Renal dysfunction is common in neonates on Extra Corporeal Membrane Oxygenation
Alexandra J.M. Zwiers
Pediatric Nephrology & Intensive Care Erasmus MC - Sophia Children’s Hospital
Rotterdam, The Netherlands
Erasmus MC – Sophia Children’s Hospital
Extra Corporeal Membrane Oxygenation (ECMO) facility since 1993
All age groups of children & diagnoses
Total number of ECMO runs > 460
Annual number of ECMO runs ± 35
Rationale I
Decreased blood pressure
Insufficient tissue perfusion
Hypoxia/Ischemia
Nephrotoxic drugs
Incidence Acute Kidney Injury in critically ill infants ranges from
8% to 60%¹ ² ³
Incidence of renal dysfunction in ECMO patients..?
¹Andreoli et al. Pediatr Nephrol 2009 24:253-263
²Askenazi DJ et al. Pediatr Nephrol. 2009 24;265-274
³Akcan-Arikan A et al. Kidney Int. 2007 May;71(10):1028-35
Renal dysfunction
Rationale II
Early detection of renal dysfunction has implications for the child’s
treatment in the short term
50% of the survivors of childhood Acute Kidney Injury on the ICU
have signs of Chronic Kidney Disease 3 to 5 years after the initial
event4
4Askenazi DJ et al. Kidney Int. 2006 Jan;69(1):184-9
Aim of the study
To determine the incidence of renal dysfunction in neonates
treated with ECMO using two methods:
Maximal serum creatinine per patient during ECMO treatment
Mean serum creatinine level per patient by means of a Z-score
Compared with recently collected serum creatinine reference values in our
hospital.4
4Boer et al. Pediatr Nephrol 2010, In press
Methods
All patients treated with ECMO before routine use of CVVH
Inclusion Criteria: Treated with ECMO in our center Age at start of ECMO max 30 days
Exclusion Criteria: Died within one week after ECMO Pre-existent renal anomalies
Statistics: Z-score, ANOVA
Clinical data from our patient data management system (PDMS) over a 6-
year period, from 1996 until 2002
Results l
Patient characteristics (n=90)
Female/Male (n) 38/52 42% / 58%
Median Range
Age (days) 4.8 1.6 – 24.4
Weight (kg) 3.4 2.2 – 4.8
ECMO duration (days) 5.6 1.8 – 21.3
125 Neonates treated with ECMO of whom 90 survived (72%)
Results ll
Primary Diagnosis
Patient characteristics (n=90)
Meconium Aspiration Syndrome* 46
Congenital Diaphragmatic Hernia* 15
Primary Persistent Pulmonary Hypertension 12
Sepsis 12
Pneumonia 3
Other 2
*Majority of the patients had severe Persistent Pulmonary Hypertension
Results llI - Maximal level of creatinine
Forty patients (44%) showed at least one serum creatinine level
(median value 62 [10 -166]) above P97.5 for age
Median time of 43
hours [5 - 222 hours]
after start of ECMO
Compared with:
Serum creatinine
reference values4
4Boer et al. Pediatr Nephrol 2010, In press
Results IV - Individual Z-scores of Creatinine
Z-scores are calculated, based on serum reference values4
Z-score:
Tells how the data-
point compares to
normal data
4Boer et al. Pediatr Nephrol 2010, In press
Results V – ANOVA Serum Creatinine
Mixed Model ANOVA with 95% Confidence Interval
Z-score:
Mean Z-values
per ECMO day
Results VII - Serum creatinine ≥ 2 SD
N=84 N=80 N=72 N=68 N=58 N=37 N=35 N=3N=17 N=14 N=12 N=8 N=3N=27
Conclusion
Renal dysfunction is common in neonates
treated with ECMO!
Limitations
Retrospective cohort study
Renal dysfunction is diagnosed by measuring serum
creatinine, which is not considered the golden standard
Discussion
“Awareness” of renal dysfunction may result into rapid adjustment of dosage of drugs eliminated by the kidneys:
Studying Chronic Kidney Disease in children with renal dysfunction during ECMO treatment is indicated
To avoid accumulation
To avoid nephrotoxic drugs
Acknowledgements
S.N. de Wildt¹, MD PhD
W.C.J. Hop², MSc PhD
K. Cransberg¹, MD PhD
D. Tibboel¹, MD PhD
¹Pediatric Nephrology & Intensive Care, ErasmusMC - Sophia Children’s Hospital
²Department of Biostatistics, ErasmusMC, Rotterdam, The Netherlands
Funding:
Sophia Foundation Scientific Research, Grant application number: 633
Statistics lV
Mean Z-scores of all patients who have been treated with ECMO
Died during ECMO
Survived ECMO