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ECMO in CRRT – What are the Data?

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Presentation on theme: "ECMO in CRRT – What are the Data?"— Presentation transcript:

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


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

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