1. THE EFFECT OF TIMING OF INITITIATION OF CRRT ON PATIENTS REQUIRING EXTRA-CORPOREAL MEMBRANE OXYGENATION (ECMO) Asif Mansuri, MD, MRCPI Fellow, Division of Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas,USA

2. DISCLOSURE STATEMENT I have no Financial relationships to disclose or Conflicts of Interest (COIs) to resolve

3. Introduction Determining optimal timing of initiation is one of the top research priorities in the clinical research agenda developed by the Acute Kidney Injury Network. Large multicenter trials in critically ill adults have shown that the modality and dosing of CRRT do not have significant impact on mortality. However, the impact of timing of initiation remains to be established.

4. Introduction Many patients on ECMO often require Continuous Renal Replacement Therapy (CRRT). We have previously demonstrated that delay in initiation of CRRT in non-ECMO patients had a significant impact on survival. Timing of Continuous Renal Replacement Therapy and Mortality in Critically Ill Children, Pediatric Critical Care, April 2014 Volume 42 Number 4 Vinai Modem, MBBS; Marita Thompson, MD; Diane Gollhofer, RN, BSN, CCRN; Archana V. Dhar, MD; Raymond Quigley, MD

5. Objective The objective of the present study was to determine the effect of the Timing of Initiation of CRRT on patients who were on ECMO.

6. Study design and patient selection Retrospective cohort design: Charts of patients admitted to the ICU at Children Medical Centre, Dallas from 1 st of January 2010 to 31 st December 2014 were reviewed. Inclusion Criteria: Age < 21 years Patients who were on ECMO and received CRRT Exclusion Criteria: Primary renal disease who were on renal replacement therapy prior to ECMO

7. Predictor Variables Time to CRRT initiation –Time from ECMO initiation to CRRT initiation (measured in hours and expressed in days) Renal function at ECMO initiation –Estimated from serum Cr using Schwartz formula Fluid balance at ECMO initiation

8. Outcome Variables ICU Survival ECMO Duration

9. Age Group All N = 65 Survivors N = 33 Non- survivors N = 32 Neonates (≤ 1 month) Infants (1 month – 2 years) Small children (2 – 6 years) School-age (6 – 13 years) Teens (> 13 years) 28 10 9 12 6 15 7 2 6 3 13 3 7 6 3 Demographic data p 0.35* * Fisher exact test

10. Demographic data p 0.30* p 0.002* * Fisher exact test

11. Median Time to CRRT from ECMO Initiation * Wilcoxon rank order test

12. Median Time to CRRT from ECMO Initiation-Neonates * Wilcoxon rank order test

13. Median Creatinine Clearance at ECMO Initiation (ml/min /1.73 m 2 ) - Neonates * Wilcoxon rank order test

14. Median Creatinine Clearance at ECMO Initiation (ml /min /1.73 m 2 ) * Wilcoxon rank order test

15. Median Fluid Balance * Wilcoxon rank order test

16. Median Fluid Balance- Neonates * Wilcoxon rank order test

17. The relationship between ECMO Duration and Time to CRRT

18. Survivors : r = 0.60; p < 0.001 Non-survivors : r = 0.61; p< 0.001

19. Conclusion In Neonates, early initiation of CRRT improves outcome. In other age groups, there was no significant difference in time to CRRT initiation between survivors and non- survivors. In neonates treated with ECMO and CRRT, survivors had a lower estimated creatinine clearance at ECMO initiation and at CRRT initiation.

20. Decreasing the time between the initiation of ECMO and initiation of CRRT correlates with a shorter treatment with ECMO. Conclusion

21. Acknowledgment Raymond Quigley,MD Professor, Division of Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas,USA Vinai Modem,MBBS,FAAP Assistant Professor Division of Pediatric Critical care and Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas,USA

22. Thank you