Acute Kidney Injury (AKI) is a common complication in patients with Acute Respiratory Distress Syndrome (ARDS) receiving VV-ECMO support, carrying a high risk of progression to Renal Replacement Therapy (RRT). Both AKI and RRT are linked to an increased risk of mortality. This study aims to evaluate the risk factors associated with the need for RRT in patients undergoing VV-ECMO.
Methods
This is a retrospective case-control study involving patients on VV-ECMO therapy admitted to the intensive care unit (ICU) between 2019 and 2023. Patients on VV ECMO support, with or without RRT, were included and their severity scores and associated mortality were calculated. A multivariate logistic regression analysis was performed to assess the variable RRT using odds ratios (OR) with their corresponding confidence intervals (CI) for the outcome variables.
Results
A total of 192 subjects were included, with a mortality rate of 39.6%. Of these, 68.7% were male, with an average ICU stay of 25.1 days and a need for RRT in 19.7% of cases. The multivariate analysis independently associated the use of vasopressors with RRT norepinephrine OR 5.61 (95% CI, 1.64-19.1) and vasopressin OR 4.64 (95% CI, 2.15-10.0)). An increase in creatinine levels before ECMO support is associated with an increased risk OR 2.21 (95% CI 1.54-3.18), and 24 h after ECMO support, the risk rises further adjusted odds ratio (AOR) 3.32 (95% IC 1.55-7.09). The accuracy of severity scores presented weak discrimination and similar behavior, except for DEOx for the primary outcome, with an AUC of 0.79 (95% CI, 0.72-0.87), and APACHE II with an AUC of 0.68 (95% CI, 0.59-0.78).
Conclusions
The prediction of RRT in patients on VV-ECMO support was superior for DEOx, which is influenced by the use of vasopressors, creatinine levels, and platelet transfusion prior to cannulation. This could be useful for predicting early interventions in this patient population.
AshbaughDGBigelowDBPettyTLLevineBE. Acute respiratory distress in adults. Lancet. 1967;2(7511):319-323.
2.
MatthayMAArabiYArroligaAC, et al.A new global definition of acute respiratory distress syndrome. Am J Respir Crit Care Med.2024;209(1):37–47.
3.
GrasselliGCalfeeCSCamporotaL, et al.ESICM Guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023;49(7):727–759.
4.
RanieriVMRubenfeldGDThompsonBT, et al.Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012;307(23):2526-2533.
5.
BellaniGLaffeyJGPhamT, et al.Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788.
6.
Ortiz RuizGDueñas CastellCGaray-FernándezM, et al.Consenso colombiano de sindrome de dificultad respiratoria aguda (SDRA) «Documento de Rionegro 2019». Acta Colomb Cuid Intensivo. 2020;20(3):200–252.
7.
GriffithsMJDMcAuleyDFPerkinsGD, et al.Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res. 2019;6(1):e000420.
8.
GajkowskiEFHerreraGHattonLVelia AntoniniMVercaemstLCooleyE. ELSO guidelines for adult and pediatric extracorporeal membrane oxygenation circuits. ASAIO J.2022;68(2):133–152.
9.
CombesAPeekGJHajageD, et al.ECMO For severe ARDS: systematic review and individual patient data meta-analysis. Intensive Care Med. 2020;46(11):2048–2057.
10.
Husain-SyedFRicciZBrodieD, et al.Extracorporeal organ support (ECOS) in critical illness and acute kidney injury: from native to artificial organ crosstalk. Intensive Care Med.2018;44(9):1447–1459.
11.
LiXHassounHTSantoraRRabbH. Organ crosstalk: the role of the kidney. Curr Opin Crit Care.2009;15(6):481–487.
12.
LiuKDGliddenDVEisnerMD, et al.Predictive and pathogenetic value of plasma biomarkers for acute kidney injury in patients with acute lung injury. Crit Care Med. 2007;35(12):2755-2761.
13.
DarmonMClec’hCAdrieC, et al.Acute respiratory distress syndrome and risk of AKI among critically ill patients. Clin J Am Soc Nephrol.2014;9(8):1347–1353.
14.
AntonucciEGarciaBChenDMatthayMALiuKDLegrandM. Incidence of acute kidney injury and attributive mortality in acute respiratory distress syndrome randomized trials. Intensive Care Med. 2024;50(8):1240–1250.
15.
PanitchoteAMehkriOHastingA, et al.Factors associated with acute kidney injury in acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):74.
16.
SchmidtMHajageDLebretonG, et al.Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study. Lancet Respir Med. 2020;8(11):1121–1131.
17.
ThongprayoonCCheungpasitpornWLertjitbanjongP, et al.Incidence and impact of acute kidney injury in patients receiving extracorporeal membrane oxygenation: a meta-analysis. J Clin Med. 2019;8(7):981.
18.
Valenzuela-FacciniNPoveda-HenaoCFlórez-NavasC, et al.Outcomes of ECMO support with polypropylene membrane during pandemic times: a retrospective cohort study. BMC Pulm Med. 2024;24(1):51.
19.
VillaGKatzNRoncoC. Extracorporeal membrane oxygenation and the kidney. Cardiorenal Med.2015;6(1):50-60.
20.
Robayo-AmorteguiHQuintero-AltareAFlorez-NavasC, et al.Fluid dynamics of life: exploring the physiology and importance of water in the critical illness. Front Med (Lausanne).2024;11:1123456.
21.
GuMMeiXLZhaoYN. A review on extracorporeal membrane oxygenation and kidney injury. J Biochem Mol Toxicol.2021;35(1):e22637.
22.
HarrisPATaylorRThielkeRPayneJGonzalezNCondeJG. Research electronic data capture (REDCap)-a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.
23.
KnausWADraperEAWagnerDPZimmermanJE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818–829.
24.
VincentJLDe MendonçaACantraineF, et al.Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Crit Care Med.1998;26(11):1793–1800.
25.
DunhamCMSiegelJHWeireterL, et al.Oxygen debt and metabolic acidemia as quantitative predictors of mortality and the severity of the ischemic insult in hemorrhagic shock. Crit Care Med. 1991;19(2):231–243.
26.
MohlerJGArmstrongBW. The oxygen deficit and debt for normal and non-athletic men. Respir Physiol. 1973;17(2):248–262.
27.
GibneyNHosteEBurdmannEA, et al.Timing of initiation and discontinuation of renal replacement therapy in AKI: unanswered key questions. Clin J Am Soc Nephrol.2008;3(3):876–880.
28.
GaudrySHajageDSchortgenF, et al.Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med.2016;375(2):122–133.
29.
BarbarSDClere-JehlRBourredjemA, et al.Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med.2018;379(15):1431–1442.
30.
The STARRT-AKI Investigators. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med.2020;383(5):240-251.
31.
GaudrySHajageDMartin-LefevreL, et al.Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial. Lancet.2021;397(10281):1293–1300.
32.
KhwajaA. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179–c184.
33.
Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Section 2: AKI definition. Kidney Int Suppl (2011). 2012;2(1):19-36.
34.
TsaiTYChienHTsaiFC, et al.Comparison of RIFLE, AKIN, and KDIGO classifications for assessing prognosis of patients on extracorporeal membrane oxygenation. J Formos Med Assoc.2017;116(11):844–851.
35.
Perez-GarzonMPoveda-HenaoCBastidas-GoyesARobayo-AmorteguiH. Oxygen debt as predictor of mortality and multiple organ dysfunction syndrome in severe COVID-19 patients: a retrospective study. J Intensive Care Med. 2023;38(10):1215-1224.
36.
CharlsonMEPompeiPAlesKLMacKenzieCR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987;40(5):373–383.
37.
ConnorRJ. Sample size for testing differences in proportions for the paired-sample design. Biometrics. 1987;43(1):207.
38.
DadoDNAinsworthCRThomasSB, et al.Outcomes among patients treated with renal replacement therapy during extracorporeal membrane oxygenation: a single-center retrospective study. Blood Purif. 2020;49(3):341–347.
39.
KleinbaumDGKleinM. Survival analysis: a self-learning text, third edition (statistics for biology and health). Biom J.2011;53(5):892-893.
40.
TiglisMPerideIFloreaIA, et al.Overview of renal replacement therapy use in a general intensive care unit. Int J Environ Res Public Health. 2022;19(4):2453.
41.
YuYXuHJiangSGaoC. Predictors for mortality and recovery in patients with acute renal injury receiving continuous renal replacement therapy. Int J Artif Organs.2022;45(5):455–461.
42.
ChoAYYoonHJLeeKYSunIO. Clinical characteristics of sepsis-induced acute kidney injury in patients undergoing continuous renal replacement therapy. Ren Fail. 2018;40(1):403–409.
43.
HilderMHerbstreitFAdamzikM, et al.Comparison of mortality prediction models in acute respiratory distress syndrome undergoing extracorporeal membrane oxygenation and development of a novel prediction score: the prediction of survival on ECMO therapy-score (PRESET-Score). Crit Care. 2017;21(1):123.
44.
PilarczykKHuengesKBewigB, et al.Acute kidney injury in patients with severe ARDS requiring extracorporeal membrane oxygenation: incidence, prognostic impact and risk factors. J Clin Med. 2022;11(4):1079.
45.
WangHLAguileraCKnopfKBChenTMBMasloveDMKuschnerWG. Thrombocytopenia in the intensive care unit. J Intensive Care Med.2013;28(5):268–280.
46.
VinclairCDe MontmollinESonnevilleR, et al.Factors associated with major adverse kidney events in patients who underwent veno-arterial extracorporeal membrane oxygenation. Ann Intensive Care. 2020;10(1):43.
47.
DeatrickKBMazzeffiMAGalvagnoSM, et al.Breathing life back into the kidney - continuous renal replacement therapy and veno-venous extracorporeal membrane oxygenation. ASAIO J. 2021;67(2):208–212.
48.
DillJBixbyBAteeliH, et al.Renal replacement therapy in patients with acute respiratory distress syndrome: a single-center retrospective study. Int J Nephrol Renovasc Dis. 2018;11:249–257.
49.
RoedlKDe RosaSFischerM, et al.Early acute kidney injury and transition to renal replacement therapy in critically ill patients with SARS-CoV-2 requiring veno-venous extracorporeal membrane oxygenation. Ann Intensive Care. 2023;13(1):17.
50.
DelmasCZapetskaiaTConilJM, et al.3-month prognostic impact of severe acute renal failure under veno-venous ECMO support: importance of time of onset. J Crit Care. 2018;44:63–71.
51.
Robayo-AmorteguiHForero-DelgadilloAPérez-GarzónM, et al.Severe gastrointestinal injury associated with SARS-CoV-2 infection: thrombosis or inflammation?: a retrospective case series study. Medicine. 2022;101(42):e30745.
52.
MichelPGClaudiaPHAndreaRSMariaDAHenryRA. Oxygen debt as a predictor of high-flow nasal cannula therapy failure in SARS-CoV-2 patients with acute respiratory failure: a retrospective cohort study. Heart Lung. 2024;64:176–181.
53.
PannucciCJWilkinsEG. Identifying and avoiding bias in research. Plast Reconstr Surg. 2010;126(2):619–625.
54.
TripepiGJagerKJDekkerFWZoccaliC. Selection bias and information bias in clinical research. Nephron Clin Pract. 2010;115(2):c94–c99.
55.
SameedMMengZMarciniakET. EOLIA Trial: the future of extracorporeal membrane oxygenation in acute respiratory distress syndrome therapy?Breathe. 2019;15(3):244–246.
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