Determinants of Major Adverse Kidney Events in Extracorporeal Membrane Oxygenation Survivors

Abstract

The majority of extracorporeal membrane oxygenation patients develop acute kidney injury, and 40-60% require renal replacement therapy. This study aimed to examine determinants of major adverse kidney events in extracorporeal membrane oxygenation survivors.

Design: Retrospective cohort study.

Setting: Barnes Jewish Hospital, St. Louis, MO.

Patients: Patients admitted at Barnes Jewish hospital between 2008 and 2017 and requiring extracorporeal membrane oxygenation. Patients 18 years old and older who survived to hospital discharge were considered for the study.

Interventions: None.

Measures and main results: Patients who were admitted to a single center between 2008 and 2017, were on extracorporeal membrane oxygenation for more than 24 hours and survived hospital discharge were included. Major adverse kidney event was defined as either doubling serum creatinine, incident end-stage renal disease, or death. Acute kidney injury was defined as Kidney Disease: Improving Global Outcomes stages 2-3. Complete acute kidney injury recovery was defined as a return to 50% of baseline serum creatinine and partial recovery as an improvement in acute kidney injury stage without a return to 50% of baseline serum creatinine. Survival analysis plots and Cox regression models were fitted to examine the associations of acute kidney injury status, acute kidney injury recovery, and other factors with major adverse kidney event. Among 188 extracorporeal membrane oxygenation patients who survived until hospital discharge, 63% had acute kidney injury and 41% required renal replacement therapy. The mean follow-up time was 3.4 years. Kaplan-Meier survival curves showed that patients with no/partial recovery from acute kidney injury had a higher rate of major adverse kidney event compared with those with no acute kidney injury. Multivariate analysis showed that acute kidney injury (adjusted hazard ratio =1.79 [95% CI = 1.00-3.21]), no/partial recovery from acute kidney injury (adjusted hazard ratio = 2.94 [95% CI = 1.46-5.92]), and initiation of renal replacement therapy on the day or after extracorporeal membrane oxygenation (adjusted hazard ratio = 5.4 [95% CI = 1.14-25.6]) were significant determinants of major adverse kidney event after adjustment for potential confounders.

Conclusions: Acute kidney injury, acute kidney injury recovery status, and timing of initiation of renal replacement therapy are determinants of major adverse kidney events in patients who received extracorporeal membrane oxygenation.

Keywords: acute kidney injury; end-stage renal disease; extracorporeal membrane oxygenation; major adverse kidney event; renal replacement therapy; serum creatinine.

Figure 1.

Study flow chart. AKI = acute kidney injury, ECMO = extracorporeal membrane oxygenation, ESRD = end-stage renal disease.

Figure 2.

Kaplan-Meier survival plots show survival rates from major adverse kidney event (MAKE) according to presence of acute kidney injury (AKI) versus no AKI.