Introduction: Fluid overload in extracorporeal membrane oxygenation (ECMO) patients has been associated with increased mortality. Patients receiving ECMO and continuous renal replacement therapy (CRRT) who achieve a negative fluid balance have improved survival. Limited data exist on the use of CRRT solely for fluid management in ECMO patients. Methods: We performed a single-center retrospective review of 19 adult ECMO patients without significant renal dysfunction who received CRRT for fluid management. These patients were compared to a cohort of propensity-matched controls. Results: After 72 h, the treatment group had a fluid balance of −3840 mL versus + 425 mL (p ≤ 0.05). This lower fluid balance correlated with survival to discharge (odds ratio 2.54, 95% confidence interval 1.10–5.87). Improvement in the ratio of arterial oxygen content to fraction of inspired oxygen was also significantly higher in the CRRT group (102.4 vs. 0.7, p ≤ 0.05). We did not observe any significant difference in renal outcomes. Conclusions: The use of CRRT for fluid management is effective and, when resulting in negative fluid balance, improves survival in adult ECMO patients without significant renal dysfunction.

1.
Sidebotham
D
,
McGeorge
A
,
McGuinness
S
,
Edwards
M
,
Willcox
T
,
Beca
J
.
Extracorporeal membrane oxygenation for treating severe cardiac and respiratory disease in adults: Part 1 – overview of extracorporeal membrane oxygenation
.
J Cardiothorac Vasc Anesth
.
2009
;
23
(
6
):
886
92
. .
2.
Sidebotham
D
,
McGeorge
A
,
McGuinness
S
,
Edwards
M
,
Willcox
T
,
Beca
J
.
Extracorporeal membrane oxygenation for treating severe cardiac and respiratory failure in adults: part 2 – technical considerations
.
J Cardiothorac Vasc Anesth
.
2010
;
24
(
1
):
164
72
. .
3.
Brogan
TV
,
Lequier
L
,
Lorusso
R
,
MacLaren
G
,
Peek
G
.
Extracorporeal life support: the ELSO red book
. 5th ed.
Ann Arbor, MI
:
ELSO
;
2017
.
4.
Kim
H
,
Paek
JH
,
Song
JH
,
Lee
H
,
Jhee
JH
,
Park
S
,
Permissive fluid volume in adult patients undergoing extracorporeal membrane oxygenation treatment
.
Crit Care
.
2018
;
22
(
1
):
270
. .
5.
Staudacher
DL
,
Gold
W
,
Biever
PM
,
Bode
C
,
Wengenmayer
T
.
Early fluid resuscitation and volume therapy in venoarterial extracorporeal membrane oxygenation
.
J Crit Care
.
2017
;
37
:
130
5
. .
6.
Thajudeen
B
,
Kamel
M
,
Arumugam
C
,
Ali
SA
,
John
SG
,
Meister
EE
,
Outcome of patients on combined extracorporeal membrane oxygenation and continuous renal replacement therapy: a retrospective study
.
Int J Artif Organs
.
2015
;
38
(
3
):
133
7
. .
7.
Claure-Del Granado
R
,
Mehta
RL
.
Fluid overload in the ICU: evaluation and management
.
BMC Nephrol
.
2016
;
17
(
1
):
109
. .
8.
Barsuk
JH
,
Gordon
RA
,
Cohen
ER
,
Cotts
WG
,
Malkenson
D
,
Yancy
CW
,
A diuretic protocol increases volume removal and reduces readmissions among hospitalized patients with acute decompensated heart failure
.
Congest Heart Fail
.
2013
;
19
(
2
):
53
60
. .
9.
Blijdorp
K
,
Cransberg
K
,
Wildschut
ED
,
Gischler
SJ
,
Jan Houmes
R
,
Wolff
ED
,
Haemofiltration in newborns treated with extracorporeal membrane oxygenation: a case-comparison study
.
Crit Care
.
2009
;
13
(
2
):
R48
. .
10.
Kelm
DJ
,
Perrin
JT
,
Cartin-Ceba
R
,
Gajic
O
,
Schenck
L
,
Kennedy
CC
.
Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death
.
Shock
.
2015
;
43
(
1
):
68
73
. .
11.
Micek
ST
,
McEvoy
C
,
McKenzie
M
,
Hampton
N
,
Doherty
JA
,
Kollef
MH
.
Fluid balance and cardiac function in septic shock as predictors of hospital mortality
.
Crit Care
.
2013
;
17
(
5
):
R246
. .
12.
Neyra
JA
,
Li
X
,
Canepa-Escaro
F
,
Adams-Huet
B
,
Toto
RD
,
Yee
J
,
Cumulative fluid balance and mortality in septic patients with or without acute kidney injury and chronic kidney disease
.
Crit Care Med
.
2016
;
44
(
10
):
1891
900
. .
13.
Schmidt
M
,
Bailey
M
,
Kelly
J
,
Hodgson
C
,
Cooper
DJ
,
Scheinkestel
C
,
Impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation
.
Intensive Care Med
.
2014
;
40
(
9
):
1256
66
. .
14.
Selewski
DT
,
Cornell
TT
,
Blatt
NB
,
Han
YY
,
Mottes
T
,
Kommareddi
M
,
Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy
.
Crit Care Med
.
2012
;
40
(
9
):
2694
9
. .
15.
Selewski
DT
,
Cornell
TT
,
Lombel
RM
,
Blatt
NB
,
Han
YY
,
Mottes
T
,
Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy
.
Intensive Care Med
.
2011
;
37
(
7
):
1166
73
. .
16.
Swaniker
F
,
Kolla
S
,
Moler
F
,
Custer
J
,
Grams
R
,
Barlett
R
,
Extracorporeal life support outcome for 128 pediatric patients with respiratory failure
.
J Pediatr Surg
.
2000
;
35
(
2
):
197
202
. .
17.
Vincent
JL
,
Sakr
Y
,
Sprung
CL
,
Ranieri
VM
,
Reinhart
K
,
Gerlach
H
,
Sepsis in European intensive care units: results of the SOAP study
.
Crit Care Med
.
2006
;
34
(
2
):
344
53
. .
18.
Wang
N
,
Jiang
L
,
Zhu
B
,
Wen
Y
,
Xi
XM
.
Beijing acute kidney injury trial W. Fluid balance and mortality in critically ill patients with acute kidney injury: a multicenter prospective epidemiological study
.
Crit Care
.
2015
;
19
:
371
.
19.
Dado
DN
,
Ainsworth
CR
,
Thomas
SB
,
Huang
B
,
Piper
LC
,
Sams
VG
,
Outcomes among patients treated with renal replacement therapy during extracorporeal membrane oxygenation: a Single-Center Retrospective Study
.
Blood Purif
.
2019
:
1
7
.
20.
Goldstein
S
,
Bagshaw
S
,
Cecconi
M
,
Okusa
M
,
Wang
H
,
Kellum
J
,
Pharmacological management of fluid overload
.
Br J Anaesth
.
2014
;
113
(
5
):
756
63
. .
21.
Murugan
R
,
Balakumar
V
,
Kerti
SJ
,
Priyanka
P
,
Chang
CH
,
Clermont
G
,
Net ultrafiltration intensity and mortality in critically ill patients with fluid overload
.
Crit Care
.
2018
;
22
(
1
):
223
. .
22.
Yap
HJ
,
Chen
YC
,
Fang
JT
,
Huang
CC
.
Combination of continuous renal replacement therapies (CRRT) and extracorporeal membrane oxygenation (ECMO) for advanced cardiac patients
.
Ren Fail
.
2003
;
25
(
2
):
183
93
. .
23.
Authors
E
.
ELSO guidelines for cardiopulmonary extracorporeal life support
.
Ann Arbor, MI
:
ELSO
;
2017
.
24.
Bissell
BD
,
Laine
ME
,
Thompson Bastin
ML
,
Flannery
AH
,
Kelly
A
,
Riser
J
,
Impact of protocolized diuresis for de-resuscitation in the intensive care unit
.
Crit Care
.
2020
;
24
(
1
):
70
. .
25.
Investigators
RRTS
,
Bellomo
R
,
Cass
A
,
Cole
L
,
Finfer
S
,
Gallagher
M
,
An observational study fluid balance and patient outcomes in the randomized evaluation of normal vs. augmented level of replacement therapy trial
.
Crit Care Med
.
2012
;
40
(
6
):
1753
60
. .
26.
Murugan
R
,
Kerti
SJ
,
Chang
CH
,
Gallagher
M
,
Clermont
G
,
Palevsky
PM
,
Association of net ultrafiltration rate with mortality among critically ill adults with acute kidney injury receiving continuous venovenous hemodiafiltration: a secondary analysis of the randomized evaluation of normal vs augmented level (RENAL) of renal replacement therapy trial
.
JAMA Netw Open
.
2019
;
2
(
6
):
e195418
. .
27.
Fleming
GM
,
Askenazi
DJ
,
Bridges
BC
,
Cooper
DS
,
Paden
ML
,
Selewski
DT
,
A multicenter international survey of renal supportive therapy during ECMO: the Kidney Intervention During Extracorporeal Membrane Oxygenation (KIDMO) group
.
ASAIO J
.
2012
;
58
(
4
):
407
14
. .
28.
Seczynska
B
,
Krolikowski
W
,
Nowak
I
,
Jankowski
M
,
Szuldrzynski
K
,
Szczeklik
W
.
Continuous renal replacement therapy during extracorporeal membrane oxygenation in patients treated in medical intensive care unit: technical considerations
.
Ther Apher Dial
.
2014
;
18
(
6
):
523
34
.
29.
Wu
MY
,
Chou
PL
,
Wu
TI
,
Lin
PJ
.
Predictors of hospital mortality in adult trauma patients receiving extracorporeal membrane oxygenation for advanced life support: a retrospective cohort study
.
Scand J Trauma Resusc Emerg Med
.
2018
;
26
(
1
):
14
. .
30.
KDIGOKAKIW Group
.
KDIGO clinical practice guideline for acute kidney injury
.
Kidney int
.
2012
;
2
(
Suppl
):
1
138
.
31.
Murphy
HJ
,
Eklund
MJ
,
Hill
J
,
Morella
K
,
Cahill
JB
,
Kiger
JR
,
Early continuous renal replacement therapy during infant extracorporeal life support is associated with decreased lung opacification
.
J Artif Organs
.
2019
;
22
(
4
):
286
93
. .
32.
Barbar
SD
,
Clere-Jehl
R
,
Bourredjem
A
,
Hernu
R
,
Montini
F
,
Bruyère
R
,
Timing of renal-replacement therapy in patients with acute kidney injury and sepsis
.
N Engl J Med
.
2018
;
379
(
15
):
1431
42
. .
33.
Gaudry
S
,
Hajage
D
,
Schortgen
F
,
Martin-Lefevre
L
,
Pons
B
,
Boulet
E
,
Initiation strategies for renal-replacement therapy in the intensive care unit
.
N Engl J Med
.
2016
;
375
(
2
):
122
33
. .
34.
Zarbock
A
,
Kellum
JA
,
Schmidt
C
,
Van Aken
H
,
Wempe
C
,
Pavenstädt
H
,
Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN Randomized Clinical Trial
.
JAMA
.
2016
;
315
(
20
):
2190
9
. .
35.
STARRT-AKI Investigators
;
Canadian Critical Care Trials Group
;
Australian and New Zealand Intensive Care Society Clinical Trials Group
;
United Kingdom Critical Care Research Group
;
Canadian Nephrology Trials Network
;
Irish Critical Care Trials Group
;
Timing of initiation of renal-replacement therapy in acute kidney injury
.
N Engl J Med
.
2020
;
383
(
3
):
240
51
.
36.
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
(
2
):
153
8
. .
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