Friday, August 10, 2018

Topic Discussion: ECMO and the Kidney

Extracorporeal membrane oxygenation (ECMO) is an effective therapy for patients with reversible cardiac and/or respiratory failure. AKI  often occurs in patients supported with ECMO; it frequently evolves into chronic kidney damage or end-stage renal disease and is associated with a reported 4-fold increase in mortality rate. What are the mechanisms of injury of AKI with ECMO?
This table below summarizes what might be the potential causes.

Patient-related variables

Pretreatment factors
Hypoperfusion, loss of autoregulation Hypoxia

Nephrotoxic drugs Systemic inflammation

ECMO-related variables

Hemodynamic factors
Blood flow alterations
Hormonal factors
Renin-angiotensin-aldosterone dysregulation ANP downregulation
Blood shear stress
Systemic inflammation
Exposure to a non-self membrane Blood/air interface
Organ crosstalk
Cardio-renal syndrome
Circuit-related factors




Hemolysis is an interesting cause. This is an image of a patient getting CRRT on ECMO.  CRRT was on a zero K bath and high clearance rates. Within hours of starting CRRT, effluent bags of the CRRT turn red. Despite being on max CRRT,  patient’s potassium rose to 9mmol/L. This is hemolysis and can be reported in 18% of cases with ECMO.  Rhabdomyolysis can also be noted in some cases. Checking a free Hgb and effluent myoglobin can aid diagnosis for both entities. In addition, classic markers for hemolysis such as LDH, haptoglobin, anemia and so forth should be checked regularly. 

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