Concurrent Use of Renal Replacement Therapy during Extracorporeal Membrane Oxygenation Support: A Systematic Review and Meta-Analysis.

Saikat Mitra,Kiran Shekar,Graeme MacLaren,Chuen Seng Tan,Ryan Ruiyang Ling,Kollengode Ramanathan

doi:10.3390/jcm10020241

Abstract

Patients supported with extracorporeal membrane oxygenation (ECMO) often receive renal replacement therapy (RRT). We conducted this systematic review and meta-analysis (between January 2000 and September 2020) to assess outcomes in patients who received RRT on ECMO. Random-effects meta-analyses were performed using R 3.6.1 and certainty of evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The primary outcome was pooled mortality. The duration of ECMO support and ICU/hospital lengths of stay were also investigated. Meta-regression analyses identified factors associated with mortality. A total of 5896 adult patients (from 24 observational studies and 1 randomised controlled trial) were included in this review. Overall pooled mortality due to concurrent use of RRT while on ECMO from observational studies was 63.0% (95% CI: 56.0–69.6%). In patients receiving RRT, mortality decreased by 20% in the last five years; the mean duration of ECMO support and ICU and hospital lengths of stay were 9.33 days (95% CI: 7.74–10.92), 15.76 days (95% CI: 12.83–18.69) and 28.47 days (95% CI: 22.13–34.81), respectively, with an 81% increased risk of death (RR: 1.81, 95% CI: 1.56–2.08, p < 0.001). RRT on ECMO was associated with higher mortality rates and a longer ICU/hospital stay compared to those without RRT. Future research should focus on minimizing renal dysfunction in ECMO patients and define the optimal timing of RRT initiation.

Highlights

25 studies detailing 5896 adult patients that reported on the use of renal replacement therapy (RRT) and extracorporeal membrane oxygenation (ECMO) were included (Table 1) [28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52]
We did not analyse any differences in outcomes based on timing of RRT initiation, different modalities of RRT, different ventricular unloading techniques while on ECMO, or different forms of shock because very few studies examined these data. Adult patients receiving both ECMO and RRT are at a greater risk of death
Patients receiving RRT on VAECMO have greater odds of death compared with those receiving RRT on VV-ECMO

Summary

Introduction

Almost 50% of patients on extracorporeal membrane oxygenation (ECMO) require renal replacement therapy (RRT) [1]. The indications for initiating RRT while on ECMO are similar to other critically ill patients and can be multifactorial [1,2]. Acute kidney injury (AKI) is a common indication in almost 80% of patients receiving extracorporeal membrane oxygenation (ECMO) [3]. The aetiology of AKI in the ECMO patient population can be attributed to pre-ECMO and ECMO factors such as hypoxaemia and haemodynamic perturbations around the time of initiation, low cardiac output state, severe right heart dysfunction, underlying multisystem disorders, systemic inflammation, hormonal imbalances, exposure to nephrotoxins, and ischaemic-reperfusion injury [2,3,4,5,6,7]. The mortality of critically ill patients who develop AKI is estimated to be 40–70% [8,9]. The reported incidence of mortality due to AKI associated with ECMO is approximately

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