renal dysfunction is common in neonates on extra corporeal membrane oxygenation alexandra j.m....

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