title: Recovery of renal function and survival after continuous renal replacement therapy during extracorporeal membrane oxygenation.
abstract: OBJECTIVE
  To assess the outcome of pediatric patients supported by concomitant extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT).
  
  
  METHODS
  Acute kidney injury is associated with mortality in ECMO patients. CRRT in patients on ECMO provides an efficient and potentially beneficial method of acute kidney injury management. Concern that concomitant CRRT use increases the risk of developing anuria and chronic renal failure limits its use in some centers. We hypothesized that development of chronic renal failure is rare with concurrent ECMO and CRRT. We evaluated the outcomes of 154 ECMO/CRRT patients cared for over 10 yrs at a referral pediatric medical center.
  
  
  METHODS
  None.
  
  
  RESULTS
  Among 68 (44%) ECMO/CRRT survivors, 45 were assigned a pediatric risk, injury, failure, loss and end-stage (referred to as "pRIFLE") score at CRRT initiation. Seventeen (38%) patients met the criteria for Risk, 15 (33%) for Injury, and 10 (22%) for Failure. Two Failure patients later met End stage criteria. Of all survivors, 18 (26%) required ongoing renal replacement therapy (15 required continuous veno-venous hemofiltration, two required peritoneal dialysis, and one patient required intermittent hemodialysis) post ECMO discontinuation. Renal recovery occurred in 65 (96%) of 68 patients before discharge. One neonatal patient had sepsis-induced renal injury on transfer, but had normal creatinine 1 month later. Two pediatric patients with vasculitis and primary renal disease at presentation (both meeting Failure criteria) developed end-stage renal disease. One received peritoneal dialysis and subsequent renal transplant. The other has diminished function without need for renal replacement therapy.
  
  
  CONCLUSIONS
  In the absence of primary renal disease, chronic renal failure did not occur after concurrent use of CRRT with ECMO. Concern for precipitating chronic renal failure by using CRRT during ECMO is not substantiated by this large single-center experience. Consistent with previous reports, mortality is higher in patients receiving concomitant CRRT and ECMO compared with those receiving ECMO alone. Mortality is similar to patients requiring CRRT who are not on ECMO. Additional studies are warranted to determine the optimal role of CRRT use in ECMO patients.
authors.affiliation: Department of Pediatrics, Divisions of Pediatric Critical Care, Emory University, Atlanta, GA, USA. matthew.paden@choa.org
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Paden
authors.forename: Barry L
authors.initials: BL
authors.lastname: Warshaw
authors.forename: Micheal L
authors.initials: ML
authors.lastname: Heard
authors.forename: James D
authors.initials: JD
authors.lastname: Fortenberry
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D005845:Georgia; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D007676:Kidney Failure, Chronic / Q000534:rehabilitation*; D007677:Kidney Function Tests; D008297:Male; D017582:Renal Replacement Therapy; D016019:Survival Analysis
references.citation: Pediatrics. 1995 Apr;95(4):573-8
references.pmid: 7700761
references.citation: Intensive Care Med. 2008 Dec;34(12):2241-7
references.pmid: 18629472
references.citation: Pediatrics. 2001 Jun;107(6):1309-12
references.pmid: 11389248
references.citation: J Pediatr Surg. 2000 Feb;35(2):197-202
references.pmid: 10693665
references.citation: Pediatr Nephrol. 2004 Dec;19(12):1394-9
references.pmid: 15517417
references.citation: Pediatrics. 1976 Aug;58(2):259-63
references.pmid: 951142
references.citation: Crit Care Clin. 2003 Jul;19(3):563-75
references.pmid: 12848321
references.citation: Ann Thorac Surg. 1990 Nov;50(5):720-3
references.pmid: 2241330
references.citation: Kidney Int. 2005 Feb;67(2):653-8
references.pmid: 15673313
references.citation: Ann Surg. 1997 Oct;226(4):544-64; discussion 565-6
references.pmid: 9351722
references.citation: Ren Fail. 2003 Mar;25(2):183-93
references.pmid: 12739825
references.citation: Crit Care Med. 2004 Aug;32(8):1771-6
references.pmid: 15286557
references.citation: ASAIO J. 2009 Jul-Aug;55(4):412-6
references.pmid: 19381083
references.citation: Nephrol Dial Transplant. 2006 Oct;21(10):2867-73
references.pmid: 16799171
references.citation: Ann Surg. 1986 Sep;204(3):236-45
references.pmid: 3530151
references.citation: Artif Organs. 2002 Nov;26(11):919-23
references.pmid: 12406143
references.citation: J Pediatr Surg. 1987 Jul;22(7):600-2
references.pmid: 3649394
references.citation: Clin J Am Soc Nephrol. 2008 Jul;3(4):948-54
references.pmid: 18417742
references.citation: Nephrol Dial Transplant. 2001;16 Suppl 5:67-72
references.pmid: 11509688
references.citation: J Pediatr Surg. 1998 Nov;33(11):1605-9
references.pmid: 9856876
references.citation: Ann Thorac Surg. 2003 Nov;76(5):1435-41; discussion 1441-2
references.pmid: 14602263
references.citation: ASAIO J. 2005 Sep-Oct;51(5):504-7
references.pmid: 16322706
references.citation: Artif Organs. 2003 Sep;27(9):781-5
references.pmid: 12940899
references.citation: J Pediatr Surg. 1991 Sep;26(9):1016-22
references.pmid: 1941476
references.citation: Kidney Int. 2007 May;71(10):1028-35
references.pmid: 17396113
references.citation: Pediatr Crit Care Med. 2001 Jul;2(3):238-242
references.pmid: 12793948