CRRT and ECMO Techniques and Outcomes from ... - CRRT Online

CRRT in ECMO Patients:Techniques and Outcomesfrom the ELSO RegistryDavid Askenazi MD MSAssociate Professor of Pediatrics17 th Annual CRRT Meeting

Objectives• Discuss how RRT is performed in critically illpatients on ECMO• Review the incidence and outcomes in ECMOpatients with AKI / RRT.• Assess if AKI and RRT provision areindependently associated with mortality

Extracorporeal MembreaneOxygenation (ECMO)• Indications for ECMO• Severe acute heart or lung failure• Expected mortality risk ≥ 80% despiteoptimal conventional therapy• ECMO initiation usually improveshemodynamic statusELSO Registry General Guidelines. April 2009

ECMO initiation maypredispose patients to AKI• ECMO initiation causes• Increased inflammatory response 1• Hypercoaguable state 2• Hemolysis/ Hemoglobinuria 31. Kurundkar et al. Pediatric Research August 20102. Shapiro A. Seminars in Hematology 19953. Toomasian J. and Bartlett R. Perfusion 2011

Not surprising that thesepatients develop AKI

Technical Considerations

How do you do it? Access

ECMO and RRT System.Adapted from Hoover N et al.Intensive Care Medicine, 2008.

CRRT machines with ECMO• Access Pressure on CRRT may be positive• Some Dialysis Machines can allow for alarmsto be adjusted during ECMO• Clamps can be used to avoid these alarms• Increases Hemolysis• Circuit prime• Can use either a saline prime or blood prime• Careful with heparin rinse

ECMO and In-Line Hemofilter System.Adapted from Hoover N et al.Intensive Care Medicine, 2008.

ECMO and In-Line Hemofilter SystemRSCUFCVVH.Adapted from Hoover N et al.Intensive Care Medicine, 2008.

ECMO and In-Line Hemofilter SystemRDCVVHD.Adapted from Hoover N et al.Intensive Care Medicine, 2008.

ECMO and In-Line Hemofilter SystemRDCVVHDF.Adapted from Hoover N et al.Intensive Care Medicine, 2008.

CRRT on ECMO using“Homemade” In-Line system• Must return “dialyzed blood” preBLADDER• IV infusion pumps control ultrafiltrate• Up to 12.5 % inaccuracies in some studies• IV pumps are not engineered to maintainaccuracy at higher pressures

Ultrafiltration Error Rate Increaseswith Increasing Flow/PressureDifferentialSucosky, Paden et al., JMD 2008

What type of modality is usedNO RRTRRT MachineIN- LINEunknownFlemming G, et al.– abstract CRRT 2012KIDMO Study Group

Modality with RRT machineSCUF CVVH CVVHD CVVHDFFlemming G, et al.– abstract CRRT 2012KIDMO Study Group

Modality w/ In-Line HemofilterSCUF CVVH CVVHD CVVHDFFlemming G, et al.– abstract CRRT 2012KIDMO Study Group

Differences between RRT methodsIn Line Hemofilter CRRT machineUltrafiltrationcontrolIV pump controlledCRRT machinecontrolledMetabolic Control NOT if only using SCUF YESECMO Flow Blood ShuntNO systemic changes-decrease ECMO flow-decreased PaO2Complexity Less People More People

Epidemiology of AKIin ECMO patients

How often does AKI happen inECMO patients?• Single Center Pediatric Data• Neonates with congenital diaphragmatichernia (CDH) 1 – 84%• Children with Cardiac Indications 2 – 71%1. Gadepalli et al. Pediatric Surgery July 20102. Smith et. al ASAIO 2009

Single Center Adult DataRetrospective analysis of 46 adults on ECMO usingRIFLEF24%I39%NO22%R15%78% ofpatientshad AKILin, C.-Y. et al. NDT. 200622

RIFLE in adults on ECMOSurvival8/10 (80%)3/7 (57%)5/18 (28%)0/11 (0%)Lin, C.-Y. et al. NDT. 2006

Adults on ECMO Post-CardiotomyAKI by RIFLE at 48 hrsAKI by AKIN at 48 hrsF36%I28%NO AKI19%R17%348%No AKI15%218%119%81% incidence of AKI 85% incidence of AKIYan X. et al.; Eur J Cardthorac Surg 2010

Adults on ECMO Post-CardiotomyAKI by RIFLE at 48 hoursStage F vs. NO AKIIndependent OR for death= 12.6 (95% CI = 2.2–72.3)p = 0.005AKI by AKIN at 48 hoursStage 3 vs NO AKIIndependent OR for Death= 30.8 (95% CI = 3.3–287.2)p = 0.003.Yan X. et al.; Eur J Cardthorac Surg 2010

RRT provision is associatedwith poor survival1009080706050403020100ECMO onlyN = 224ECMO + CRRT N= 154NeonatalPaden et al. PCCM March 2011

RRT provision is associatedwith poor survival1009080706050403020100ECMO onlyN = 224ECMO + CRRT N= 154NeonatalPediatricPaden et al. PCCM March 2011

ELSO Registry 1985- 2008:Pediatric Cardiac Indications6050403020No dialysisDialysis1000-30 days 1-12 months 1-16 years > 16 years28

Association ≠ CausalityAre AKI / RRT independentlyassociated with mortality in ECMOpatients?

Extracorporeal Life SupportOrganization (ELSO) Registry• ELSO Registry• Composed of nearly all ECMO casesworldwide• Over 40,000 cases• 2 separate registries – cadiac andnoncardiac

ELSO Registry – 1998 - 2008NeonatesN =7941 children

ELSO Registry – 1998 - 2008PediatricsN = 1962 children

ELSO Registry – 1998 - 2008AdultsN = 1011 adults

Variables Analyzed• Outcome – Survival vs. Non-survival• Primary exposures of interest• AKI• Complication code of SCr ≥ 1.5 mg/dl or• ICD-9 code of Acute renal failure• Dialysis• CPT codes usedAskenazi et al. Pediatric Critical Care Medicine 2011

Potential Confounders Analyzed• Demographics• Physiologic Data before ECMO• Physiologic Data during ECMO• Therapy characteristics• Co-morbid conditions• Complications• InterventionsAskenazi et al. Pediatric CCM 2011

ELSO Registry - Neonates18%5%3%74%NeitherAKIBothRRTAskenazi et al. Pediatric CCM 2011

Pediatric ELSO registry16%4%26%54%NeitherRRTSCr > 1.5 mg/dlBothAskenazi et al. Pediatric Critical Care Medicine 2011

Adult Non-Cardiac ELSORegistryAKI7%Neither51%Both27%RRT15%

10080604020Survival in AKI/ RRT subjects0Neither RRT AKI BothAskenazi et al. Pediatric Critical Care Medicine 2011

10080Survival in AKI/ RRT subjects604020NeonatesChildrenAdults0Neither RRT AKI BothAskenazi et al. Pediatric Critical Care Medicine 2011

Odds of Death for AKI / RRTfrom ELSO RegistryCrude OR Adjusted OR p-valueNeonate AKI 5.8 3.2

AKI / RRT are IndependentlyAssociated with Adult MortalityPropensity Score Matched Case-ControlAcute Kidney InjuryOdds Ratio (95% p-valueCI)Acute Kidney Crude Injury Odds 2.78 Ratio (2.14(95% – 3.60) CI) p < p-value 0.001Propensity Crude score 1.32 2.78 (1.12 (2.14 – 3.60) 1.55) p

Summary• ECMO patients can receive RRT on ECMO• CRRT machine – in series• In-line hemofilter• Watch Ultrafiltration carefully !

Summary• ECMO patients can receive RRT on ECMO• Acute Kidney Injury is extremely common inECMO patients• Those with AKI and those who receive RRThave worse outcomes – independent ofimportant confounders• Improved understanding of how best tosupport ECMO patients with AKI is likely toimprove outcomes