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

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 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

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

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

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

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

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