Introduction: The incidence of thrombocytopenia in neonates receiving extracorporeal membrane oxygenation (ECMO) with and without concurrent continuous renal replacement therapy (CRRT) and associated complications have not been well described. The primary aims of the current study were to (1) characterize thrombocytopenia in neonates receiving ECMO (including those treated concurrently with CRRT) and (2) evaluate risk factors (including CRRT utilization) associated with severe thrombocytopenia. In a planned exploratory secondary aim, we explored the association of severe thrombocytopenia with outcomes in neonates receiving ECMO. Methods: We conducted a retrospective single-center chart review of neonates who received ECMO 07/01/14–03/01/20 and evaluated associations between CRRT, severe thrombocytopenia (platelet count <50,000/mm3), and outcomes (ECMO duration, length of stay, and survival). Results: Fifty-two neonates received ECMO; 35 (67%) received concurrent CRRT. Severe thrombocytopenia occurred in 27 (52%) neonates overall and in 21 (60%) neonates who received concurrent CRRT. Underlying diagnosis, ECMO mode, care unit, and moderate/severe hemolysis differed between those who did and did not receive CRRT. CRRT receivers experienced shorter hospital stays than CRRT non-receivers, but ECMO duration, length of intensive care unit (ICU) stay, and survival did not differ between groups. CRRT receipt was associated with severe thrombocytopenia. Exploratory classification and regression tree (CART) analysis suggests CRRT use, birthweight, and ICU location are all predictors of interest for severe thrombocytopenia. Conclusions: In our cohort, CRRT use during ECMO was associated with severe thrombocytopenia, and patients who received ECMO with CRRT experienced shorter hospital stays than those who did not receive CRRT. Exploratory CART analysis suggests CRRT use, birthweight, and ICU location are all predictors for severe thrombocytopenia and warrant further investigations in larger studies.

Heart and lung life support, or extracorporeal membrane oxygenation (ECMO), is a form of life support that can be utilized in critically ill neonates. Continuous dialysis, or continuous renal replacement therapy (CRRT), can be used in conjunction with ECMO to help support and supplement kidney function. The frequency of low platelet counts in neonates receiving ECMO with and without concurrent CRRT and associated outcomes have not been well described in the literature. The primary aims of the current study were to (1) characterize low platelet counts in neonates receiving ECMO (including those treated concurrently with CRRT) and (2) evaluate risk factors (including CRRT utilization) associated with low platelets. In our study, CRRT use during ECMO was associated with severely low platelet counts. Exploratory analysis suggests CRRT use, birthweight, and intensive care unit location are all predictors of interest for low platelet counts and worthy of further investigations in larger studies.

1.
Ferreira
JA
,
Johnson
DW
.
The incidence of thrombocytopenia associated with continuous renal replacement therapy in critically ill patients
.
Ren Fail
.
2015
;
37
(
7
):
1232
6
. doi: .
2.
Guru
PK
,
Singh
TD
,
Akhoundi
A
,
Kashani
KB
.
Association of thrombocytopenia and mortality in critically ill patients on continuous renal replacement therapy
.
Nephron
.
2016
;
133
(
3
):
175
82
. doi: .
3.
Droege
CA
,
Ernst
NE
,
Messinger
NJ
,
Burns
AM
,
Mueller
EW
.
Evaluation of thrombocytopenia in critically ill patients receiving continuous renal replacement therapy
.
Ann Pharmacother
.
2018
;
52
(
12
):
1204
10
. doi: .
4.
Nishimi
S
,
Sugawara
H
,
Onodera
C
,
Toya
Y
,
Furukawa
H
,
Konishi
Y
, et al
.
Complications during continuous renal replacement therapy in critically ill neonates
.
Blood Purif
.
2019
;
47
(
Suppl 2
):
74
80
. doi: .
5.
Gautam
SC
,
Lim
J
,
Jaar
BG
.
Complications associated with continuous RRT
.
Kidney360
.
2022
;
3
(
11
):
1980
90
. doi: .
6.
Robinson
TM
,
Kickler
TS
,
Walker
LK
,
Ness
P
,
Bell
W
.
Effect of extracorporeal membrane oxygenation on platelets in newborns
.
Crit Care Med
.
1993
;
21
(
7
):
1029
34
. doi: .
7.
Jiritano
F
,
Serraino
GF
,
Ten Cate
H
,
Fina
D
,
Matteucci
M
,
Mastroroberto
P
, et al
.
Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis
.
Intensive Care Med
.
2020
;
46
(
6
):
1154
69
. doi: .
8.
Kohs
TCL
,
Liu
P
,
Raghunathan
V
,
Amirsoltani
R
,
Oakes
M
,
McCarty
OJT
, et al
.
Severe thrombocytopenia in adults undergoing extracorporeal membrane oxygenation is predictive of thrombosis
.
Platelets
.
2022
;
33
(
4
):
570
6
. doi: .
9.
Hoover
NG
,
Heard
M
,
Reid
C
,
Wagoner
S
,
Rogers
K
,
Foland
J
, et al
.
Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support
.
Intensive Care Med
.
2008
;
34
(
12
):
2241
7
. doi: .
10.
Fleming
GM
,
Askenazi
DJ
,
Bridges
BC
,
Cooper
DS
,
Paden
ML
,
Selewski
DT
, 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
(
4
):
407
14
. doi: .
11.
Chen
H
,
Yu
RG
,
Yin
NN
,
Zhou
JX
.
Combination of extracorporeal membrane oxygenation and continuous renal replacement therapy in critically ill patients: a systematic review
.
Crit Care
.
2014
;
18
(
6
):
675
. doi: .
12.
Selewski
DT
,
Askenazi
DJ
,
Bridges
BC
,
Cooper
DS
,
Fleming
GM
,
Paden
ML
, 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
(
12
):
1126
35
. doi: .
13.
Mah
KE
,
Hao
S
,
Sutherland
SM
,
Kwiatkowski
DM
,
Axelrod
DM
,
Almond
CS
, et al
.
Fluid overload independent of acute kidney injury predicts poor outcomes in neonates following congenital heart surgery
.
Pediatr Nephrol
.
2018
;
33
(
3
):
511
20
. doi: .
14.
Gorga
SM
,
Sahay
RD
,
Askenazi
DJ
,
Bridges
BC
,
Cooper
DS
,
Paden
ML
, et al
.
Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy: a multicenter retrospective cohort study
.
Pediatr Nephrol
.
2020
;
35
(
5
):
871
82
. doi: .
15.
Mallory
PP
,
Selewski
DT
,
Askenazi
DJ
,
Cooper
DS
,
Fleming
GM
,
Paden
ML
, et al
.
Acute kidney injury, fluid overload, and outcomes in children supported with extracorporeal membrane oxygenation for a respiratory indication
.
Asaio j
.
2020
;
66
(
3
):
319
26
. doi: .
16.
Anton-Martin
P
,
Quigley
R
,
Dhar
A
,
Bhaskar
P
,
Modem
V
.
Early fluid accumulation and intensive care unit mortality in children receiving extracorporeal membrane oxygenation
.
Asaio J
.
2021
;
67
(
1
):
84
90
. doi: .
17.
Murphy
HJ
,
Gien
J
,
Sahay
R
,
King
E
,
Selewski
DT
,
Bridges
BC
, et al
.
Acute kidney injury, fluid overload, and renal replacement therapy differ by underlying diagnosis in neonatal extracorporeal support and impact mortality disparately
.
Blood Purif
.
2021
;
50
(
6
):
808
17
. doi: .
18.
Gist
KM
,
Misfeldt
A
,
Sahay
RD
,
Gorga
SM
,
Askenazi
DJ
,
Bridges
BC
, et al
.
Acute kidney injury and fluid overload in pediatric extracorporeal cardio-pulmonary resuscitation: a multicenter retrospective cohort study
.
Asaio J
.
2022
;
68
(
7
):
956
63
. doi: .
19.
Gorga
SM
,
Lima
L
,
Askenazi
DJ
,
Bridges
BC
,
Cooper
DS
,
Paden
ML
, et al
.
Fluid balance management informs renal replacement therapy use during pediatric extracorporeal membrane oxygenation: a survey report from the kidney intervention during extracorporeal membrane oxygenation group
.
Asaio J
.
2022
;
68
(
3
):
407
12
. doi: .
20.
Totapally
A
,
Bridges
BC
,
Selewski
DT
,
Zivick
EE
.
Managing the kidney: the role of continuous renal replacement therapy in neonatal and pediatric ECMO
.
Semin Pediatr Surg
.
2023
;
32
(
4
):
151332
. doi: .
21.
ECMO registry of the extracorporeal life support organization (ELSO). April
. 2022 ed.
Ann Arbor, Michigan
.
22.
von Elm
E
,
Altman
DG
,
Egger
M
,
Pocock
SJ
,
Gøtzsche
PC
,
Vandenbroucke
JP
, et al
.
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies
.
Bmj
.
2007
;
335
(
7624
):
806
8
. doi: .
23.
Harris
PA
,
Taylor
R
,
Thielke
R
,
Payne
J
,
Gonzalez
N
,
Conde
JG
.
Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support
.
J Biomed Inform
.
2009
;
42
(
2
):
377
81
. doi: .
24.
Harris
PA
,
Taylor
R
,
Minor
BL
,
Elliott
V
,
Fernandez
M
,
O’Neal
L
, et al
.
The REDCap consortium: building an international community of software platform partners
.
J Biomed Inform
.
2019
;
95
:
103208
. doi: .
25.
Murphy
HJ
,
Cahill
JB
,
Twombley
KE
,
Annibale
DJ
,
Kiger
JR
.
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
.
2018
;
21
(
1
):
76
85
. doi: .
26.
Fernández
KS
,
de Alarcón
P
.
Neonatal thrombocytopenia
.
NeoReviews
.
2013
;
14
(
2
):
e74
82
. doi: .
27.
Mulder
J
,
Tan
HK
,
Bellomo
R
,
Silvester
W
.
Platelet loss across the hemofilter during continuous hemofiltration
.
Int J Artif Organs
.
2003
;
26
(
10
):
906
12
. doi: .
28.
Daugirdas
JT
,
Bernardo
AA
.
Hemodialysis effect on platelet count and function and hemodialysis-associated thrombocytopenia
.
Kidney Int
.
2012
;
82
(
2
):
147
57
. doi: .
29.
Berger
TM
,
Allred
EN
,
Van Marter
LJ
.
Antecedents of clinically significant pulmonary hemorrhage among newborn infants
.
J Perinatol
.
2000
;
20
(
5
):
295
300
. .
30.
Zahr
RA
,
Ashfaq
A
,
Marron-Corwin
M
.
Neonatal pulmonary hemorrhage
.
NeoReviews
.
2012
;
13
(
5
):
e302
06
. doi: .
31.
Barnes
ME
,
Feeney
E
,
Duncan
A
,
Jassim
S
,
MacNamara
H
,
O’Hara
J
, et al
.
Pulmonary haemorrhage in neonates: systematic review of management
.
Acta Paediatr
.
2022
;
111
(
2
):
236
44
. doi: .
32.
Cavagnaro
F
,
Kattan
J
,
Godoy
L
,
Gonzáles
A
,
Vogel
A
,
Rodríguez
JI
, et al
.
Continuous renal replacement therapy in neonates and young infants during extracorporeal membrane oxygenation
.
Int J Artif Organs
.
2007
;
30
(
3
):
220
6
. doi: .
33.
Meyer
AD
,
Rishmawi
AR
,
Kamucheka
R
,
Lafleur
C
,
Batchinsky
AI
,
Mackman
N
, et al
.
Effect of blood flow on platelets, leukocytes, and extracellular vesicles in thrombosis of simulated neonatal extracorporeal circulation
.
J Thromb Haemost
.
2020
;
18
(
2
):
399
410
. doi: .
You do not currently have access to this content.