO is not associated with an increased risk of chronic renal failure in pediatric patients without primary renal disease.
- CRRT is a safe and effective management strategy for AKI in ECMO patients, and concerns about precipitating chronic renal failure are largely unsubstantiated.
- Further research is needed to optimize the role and timing of CRRT in pediatric ECMO patients.
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 is associated with mortality in ECMO patients. CRRT in patients on ECMO provides an efficient and potentially beneficial method of acute kidney injury management. Concern that concomitant CRRT use increases the risk of developing anuria and chronic renal failure limits its use in some centers. We hypothesized that development of chronic renal failure is rare with concurrent ECMO and CRRT. We evaluated the outcomes of 154 ECMO/CRRT patients cared for over 10 yrs at a referral pediatric medical center.
Interventions:
None.
Measurements And Main Results:
Among 68 (44%) ECMO/CRRT survivors, 45 were assigned a pediatric risk, injury, failure, loss and end-stage (referred to as "pRIFLE") score at CRRT initiation. Seventeen (38%) patients met the 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 renal replacement therapy (15 required continuous veno-venous hemofiltration, two required peritoneal dialysis, and one patient required intermittent hemodialysis) post ECMO discontinuation. Renal recovery occurred in 65 (96%) of 68 patients before discharge. One neonatal patient had sepsis-induced renal injury on transfer, but had normal creatinine 1 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, chronic renal failure did not occur after concurrent use of CRRT with ECMO. Concern for precipitating chronic renal failure 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 with 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.
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