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Background: Volume overload is increasingly being understood as an independent risk factor for increased mortality in the setting of acute kidney injury (AKI) and critical illness, but little is known about its impact in the setting of extracorporeal membrane oxygenation (ECMO). We sought to evaluate the incidence of AKI and volume overload and their impact on all-cause mortality in adults following 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, renal replacement therapy (RRT) and volume overload. Volume overload was defined as achieving a positive fluid balance of 10% above admission weight over the first 72 hours following 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%); with 48 (49%) requiring RRT and 19 (19%) developing volume overload at 72 hours. Patients with volume overload had increased risk of death at 90 days compared to those without volume overload (HR 2.3(1.3, 4.2); p=0.004). Patients with AKI-D had increased risk of death at 90 days compared to those without AKI-D (HR 2.2(1.3, 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(1.4, 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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Introduction. Novel urinary biomarkers, including Tissue Inhibitor Metallo-protease-2 and Insulin-like Growth Factor Binding Protein 7 ([TIMP-2]*[IGFBP7]), have been developed to identify patients at risk for acute kidney injury (AKI). We investigated the “real world” clinical utility of [TIMP-2]*[IGFBP7] in preventing AKI. Methods. We performed a prospective single-center quality improvement study of intensive care unit (ICU) patients at risk for severe (KDIGO stage 2 or 3) AKI. In the prospective cohort, ICU providers were allowed to order [TIMP-2]*[IGFBP7] for patients at their discretion, then offered AKI practice recommendations based on the result. Outcomes were compared to a historical cohort in which biomarker values were not reported to clinical teams. Results. There was no difference in 7-day progression to severe AKI between the prospective (n=116) and historical cohorts (n=63) when [TIMP-2]*[IGFBP7] ≥0.3 (24(28%) vs 8(21%), p=0.38) despite more stage 1 AKI at time of biomarker measurement in the prospective cohort (58(67%) vs 9(23%), p<0.001). In the prospective cohort, patients with higher [TIMP-2]*[IGFBP7] values were more likely to receive a nephrology consult. Early consultation (within 24 hours of biomarker measurement, n=20) had a nonsignificant trends towards net negative volume balance (-1787mL(6716mL) vs +4974mL(15540mL)) and more diuretic use (19(95%) vs 8(80%)), and was associated with less severe AKI (9(45%) vs 10(100%), p=0.004) and inpatient dialysis (2(10%) vs 7(70%), p=0.002) compared to delayed consultation (n=10). Discussion/Conclusions. Despite the prospective cohort having more preexisting stage 1 AKI, there were equal rates of progression to severe AKI in the prospective and historical cohorts. In the setting of [TIMP-2]*[IGFBP7] reporting, there were more nephrology consults in response to elevated biomarker levels. Early nephrology consultation resulted in improved volume balance and favorable outcomes compared to delayed consultation.