Renal Replacement Therapy in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation

Abstract

Summary Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure used in neonates, children, and adults with severe, reversible, cardiopulmonary failure. On the basis of single-center studies, the incidence of AKI occurs in 70%–85% of ECMO patients. Those with AKI and those who require renal replacement therapy (RRT) are at high risk for mortality, independent of potentially confounding variables. Fluid overload is common in ECMO patients, and is one of the main indications for RRT. RRT to maintain fluid balance and metabolic control is common in some but not all centers. RRT on ECMO can be performed via an in-line hemofilter or by incorporating a standard continuous renal replacement machine into the ECMO circuit. Both of these methods require specific technical considerations to provide safe and effective RRT. This review summarizes available epidemiologic data and how they apply to our understanding of AKI pathophysiology during ECMO, identifies indications for RRT while on ECMO, reviews technical elements for RRT application in the setting of ECMO, and finally identifies specific research-focused questions that need to be addressed to improve outcomes in this at-risk population.

Utilization of Extracorporeal Membrane Oxygenation In Pediatric Cardiac Surgery: A Single Center Experience, 34 Cases in 8 Years

“…The treatment of acute renal failure is managed with fluid restriction, diuretic therapy, peritoneal dialysis, hemodialysis in ECMO system and renal replacement therapy including hemodiafiltration. Higher mortality rates have been observed in cases of ECMO with acute renal damage requiring renal replacement therapy (27). In 10 out of our 14 cases, liquid administration modifications and normal urine output was ensured and the renal damage was treated with medication alone.…”

Terapia de reemplazo renal continua en el paciente con oxigenación por membrana extracorpórea: consideraciones para la combinación de ambas terapias

“…Pero también tiene desventajas: las bombas de infusión son incapaces de contener la filtración, no se monitorizan las presiones en el circuito de hemofiltración y la coagulación o la rotura del filtro no se pueden detectar tempranamente 3 . El control de la ultrafiltración puede ser especialmente deficiente cuando se requiere ultrafiltrar más de 800 ml en 24 h 17,21 . Los datos disponibles sobre la exactitud de estos dispositivos de infusión intravenosos para regular la ultrafiltración en un circuito de ECMO describen tasas de error de hasta 12,5%.…”

Review of Extracorporeal Membrane Oxygenation and Dialysis-Based Liver Support Devices for the Use of Nephrologists

“…Patients initiated on ECMO are severely ill and often have a preexisting impairment in hemodynamics and/or systemic inflammation [33]. Many patients are already receiving RRT prior to ECMO initiation [31].…”