Acute kidney injury in the intensive care unit (ICU) is a manifestation of an underlying severe illness that commonly involves other organ systems. Pulmonary, cardiac, and hepatic failures are the most prevalent. This article provides a simplified review of the technical aspects of extracorporeal cardiopulmonary and liver support devices used in the adult ICU patient, as well as a summary of the most relevant and up-to-date clinical evidence that supports their use.

Keywords:
Extracorporeal membrane oxygenation, Continuous renal replacement therapy, Molecular adsorbent recirculation support, Prometheus liver support device, Single pass albumin dialysis, Selective cytopheretic device
1.
Ostermann M, Chang RW: Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007;35:1837-1843; quiz 1852.
2.
Bagshaw SM, George C, Bellomo R; ANZICS Database Management Committe: A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients. Nephrol Dial Transplant 2008;23:1569-1574.
3.
Thakar CV, Christianson A, Freyberg R, Almenoff P, Render ML: Incidence and outcomes of acute kidney injury in intensive care units: a Veterans Administration study. Crit Care Med 2009;37:2552-2558.
4.
Mehta RL, Pascual MT, Soroko S, et al: Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int 2004;66:1613-1621.
5.
Gibbon JH Jr: Application of a mechanical heart and lung apparatus to cardiac surgery. Minn Med 1954;37:171-185.
6.
Hill JD, O'Brien TG, Murray JJ, et al: Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med 1972;286:629-634.
7.
Bartlett RH, Gazzaniga AB, Fong SW, Burns NE: Prolonged extracorporeal cardiopulmonary support in man. J Thorac Cardiovasc Surg 1974;68:918-932.
9.
Peek GJ, Mugford M, Tiruvoipati R, et al: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009;374:1351-1363.
10.
Australia, New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, Davies A, et al: Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA 2009;302:1888-1895.
11.
ELSO Guidelines for Adult Respiratory Failure v1.3. December 2013. https://www.elso.org/Resources/Guidelines.aspx.
12.
Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL: Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med 2009;35:2105-2114.
13.
Beiderlinden M, Eikermann M, Boes T, Breitfeld C, Peters J: Treatment of severe acute respiratory distress syndrome: role of extracorporeal gas exchange. Intensive Care Med 2006;32:1627-1631.
14.
Schmidt M, Zogheib E, Roze H, et al: The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Intensive Care Med 2013;39:1704-1713.
15.
Schmidt M, Bailey M, Sheldrake J, et al: Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med 2014;189:1374-1382.
16.
Bermudez CA, Rocha RV, Sappington PL, Toyoda Y, Murray HN, Boujoukos AJ: Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults. Ann Thorac Surg 2010;90:991-995.
17.
Wang D, Zhou X, Liu X, Sidor B, Lynch J, Zwischenberger JB: Wang-Zwische double lumen cannula-toward a percutaneous and ambulatory paracorporeal artificial lung. ASAIO J 2008;54:606-611.
18.
Ius F, Sommer W, Tudorache I, et al: Veno-veno-arterial extracorporeal membrane oxygenation for respiratory failure with severe haemodynamic impairment: technique and early outcomes. Interact Cardiovasc Thorac Surg 2015;20:761-767.
19.
Sklar MC, Sy E, Lequier L, Fan E, Kanji HD: Anticoagulation practices during venovenous extracorporeal membrane oxygenation for respiratory failure. A systematic review. Ann Am Thorac Soc 2016;13:2242-2250.
20.
Zapol WM, Snider MT, Hill JD, et al: Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 1979;242:2193-2196.
21.
Morris AH, Wallace CJ, Menlove RL, et al: Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 1994;149(2 pt 1):295-305.
23.
Moravec R, Neitzel T, Stiller M, et al: First experiences with a combined usage of veno-arterial and veno-venous ECMO in therapy-refractory cardiogenic shock patients with cerebral hypoxemia. Perfusion 2014;29:200-209.
24.
Hendrickson SC, Glower DD: A method for perfusion of the leg during cardiopulmonary bypass via femoral cannulation. Ann Thorac Surg 1998;65:1807-1808.
25.
Madershahian N, Nagib R, Wippermann J, Strauch J, Wahlers T: A simple technique of distal limb perfusion during prolonged femoro-femoral cannulation. J Card Surg 2006;21:168-169.
26.
Koeckert MS, Jorde UP, Naka Y, Moses JW, Takayama H: Impella LP 2.5 for left ventricular unloading during venoarterial extracorporeal membrane oxygenation support. J Card Surg 2011;26:666-668.
27.
Weymann A, Schmack B, Sabashnikov A, et al: Central extracorporeal life support with left ventricular decompression for the treatment of refractory cardiogenic shock and lung failure. J Cardiothorac Surg 2014;9:60.
28.
Ma P, Zhang Z, Song T, et al: Combining ECMO with IABP for the treatment of critically Ill adult heart failure patients. Heart Lung Circ 2014;23:363-368.
29.
Lin CY, Chen YC, Tsai FC, et al: RIFLE classification is predictive of short-term prognosis in critically ill patients with acute renal failure supported by extracorporeal membrane oxygenation. Nephrol Dial Transplant 2006;21:2867-2873.
30.
Yan X, Jia S, Meng X, et al: Acute kidney injury in adult postcardiotomy patients with extracorporeal membrane oxygenation: evaluation of the RIFLE classification and the Acute Kidney Injury Network criteria. Eur J Cardiothorac Surg 2010;37:334-338.
31.
Kielstein JT, Heiden AM, Beutel G, et al: Renal function and survival in 200 patients undergoing ECMO therapy. Nephrol Dial Transplant 2013;28:86-90.
32.
Han SS, Kim HJ, Lee SJ, et al: Effects of renal replacement therapy in patients receiving extracorporeal membrane oxygenation: a meta-analysis. Ann Thorac Surg 2015;100:1485-1495.
33.
Askenazi DJ, Selewski DT, Paden ML, et al: Renal replacement therapy in critically ill patients receiving extracorporeal membrane oxygenation. Clin J Am Soc Nephrol 2012;7:1328-1336.
34.
Villa G, Katz N, Ronco C: Extracorporeal membrane oxygenation and the kidney. Cardiorenal Med 2015;6:50-60.
35.
Bouchard J, Soroko SB, Chertow GM, et al: Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009;76:422-427.
36.
Fleming GM, Askenazi DJ, Bridges BC, et al: A multicenter international survey of renal supportive therapy during ECMO: the kidney intervention during extracorporeal membrane oxygenation (KIDMO) group. ASAIO J 2012;58:407-414.
37.
Schmidt M, Bailey M, Kelly J, et al: Impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation. Intensive Care Med 2014;40:1256-1266.
38.
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, et al: Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006;354:2564-2575.
39.
Cerda J, Tolwani AJ, Warnock DG: Critical care nephrology: management of acid-base disorders with CRRT. Kidney Int 2012;82:9-18.
40.
Kallet RH, Liu K, Tang J: Management of acidosis during lung-protective ventilation in acute respiratory distress syndrome. Respir Care Clin N Am 2003;9:437-456.
41.
Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-1308.
42.
Rubenfeld GD, Cooper C, Carter G, Thompson BT, Hudson LD: Barriers to providing lung-protective ventilation to patients with acute lung injury. Crit Care Med 2004;32:1289-1293.
43.
Paden ML, Warshaw BL, Heard ML, Fortenberry JD: Recovery of renal function and survival after continuous renal replacement therapy during extracorporeal membrane oxygenation. Pediatr Crit Care Med 2011;12:153-158.
44.
Meyer RJ, Brophy PD, Bunchman TE, et al: Survival and renal function in pediatric patients following extracorporeal life support with hemofiltration. Pediatr Crit Care Med 2001;2:238-242.
45.
Hoover NG, Heard M, Reid C, et al: Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support. Intensive Care Med 2008;34:2241-2247.
46.
Santiago MJ, Sanchez A, Lopez-Herce J, et al: The use of continuous renal replacement therapy in series with extracorporeal membrane oxygenation. Kidney Int 2009;76:1289-1292.
47.
Sucosky P, Dasi LP, Paden ML, Fortenberry JD, Yoganathan AP: Assessment of current continuous hemofiltration systems and development of a novel accurate fluid management system for use in extracorporeal membrane oxygenation. J Med Devices 2008;2:035002.
48.
Kormos RL, Teuteberg JJ, Pagani FD, et al: Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg 2010;139:1316-1324.
49.
Kazui T, Tran PL, Echeverria A, et al: Minimally invasive approach for percutaneous CentriMag right ventricular assist device support using a single PROTEKDuo Cannula. J Cardiothorac Surg 2016;11:123.
50.
Takeda K, Naka Y, Yang JA, et al: Outcome of unplanned right ventricular assist device support for severe right heart failure after implantable left ventricular assist device insertion. J Heart Lung Transplant 2014;33:141-148.
51.
Shen TC, Tsai KT, Hu CY, Chen RJ: Skirted cannula technique for apical cannulation in implantation of centrimag left ventricular assist device. Ann Thorac Surg 2016;101:2404-2406.
52.
Takayama H, Soni L, Kalesan B, et al: Bridge-to-decision therapy with a continuous-flow external ventricular assist device in refractory cardiogenic shock of various causes. Circ Heart Fail 2014;7:799-806.
53.
Thiele H, Sick P, Boudriot E, et al: Randomized comparison of intra-aortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. Eur Heart J 2005;26:1276-1283.
54.
Kapur NK, Paruchuri V, Korabathina R, et al: Effects of a percutaneous mechanical circulatory support device for medically refractory right ventricular failure. J Heart Lung Transplant 2011;30:1360-1367.
55.
Kiernan MS, Krishnamurthy B, Kapur NK: Percutaneous right ventricular assist via the internal jugular vein in cardiogenic shock complicating an acute inferior myocardial infarction. J Invasive Cardiol 2010;22:E23-E26.
56.
Lee WM: Acute liver failure. N Engl J Med 1993;329:1862-1872.
57.
Lee WM, Squires RH Jr, Nyberg SL, Doo E, Hoofnagle JH: Acute liver failure: summary of a workshop. Hepatology 2008;47:1401-1415.
58.
Munoz SJ: Difficult management problems in fulminant hepatic failure. Semin Liver Dis 1993;13:395-413.
59.
Caraceni P, Van Thiel DH: Acute liver failure. Lancet 1995;345:163-169.
60.
Barshes NR, Gay AN, Williams B, Patel AJ, Awad SS: Support for the acutely failing liver: a comprehensive review of historic and contemporary strategies. J Am Coll Surg 2005;201:458-476.
61.
Park JK, Lee DH: Bioartificial liver systems: current status and future perspective. J Biosci Bioeng 2005;99:311-319.
62.
Nevens F, Laleman W: Artificial liver support devices as treatment option for liver failure. Best Pract Res Clin Gastroenterol 2012;26:17-26.
63.
Stange J, Ramlow W, Mitzner S, Schmidt R, Klinkmann H: Dialysis against a recycled albumin solution enables the removal of albumin-bound toxins. Artif Organs 1993;17:809-813.
64.
Banares R, Nevens F, Larsen FS, et al: Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute-on-chronic liver failure: the RELIEF trial. Hepatology 2013;57:1153-1162.
65.
Falkenhagen D, Strobl W, Vogt G, et al: Fractionated plasma separation and adsorption system: a novel system for blood purification to remove albumin bound substances. Artif Organs 1999;23:81-86.
66.
Kribben A, Gerken G, Haag S, et al: Effects of fractionated plasma separation and adsorption on survival in patients with acute-on-chronic liver failure. Gastroenterology 2012;142:782-789.e783.
67.
Krisper P, Haditsch B, Stauber R, et al: In vivo quantification of liver dialysis: comparison of albumin dialysis and fractionated plasma separation. J Hepatol 2005;43:451-457.
68.
Sauer IM, Goetz M, Steffen I, et al: In vitro comparison of the molecular adsorbent recirculation system (MARS) and single-pass albumin dialysis (SPAD). Hepatology 2004;39:1408-1414.
69.
Sponholz C, Matthes K, Rupp D, et al: Molecular adsorbent recirculating system and single-pass albumin dialysis in liver failure - a prospective, randomised crossover study. Crit Care 2016;20:2.
70.
Benyoub K, Muller M, Bonnet A, et al: Amounts of bile acids and bilirubin removed during single-pass albumin dialysis in patients with liver failure. Ther Apher Dial 2011;15:504-506.
71.
Chawla LS, Georgescu F, Abell B, Seneff MG, Kimmel PL: Modification of continuous venovenous hemodiafiltration with single-pass albumin dialysate allows for removal of serum bilirubin. Am J Kidney Dis 2005;45:e51-e56.
72.
Askenazi DJ, Goldstein SL, Chang IF, Elenberg E, Feig DI: Management of a severe carbamazepine overdose using albumin-enhanced continuous venovenous hemodialysis. Pediatrics 2004;113:406-409.
73.
Chan WK, Hui WF: Sequential use of hemoperfusion and single-pass albumin dialysis can safely reverse methotrexate nephrotoxicity. Pediatr Nephrol 2016;31:1699-1703.
74.
Churchwell MD, Pasko DA, Smoyer WE, Mueller BA: Enhanced clearance of highly protein-bound drugs by albumin-supplemented dialysate during modeled continuous hemodialysis. Nephrol Dial Transplant 2009;24:231-238.
75.
Ding F, Song JH, Jung JY, et al: A biomimetic membrane device that modulates the excessive inflammatory response to sepsis. PLoS One 2011;6:e18584.
76.
Szamosfalvi B, Westover A, Buffington D, Yevzlin A, Humes HD: Immunomodulatory device promotes a shift of circulating monocytes to a less inflammatory phenotype in chronic hemodialysis patients. ASAIO J 2016;62:623-630.
77.
Tumlin JA, Chawla L, Tolwani AJ, et al: The effect of the selective cytopheretic device on acute kidney injury outcomes in the intensive care unit: a multicenter pilot study. Semin Dial 2013;26:616-623.
78.
Tumlin JA, Galphin CM, Tolwani AJ, et al: A multi-center, randomized, controlled, pivotal study to assess the safety and efficacy of a selective cytopheretic device in patients with acute kidney injury. PLoS One 2015;10:e0132482.
© 2017 S. Karger AG, Basel
2017
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.