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Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy: a multicenter retrospective cohort study

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Abstract

Objective

The aim of this study was to characterize continuous renal replacement therapy (CRRT) utilization on extracorporeal membrane oxygenation (ECMO) and to determine the association of both fluid overload (FO) at CRRT initiation and fluid removal during CRRT with mortality in a large multicenter cohort.

Methods

Retrospective chart review of all children < 18 years of age concurrently treated with ECMO and CRRT from January 1, 2007, to December 31, 2011, at six tertiary care children’s hospital. Children treated with hemodialysis or peritoneal dialysis were excluded from the FO analysis.

Measurements and main results

A total of 756 of the 1009 children supported with ECMO during the study period had complete FO data. Of these, 357 (47.2%) received either CRRT or were treated with an in-line filter and thus entered into the final analysis. Survival to ECMO decannulation was 66.4% and survival to hospital discharge was 44.3%. CRRT initiation occurred at median of 1 day (IQR 0, 2) after ECMO initiation. Median FO at CRRT initiation was 20.1% (IQR 5, 40) and was significantly lower in ECMO survivors vs. non-survivors (15.3% vs. 30.5% p = 0.005) and in hospital survivors vs. non-survivors (13.5% vs. 25.9%, p = 0.004). Median FO at CRRT discontinuation was significantly lower in ECMO survivors (23% vs. 37.6% p = 0.002) and hospital survivors vs. non-survivors (22.6% vs. 36.1%, p = 0.002). In ECMO survivors, after adjusting for pH at CRRT initiation, non-renal complications, ECMO mode, support type, center, patient age and AKI, FO at CRRT initiation (p = 0.01), and FO at CRRT discontinuation (p = 0.0002) were independently associated with duration of ECMO. In a similar multivariable analysis, FO at CRRT initiation (adjusted adds ratio [aOR] 1.09, 95% CI 1.00–1.18, p = 0.045) and at CRRT discontinuation (aOR 1.11, 95% CI 1.03–1.19, p = 0.01) were independently associated with hospital mortality.

Conclusions

In a multicenter pediatric ECMO cohort, this study demonstrates that severe FO was very common at CRRT initiation. We found an independent association between the degree of FO at CRRT initiation with adverse outcomes including mortality and increased duration of ECMO support. The results suggest that intervening prior to the development of significant FO may be a clinical therapeutic target and warrants further evaluation.

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Acknowledgments

The authors would like the thank Elaine Cooley (University of Michigan) and Heart Institute Research Core (CCHMC).

Funding

RedCap is supported by UL1 TR000445 from NACTS/NIH. Dr. Askenazi receives funding from the NIH (R01 DK13608–01) and the Pediatric and Infant Center for Acute Nephrology (PICAN), which is sponsored by Children’s of Alabama and the University of Alabama at Birmingham (UAB) School of Medicine, as well as by the Department of Pediatrics, and Center for Clinical and Translational Science (CCTS) under award number UL1TR00165. Dr. Askenazi and Dr. Basu are speakers for Baxter Renal Products. MZ received research salary support from the Fonds de Recherche de Québec-Santé (FRQ-S) during this study.

Author information

Authors and Affiliations

  1. Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA

    Stephen M. Gorga

  2. Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA

    David J. Askenazi & Eileen King

  3. Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

    Rashmi D. Sahay

  4. Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA

    Brian C. Bridges & Geoffrey M. Fleming

  5. Department of Pediatrics, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    David S. Cooper

  6. Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA

    Matthew L. Paden & Rajit K. Basu

  7. Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada and McGill University Health Centre, Montreal, Canada

    Michael Zappitelli

  8. Department of Pediatrics, Children’s Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Aurora, CO, USA

    Katja M. Gist & Jason Gien

  9. Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Children’s Hospital, Iowa City, IA, USA

    Jennifer G. Jetton

  10. Department of Pediatric, Medical University of South Carolina, Charleston, SC, USA

    Heidi J. Murphy & David T. Selewski

  11. Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Eileen King

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  1. Stephen M. Gorga
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Correspondence to David T. Selewski.

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The authors declare that they have no conflict of interest. The results presented in this paper have not been published previously except in abstract form.

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Gorga, S.M., Sahay, R.D., Askenazi, D.J. et al. Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy: a multicenter retrospective cohort study. Pediatr Nephrol 35, 871–882 (2020). https://doi.org/10.1007/s00467-019-04468-4

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  • DOI: https://doi.org/10.1007/s00467-019-04468-4

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