aki in ecmo therapy

1. AKI in ECMO
therapy

2. Extracorporeal membrane oxygenation
(ECMO)
• Extracorporeal membrane oxygenation (ECMO) is a
lifesaving therapy for patients with severe respiratory and/
or cardiovascular failure. There are two main
configurations:
(1) Veno-arterial ECMO (VA-ECMO) in patients with
refractory cardiogenic shock or combined
cardiorespiratory failure, and
(2) Veno-venous ECMO (VVECMO) in patients with
potentially reversible causes of respiratory failure.
Ostermann and Lumlertgul Crit Care (2021)

3. ECMO & AKI
• The in-hospital mortality ranges from 21 to 37% in patients receiving VV-ECMO
compared to 40–60% in patients treated with VA-ECMO.
• Despite improving survival in recent years, adverse effects are common including
acute kidney injury (AKI), infection, thrombosis, and bleeding.
• AKI is a frequent complication among patients treated with ECMO, resulting in
increased morbidity and mortality
Ostermann and Lumlertgul Crit Care (2021)

4. Incidence of AKI in ECMO
• The reported incidence of AKI in patients treated with ECMO varies from 26 to 85%.
• The pooled estimated incidence of severe AKI requiring RRT is 45%.
• AKI is more common in VA-ECMO than in VV-ECMO (61% vs. 46%) and is most often
present on the day of ECMO cannulation.
• The Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome
(EOLIA) and Conventional Ventilatory Support versus Extracorporeal Membrane
Oxygenation for Severe Adult Respiratory Failure (CESAR) trials demonstrated a lower
incidence of AKI and use of RRT in patients receiving VV-ECMO compared with standard
treatment
Ostermann and Lumlertgul Crit Care (2021)

5. Epidemiology in Retrospective Studies Evaluating
ECMO Patients with and without Renal Dysfunction
International Journal of Nephrology and Renovascular Disease 2021:14

6. Pathophysiology of AKI in ECMO
Ostermann and Lumlertgul Crit Care (2021)
• Prior to ECMO initiation, hemodynamic
instability, low cardiac output, high intra-
thoracic pressure, exposure to nephrotoxic
agents, severe hypoxemia, hypercapnia,
systemic inflammation/immune-mediated
effects, and neurohormonal dysregulation
can contribute to AKI

7. Pathophysiology of AKI in ECMO
Cardiorenal Med 2016;6:50–60

8. Major hemodynamic factors related to the development of AKI in patients treated with ECMO. CRS 1 =
Cardiorenal syndrome type 1; RBF = renal blood flow. Cardiorenal Med 2016;6:50–60

9. Major inflammatory factors related to the development of AKI in patients treated with ECMO.
Cardiorenal Med 2016;6:50–60

10. The kidney during organ crosstalk. Interorgan crosstalk
between the heart, lung, liver and sepsis with the kidney
as the common organ.
Intensive Care Med (2018) 44:1447–1459

11. The kidney during artificial organ support. The figure
illustrates the potential risks associated with multiple
organ support, which may increase the risk of AKI.
Intensive Care Med (2018) 44:1447–1459

12. Risk factor for AKI in ECMO
• Older age,
• Pre-existing comorbidities (e.g., cirrhosis),
• Post cardiotomy shock as indication for ECMO,
• Late implantation of ECMO,
• Reduced LV ejection fraction (LVEF),
• Intraoperative transfusion,
Ostermann and Lumlertgul Crit Care (2021)
• High lactate, high plasma free Hemoglobin,
• Increased bilirubin,
• High neutrophil to lymphocyte ratio.
• Red blood cell distribution width >14.1%, a
marker of inflammation and anemia
• High inotropic equivalents, ECMO pump
speed, and ECMO duration

13. J. Clin. Med. 2018, 7, 307; doi:10.3390/jcm7100307

15. Recommends following new
biomarkers for AKI detection

17. Treatments for AKI in ECMO
Cardiorenal Med 2016;6:50–60

19. Timing of CRRT
• In patients receiving ECMO, as well as critically ill patients in general, the right timing to start
CRRT should be evaluated on a case-by-case and daily basis considering the risks and benefits
• Fluid overload is a determining factor in higher mortality, especially in patients with heart
and respiratory failure and it should be kept as one of the main triggers for a proactive CRRT
start.
• As reported by the ELSO guidelines, the real goal is to keep the patient close to dry weight.
• CRRT should be promptly instituted when diuretic therapy is not effective with the aim of
preventing or treating Fluid overload.
International Journal of Nephrology and Renovascular Disease 2021:14

21. Advantages and disadvantages of each
RRT during ECMO
Ostermann and Lumlertgul Crit Care (2021)

22. Advantages and disadvantages of RRT
during ECMO
Ostermann and Lumlertgul Crit Care (2021)

23. Interactions between RRT and other extracorporeal organ supports.
Intensive Care Med (2018) 44:1447–1459