1. 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
September 27-30, 2012

2. Thank You, STU

3. 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

4. Background 2 sources of data Single center reviews ELSO
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

5. AKI Neonates Pediatric 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

6. AKI – Neonatal/Cardiac
Neonatal Respiratory – 75% overall survival
Neonatal Cardiac – 39% overall survival
ELSO, July 2012

7. AKI – Pediatric/Cardiac
Pediatric Respiratory – 56% overall survival
Pediatric Cardiac – 47% overall survival
ELSO, July 2012

8. ELSO registry review
Non-cardiac patients

9. ELSO review - Neonates AKI + RRT 28% survival AKI Ø RRT 45.7% survival

10. ELSO review - Pediatric
AKI + RRT % survival
AKI Ø RRT % survival
ØAKI + RRT % survival
ØAKI Ø RRT % survival .

11. ELSO review - Conclusions
AKI and RRT are independent predictors of mortality
Even after controlling for comorbidity variables

12. 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 Aug;7(8):

13. 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 Aug;7(8):

14. Used to define current practice
65 centers
23% reported NO RST
43% use for FO
16% for FO prevention
35% AKI
4% Electrolyte

15. KIDMO

16. KIDMO - Indication

17. KIDMO – Mode employed
Predominant mode convection
CVVH
SCUF

18. 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

19. FO and ECMO/RRT
33 neonates
FO indication in 48/53 patients

20. 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

21. 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

22. 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

23. 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.”

25. Single center retrospective review
378 total ECMO with 66% survival
154 (41%) concomitant CVVH

26. Recovery
CVVH has a lower survival rate
Similar to non-ECMO patients

27. 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

28. 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.

30. 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

31. ECMO in CRRT – What are the Data?is
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

32. 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)

33. Thank you