Abstract
Lung opacification on chest radiography (CXR) is common during extracorporeal life support (ECLS), often resulting from pulmonary edema or inflammation. Concurrent use of continuous renal replacement therapy (CRRT) during ECLS is associated with improved fluid balance and cytokine filtration; through modification of these pathologic states, CRRT may modulate lung opacification observed on CXRs. We hypothesize that early CRRT use during infant ECLS decreases lung opacification on CXR. We conducted a retrospective cohort study comparing CXRs from infants receiving ECLS and early CRRT (n = 7) to matched infants who received ECLS alone (n = 7). The CXR obtained prior to ECLS, all CXRs obtained within the first 72 h of ECLS, and daily CXRs for the remainder of the ECLS course were analyzed. The outcome measure was the degree of opacification, determined by independent assessment of two, blinded pediatric radiologists using a modified Edwards et al.’s lung opacification scoring system (from Score 0: no opacification to Score 5: complete opacification). 220 CXRs were assessed (cases: 93, controls: 127). Inter-rater reliability was established (Cohen’s weighted к = 0.74; p < 0.0001, good agreement). At baseline, the mean opacification score difference between cases and controls was 1 point (cases: 1.8, controls 2.8; p = 0.049). Using mixed modeling analysis for repeated measures accounting for differences at baseline, the average overall opacification score was 1.2 points lower in cases than controls (cases: 2.1, controls: 3.3; p < 0.0001). The overall distribution of scores was lower in cases than controls. Early CRRT utilization during infant ECLS was associated with decreased lung opacification on CXR.
Similar content being viewed by others
References
Barbaro R, et al. Pediatric extracorporeal life support organization registry International Report 2016. ASAIO J. 2017;63:456–63.
Peek G, Firmin R. The inflammatory and coagulative response to prolonged extracorporeal membrane oxygenation. ASAIO J. 1999;45:250–63.
Annich G et al. (2017) Adverse effects of extracorporeal life support: the blood biomaterial interaction in Extracorporeal Life Support: the ELSO Red Book. Brogan T et al. (ed). Extracorporeal Life Support Organization, Ann Arbor
Selewski DT, et al. The impact of fluid overload on outcomes in children treated with extracorporeal membrane oxygenation: a multicenter retrospective cohort study. Pediatr Crit Care Med. 2017;18:1126.
Jamadar D, et al. Extracorporeal membrane oxygenation in adults: radiographic findings and correlation of lung opacification and patient mortality. Radiology. 1996;198:693–8.
Kelly RE Jr, et al. Pulmonary edema and fluid mobilization as determinants of the duration of ECMO support. J Pediatr Surg. 1991;26:1016–22.
Taylor GA, et al. Diffuse pulmonary opacification in infants undergoing extracorporeal membrane oxygenation: clinical and pathologic correlation. Radiology. 1986;161:347–50.
Blijdorp K, et al. Haemofiltration in newborns treated with extracorporeal membrane oxygenation: a case-comparison study. Crit Care. 2009;13:R48.
Hoover N, et al. Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support. Intensive Care Med. 2008;34:2241–7.
Shen J, et al. Continuous renal replacement therapy (CRRT) attenuates myocardial inflammation and mitochondrial injury induced by venovenous extracorporeal membrane oxygenation (VV ECMO) in a healthy piglet model. Inflammation. 2013;36:1186–93.
Morgera S, et al. Intermittent high permeability hemofiltration in septic patients with acute renal failure. Intensive Care Med. 2003;29:1989–95.
Edwards DK, et al. Respiratory distress syndrome treated with human surfactant: radiographic findings. Radiology. 1985;157:329–34.
Murphy HJ, et al. Implementing a practice change: early initiation of continuous renal replacement therapy during neonatal extracorporeal life support standardizes care and improves short-term outcomes. J Artif Organs. 2017;21:76–85.
Askenazi DJ, et al. Acute kidney injury and renal replacement therapy independently predict mortality in neonatal and pediatric noncardiac patients on extracorporeal membrane oxygenation. Pediatr Crit Care Med. 2011;12:e1–6.
Goldstein SL, et al. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics. 2001;107:1309–12.
Foland JA, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med. 2004;32:1771–6.
Sutherland SM, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis. 2010;55:316–25.
Askenazi DJ, et al. Renal replacement therapy in critically ill patients receiving extracorporeal membrane oxygenation. Clin J Am Soc Nephrol. 2012;7:1328–36.
Bellomo R, Tippping P, Boyce N. Interleukin-6 and interleukin-8 extraction during continuous venovenous hemodiafiltration in septic acute renal failure. Renal Failure. 1995;17:457–66.
Mu TS, et al. Continuous renal replacement therapy to reduce inflammation in a piglet hemorrhage-reperfusion extracorporeal membrane oxygenation model. Pediatr Res. 2012;72:249–55.
Murphy H, et al. Early continuous renal replacement therapy improves nutrition delivery in neonates during extracorporeal life support. J Ren Nutr. 2018;28:64–70.
McILwain RB, et al. Plasma concentrations of inflammatory cytokines rise rapidly during ECMO-related SIRS due to the release of preformed stores in the intestine. Lab Invest. 2010;90:128–39.
Zwiers AJ, et al. Acute kidney injury is a frequent complication in critically ill neonates receiving extracorporeal membrane oxygenation: a 14-year cohort study. Crit Care. 2013;17:R151.
Selewski DT, et al. Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy. Crit Care Med. 2012;40:2694–9.
Wolf MJ, et al. Early renal replacement therapy during pediatric cardiac extracorporeal support increases mortality. Ann Thorac Surg. 2013;96:917–22.
Arikan AA, et al. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med. 2012;13:253–8.
Author information
Authors and Affiliations
Corresponding authors
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Murphy, H.J., Eklund, M.J., Hill, J. et al. Early continuous renal replacement therapy during infant extracorporeal life support is associated with decreased lung opacification. J Artif Organs 22, 286–293 (2019). https://doi.org/10.1007/s10047-019-01119-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10047-019-01119-1