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Synergistic association of fluid overload and acute kidney injury on outcomes in pediatric cardiac ECMO: a retrospective analysis of the KIDMO database

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Abstract

Background

Acute kidney injury (AKI) and fluid overload (FO) are associated with poor outcomes in children receiving extracorporeal membrane oxygenation (ECMO). Our objective is to evaluate the impact of AKI and FO on pediatric patients receiving ECMO for cardiac pathology.

Methods

We performed a secondary analysis of the six-center Kidney Interventions During Extracorporeal Membrane Oxygenation (KIDMO) database, including only children who underwent ECMO for cardiac pathology. AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. FO was defined as < 10% (FO–) vs. ≥ 10% (FO +) and was evaluated at ECMO initiation, peak during ECMO, and ECMO discontinuation. Primary outcomes were mortality and length of stay (LOS).

Results

Data from 191 patients were included. Non-survivors (56%) were more likely to be FO + than survivors at peak ECMO fluid status and ECMO discontinuation. There was a significant interaction between AKI and FO. In the presence of AKI, the adjusted odds of mortality for FO + was 4.79 times greater than FO– (95% CI: 1.52–15.12, p = 0.01). In the presence of FO + , the adjusted odds of mortality for AKI + was 2.7 times higher than AKI– [95%CI: 1.10–6.60; p = 0.03]. Peak FO + was associated with a 55% adjusted relative increase in LOS [95%CI: 1.07–2.26, p = 0.02].

Conclusions

The association of peak FO + with mortality is present only in the presence of AKI + . Similarly, AKI + is associated with mortality only in the presence of peak FO + . FO + was associated with LOS. Studies targeting fluid management have the potential to improve LOS and mortality outcomes.

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Data availability

The datasets generated during and/or analyzed during the current study are not publicly available due to regulatory requirements from the participating site institutional review boards but are available from the corresponding author on reasonable request.

Abbreviations

AKI:

Acute Kidney Injury by Kidney Disease: Improving Global Outcomes or Neonatal Modification Serum Creatinine Criteria

AKIKST :

Acute Kidney Injury by Kidney Disease: Improving Global Outcomes or Neonatal Modification Serum Creatinine Criteria or by utilization of kidney support therapy

aOR:

Adjusted odds ratio

AVV:

Atrioventricular valve

CI:

Confidence interval

CPB:

Cardiopulmonary bypass

ECMO:

Extracorporeal membrane oxygenation

EHR:

Electronic health record

ELSO:

Extracorporeal Life Support Organization

FO:

Fluid overload

IQR:

Interquartile range

KDIGO:

Kidney Disease: Improving Global Outcomes

KIDMO:

Kidney Interventions During Extracorporeal Membrane Oxygenation

KST:

Kidney support therapy

LOS:

Length of stay

MV:

Mechanical ventilation

OR:

Unadjusted odds ratio

SCr:

Serum creatinine

Severe AKI:

Kidney Disease: Improving Global Outcomes stage 2 or 3 acute kidney injury

VA ECMO:

Venoarterial extracorporeal membrane oxygenation

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Authors and Affiliations

  1. Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA

    Kevin A. Pettit & Jason Gien

  2. Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA

    David T. Selewski & Heidi J. Steflik

  3. Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA

    David J. Askenazi

  4. Division of Critical Care Medicine, Lurie Children’s Hospital, Chicago, IL, USA

    Rajit K. Basu

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

    Brian C. Bridges & Geoffrey M. Fleming

  6. Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    David S. Cooper & Katja M. Gist

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

    Stephen M. Gorga

  8. Divison of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children’s Hospital, Iowa City, IO, USA

    Jennifer G. Jetton

  9. Divison of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    Eileen C. King & Rashmi D. Sahay

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

    Matthew L. Paden

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

    Michael Zappitelli

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  1. Kevin A. Pettit
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, analysis, and writing of the first draft were performed by Kevin Pettit, Katja Gist, and Rashmi Sahay. Dr. Geoffrey Fleming was the leader of the KIDMO group and recently passed away. He was an integral member of the team and was involved in study conception and design. All other authors assisted in the writing of the manuscript and have read and approved the final manuscript.

Corresponding author

Correspondence to Kevin A. Pettit.

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Ethical oversight for this retrospective research was provided by local institutional review boards at each participating site with a waiver of informed consent.

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Pettit, K.A., Selewski, D.T., Askenazi, D.J. et al. Synergistic association of fluid overload and acute kidney injury on outcomes in pediatric cardiac ECMO: a retrospective analysis of the KIDMO database. Pediatr Nephrol 38, 1343–1353 (2023). https://doi.org/10.1007/s00467-022-05708-w

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