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THE EFFECT OF TIMING OF INITITIATION OF CRRT ON PATIENTS REQUIRING EXTRA-CORPOREAL
MEMBRANE OXYGENATION (ECMO)
Asif Mansuri, MD, MRCPIFellow, Division of Pediatric Nephrology,
University of Texas Southwestern Medical Center, Dallas,USA
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DISCLOSURE STATEMENT
I have no Financial relationships to disclose or Conflicts of Interest (COIs) to resolve
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Introduction
• Determining optimal timing of initiation is one of the top research priorities in the clinical research agenda developed by the Acute Kidney Injury Network.
• Large multicenter trials in critically ill adults have shown that the modality and dosing of CRRT do not have significant impact on mortality.
• However, the impact of timing of initiation remains to be established.
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Introduction
• Many patients on ECMO often require Continuous Renal Replacement Therapy (CRRT).
• We have previously demonstrated that delay in initiation of CRRT in non-ECMO patients had a significant impact on survival.
Timing of Continuous Renal Replacement Therapy and Mortality in Critically Ill Children, Pediatric Critical Care, April 2014 • Volume 42 • Number 4Vinai Modem, MBBS; Marita Thompson, MD; Diane Gollhofer, RN, BSN, CCRN;Archana V. Dhar, MD; Raymond Quigley, MD
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Objective
• The objective of the present study was to determine the effect of the Timing of Initiation of CRRT on patients who were on ECMO.
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Study design and patient selection• Retrospective cohort design:
• Charts of patients admitted to the ICU at Children Medical Centre, Dallas from 1st of January 2010 to 31st December 2014 were reviewed.
• Inclusion Criteria:• Age < 21 years• Patients who were on ECMO and received CRRT
• Exclusion Criteria:• Primary renal disease who were on renal replacement
therapy prior to ECMO
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Predictor Variables
• Time to CRRT initiation– Time from ECMO initiation to CRRT initiation
(measured in hours and expressed in days)
• Renal function at ECMO initiation– Estimated from serum Cr using Schwartz formula
• Fluid balance at ECMO initiation
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Outcome Variables
• ICU Survival
• ECMO Duration
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Age Group
AllN = 65
SurvivorsN = 33
Non-survivors
N = 32
Neonates (≤ 1 month)Infants (1 month – 2 years)Small children (2 – 6 years)
School-age (6 – 13 years)Teens (> 13 years)
28 10 9
12 6
15 7 2 6 3
13 3 7 6 3
Demographic data
p 0.35*
* Fisher exact test
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Demographic data
p 0.30*
p 0.002*
* Fisher exact test
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Median Time to CRRT from ECMO Initiation
* Wilcoxon rank order test
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Median Time to CRRT from ECMO Initiation-Neonates
* Wilcoxon rank order test
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Median Creatinine Clearance at ECMO Initiation (ml/min /1.73 m2) - Neonates
* Wilcoxon rank order test
* Wilcoxon rank order test
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Median Creatinine Clearance at ECMO Initiation (ml /min /1.73 m2)
* Wilcoxon rank order test
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Median Fluid Balance
* Wilcoxon rank order test
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Median Fluid Balance- Neonates
* Wilcoxon rank order test
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The relationship between ECMO Duration and Time to CRRT
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The relationship between ECMO Duration and Time to CRRT
Survivors : r = 0.60; p < 0.001Non-survivors : r = 0.61; p< 0.001
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Conclusion
• In Neonates, early initiation of CRRT improves outcome. In other age groups, there was no significant difference in time to CRRT initiation between survivors and non-survivors.
• In neonates treated with ECMO and CRRT, survivors had a lower estimated creatinine clearance at ECMO initiation and at CRRT initiation.
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• Decreasing the time between the initiation of ECMO and initiation of CRRT correlates with a shorter treatment with ECMO.
Conclusion
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Acknowledgment
• Raymond Quigley,MD
Professor, Division of Pediatric Nephrology,
University of Texas Southwestern Medical Center, Dallas,USA
• Vinai Modem,MBBS,FAAP
Assistant Professor Division of Pediatric Critical care and Pediatric
Nephrology, University of Texas Southwestern Medical Center,
Dallas,USA
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Thank you