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Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know—PCRRT-ICONIC practice points

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Abstract

Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.

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Authors and Affiliations

  1. Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA

    Rupesh Raina

  2. Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA

    Rupesh Raina & Kush Doshi

  3. Case Western University School of Medicine, Cleveland, OH, USA

    Nikhil Nair

  4. Division of Critical Care Medicine, Department of Pediatrics, Akron Children’s Hospital, Akron, OH, USA

    Jonathan Pelletier

  5. Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA

    Jonathan Pelletier & Tarik Whitham

  6. Department of Internal Medicine, Case Western Reserve / University Hospitals, Cleveland, OH, USA

    Matthew Nied

  7. Department of Pediatrics, University of Pittsburgh Medical Center Children’s Hospital, Pittsburgh, PA, USA

    Tara Beck & Dana Fuhrman

  8. Department of Surgery, Emory University, Atlanta, GA, USA

    Goeto Dantes

  9. Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India

    Sidharth Kumar Sethi

  10. Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Yap Hui Kim

  11. Department of Pediatric Nephrology, Children’s Hospital of Richmond, Richmond, VA, USA

    Timothy Bunchman

  12. Pediatric Nephrology, King Saud University, Riyadh, Saudi Arabia

    Kahild Alhasan

  13. Department of Pediatric Critical Care, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA

    Lisa Lima & Matthew Paden

  14. Division of Nephrology and Dialysis, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy

    Isabella Guzzo

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Correspondence to Rupesh Raina.

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Conflict of interest

Matthew L. Paden discloses that he is the current past President of the Extracorporeal Life Support Organization, and that he has multiple patents and intellectual property for pediatric CKRT devices. All the patents and intellectual property are currently owned by Emory university/Georgia Institute of Technology/Children’s Healthcare of Atlanta and are not licensed. All other authors have no conflicts of interest to disclose or relevant financial or non-financial interests to disclose.

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Raina, R., Nair, N., Pelletier, J. et al. Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know—PCRRT-ICONIC practice points. Pediatr Nephrol (2024). https://doi.org/10.1007/s00467-024-06311-x

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  • DOI: https://doi.org/10.1007/s00467-024-06311-x

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