ECMO in CRRT – What are the
Data?
Jason S. Frischer, MD
Director, ECMO Program
Division of Pediatric General & Thoracic Surgery
Cincinnati Children's Hospital Medical Center
Cincinnati, OH
1st International Symposium on AKI in Children at the 7th
International Conference on Pediatric Continuous Renal
Replacement Therapy
Cincinnati, OH
September 27-30, 2012
Thank You, STU
Background
• As many as 30 definitions of renal failure exist in
the literature
– Difficult to compare:
• Incidence
• Therapeutics
• Outcomes
– pRIFLE
– AKIN
– Neonatal definition even more difficult
Background
• 2 sources of data
– Single center reviews
• Details available
• Able to control variables
– ELSO
• Renal complications
– Serum Cr
– Need for dialytic therapy
– No data on indication, practice based on local expert opinion
• Until this year
AKI
• Neonates
– Single center incidence: 22-71%
– ELSO based publications: 10-22%
• Pediatric
– Single center incidence: 12-30%
ECMO, Extracorporeal Cardiopulmonary Support in Critical Care, 4th Ed
AKI – Neonatal/Cardiac
• Neonatal Respiratory – 75% overall survival
• Neonatal Cardiac – 39% overall survival
ELSO, July 2012
AKI – Pediatric/Cardiac
Pediatric Respiratory – 56% overall survival
Pediatric Cardiac – 47% overall survival
ELSO, July 2012
• ELSO registry review
– Non-cardiac patients
– 1998 - 2008
ELSO review - Neonates
• AKI + RRT 28% survival
• AKI Ø RRT 45.7% survival
• ØAKI + RRT 58.1% survival
• ØAKI Ø RRT 80.1% survival
.
ELSO review - Pediatric
• AKI + RRT 32.2% survival
• AKI Ø RRT 41.3% survival
• ØAKI + RRT 48.3% survival
• ØAKI Ø RRT 72.3% survival
.
ELSO review - Conclusions
• AKI and RRT are independent predictors of
mortality
• Even after controlling for comorbidity variables
RRT in Critically Ill Patients
• Using RIFLE definition in ECMO patients
– AKI incidence:
•
•
•
•
CDH – 71% : associated with mortality
Cardiac – 71%
Adults respiratory – 78%
Adults post-cardiotomy – 81%
Clin J Am Soc Nephrol. 2012 Aug;7(8):1328-1336.
RRT in Critically Ill Patients
• Indications for RRT on ECMO
–
–
–
–
Issue with ELSO database
Fluid Overload (FO) – 43%
AKI – 35%
Electrolyte – 4%
• Cumulative FO and failure to return to dry weight
– Associated with higher mortality and prolonged ECMO run
Clin J Am Soc Nephrol. 2012 Aug;7(8):1328-1336.
• Used to define current practice
– 65 centers
– 23% reported NO RST
– 43% use for FO
– 16% for FO prevention
– 35% AKI
– 4% Electrolyte
KIDMO
KIDMO - Indication
KIDMO – Mode employed
• Predominant mode
convection
– CVVH
– SCUF
•
•
•
•
Single center retrospective review
July 2006 – October 2010 @ U of M
Hemofiltration through 2008, then CVVH
203 total ECMO
– 57 CRRT (28%), 4 prior to run
FO and ECMO/RRT
• 33 neonates
• FO indication in 48/53 patients
FO and ECMO/RRT
Outcomes:
• 58% overall survival
– CRRT – 34%
– Filter vs CVVH : 25 vs 53%
• Improved institutional practices?
– Median initiation of FO
• Significantly lower in survivors
• 24.5% survivors vs 38% nonsurvivors, P=.006
FO and ECMO/RRT
Outcomes:
• Cardiac
– Degree of FO at CRRT
initiation significantly
higher in nonsurvivors
– 38% vs 14%, P=.039
• Degree of fluid removal
and rate of removal:
• NO improvement in
outcome
FO and ECMO/RRT
Outcomes:
• Univariate Analysis
– Significant association b/w initiation and discontinuation
of FO and mortality
– For each 1% increase in FO - odds of mortality increase
4%
• Multivariate Analysis
– Borderline significance with initiation FO and mortality
– Significant increased mortality with dicontinuation level
of FO
– Examined % change in FO, NOT significantly associated
with mortality
FO and ECMO/RRT
Conclusions:
• “These data suggest that PREVENTION of
significant FO is likely to be more effective at
improving outcomes than attempting fluid
removal once significant FO is established.”
• Single center retrospective review
• 378 total ECMO with 66% survival
• 154 (41%) concomitant CVVH
Recovery
• CVVH has a lower survival rate
– Similar to non-ECMO patients
Renal Outcomes
• 52% FO
• 37% ARF
• 18/68 (26%) survivors required ongoing RRT
following decannulation
• 65/68 (96%) no RRT by hospital discharge
– 30/31 FO and 20/23 AKI
Recovery - Conclusions
• Confirms higher risk of CRRT compared with
ECMO use alone
• In the absence of primary renal disease at
presentation, CRF did not occur in ECMO pts.
treated with CVVH.
Biomarkers
• 10 pediatric cardiac patients
– 50% survive to d/c from ICU
• Increased NGAL on ECMO day #1 who needed
CVVH
– NGAL remained higher while on CVVH
– Cr levels equivalent b/w groups
is
ECMO in CRRT – What are the
Data?
Pubmed:
ECMO and anticoagulation: 161
ECMO and RRT: 11
1st International Symposium on AKI in Children at the 7th
International Conference on Pediatric Continuous Renal
Replacement Therapy
Cincinnati, OH
September 27-30, 2012
Conclusions
• Consensus definitions of AKI will help future
studies
– ELSO registry
• We have insufficient data to answer some basic
questions
– True incidence
– Best mechanical practice
• Site of connection
• Equipment
• Mode (convection vs diffusion)
Thank you