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Effect of a standardized fluid management algorithm on acute kidney injury and mortality in pediatric patients on extracorporeal support

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Abstract

Acute kidney injury (AKI), fluid overload (FO), and mortality are common in pediatric patients supported by extracorporeal membrane oxygenation (ECMO). The aim of this study is to evaluate if using a fluid management algorithm reduced AKI and mortality in children supported by ECMO. We performed a retrospective study of pediatric patients aged birth to 25 years requiring ECMO at a quaternary level children’s hospital from 2007 to 2019 In October 2017, a fluid management algorithm was implemented for protocolized fluid removal after deriving a daily fluid goal using a combination of diuretics and ultrafiltration. Daily algorithm compliance was defined as ≥ 12 h on the algorithm each day. The primary and secondary outcomes were AKI and mortality, respectively, and were assessed in the entire cohort and the sub-analysis of children from the era in which the algorithm was implemented. Two hundred and ninety-nine (median age 5.3 months; IQR: 0.2, 62.3; 45% male) children required ECMO (venoarterial in 85%). The fluid algorithm was applied in 74 patients. The overall AKI rate during ECMO was 38% (26% severe—stage 2/3). Both AKI incidence and mortality were significantly lower in patients managed on the algorithm (p = 0.02 and p = 0.05). After adjusting for confounders, utilization of the algorithm was associated with lower odds of AKI (aOR: 0.40, 95%CI: 0.21, 0.76; p = 0.005) but was not associated with a reduction in mortality. In the sub-analysis, algorithm compliance of 80–100% was associated with a 54% reduction in mortality (ref: < 60% compliant; aOR:0.46, 95%CI:0.22–1.00; p = 0.05).

  Conclusion: Among the entire cohort, the use of a fluid management algorithm reduced the odds of AKI. Better compliance on the algorithm was associated with lower mortality. Multicenter studies that implement systematic fluid removal may represent an opportunity for improving ECMO-related outcomes.

What is Known:

• Acute kidney injury and fluid overload are associated with morbidity and mortality in children supported by extracorporeal membrane oxygenation.

What is New:

• A systematic and protocolized approach to fluid removal in children supported by extracorporeal membrane oxygenation reduces acute kidney injury incidence.

• Greater adherence to a protocolized fluid removal algorithm is associated with a reduction in mortality.

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Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AKI:

Acute kidney injury

CKRT:

Continuous kidney replacement therapy

ECMO:

Extracorporeal membrane oxygenation

ECPR:

Extracorporeal cardiopulmonary resuscitation

endECMO:

Cessation of extracorporeal membrane oxygenation support

FO:

Fluid overload

%FO:

Percent fluid overload

KRT:

Kidney replacement therapy

preECMO:

Prior to extracorporeal membrane oxygenation support

SCr:

Serum creatinine

UF:

Ultrafiltration

VA:

Venoarterial

VV:

Venovenous

References

  1. Askenazi DJ, Ambalavanan N, Hamilton K, Cutter G, Laney D, Kaslow R et al (2011) Acute kidney injury and renal replacement therapy independently predict mortality in neonatal and pediatric noncardiac patients on extracorporeal membrane oxygenation. Pediatr Crit Care Med 12(1):e1-6

    Article  Google Scholar 

  2. Duncan BW, Hraska V, Jonas RA, Wessel DL, Del Nido PJ, Laussen PC et al (1999) Mechanical circulatory support in children with cardiac disease. J Thorac Cardiovasc Surg 117(3):529–542

    Article  CAS  Google Scholar 

  3. Gorga SM, Sahay RD, Askenazi DJ, Bridges BC, Cooper DS, Paden ML et al (2020) Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy: a multicenter retrospective cohort study. Pediatr Nephrol 35(5):871–882

    Article  Google Scholar 

  4. Hoover NG, Heard M, Reid C, Wagoner S, Rogers K, Foland J et al (2008) Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support. Intensive Care Med 34(12):2241–2247

    Article  Google Scholar 

  5. Mallory PP, Selewski DT, Askenazi DJ, Cooper DS, Fleming GM, Paden ML et al (2020) Acute kidney injury, fluid overload, and outcomes in children supported with extracorporeal membrane oxygenation for a respiratory indication. ASAIO J 66(3):319–326

    Article  Google Scholar 

  6. Murphy HJ, Gien J, Sahay R, King E, Selewski DT, Bridges BC et al (2021) Acute kidney injury, fluid overload, and renal replacement therapy differ by underlying diagnosis in neonatal extracorporeal support and impact mortality disparately. Blood Purif 1–10

  7. Selewski DT, Cornell TT, Blatt NB, Han YY, Mottes T, Kommareddi M et al (2012) Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy. Crit Care Med 40(9):2694–2699

    Article  CAS  Google Scholar 

  8. Sell LL, Cullen ML, Whittlesey GC, Lerner GR, Klein MD (1987) Experience with renal failure during extracorporeal membrane oxygenation: treatment with continuous hemofiltration. J Pediatr Surg 22(7):600–602

    Article  CAS  Google Scholar 

  9. Weber TR, Connors RH, Tracy TF Jr, Bailey PV, Stephens C, Keenan W (1990) Prognostic determinants in extracorporeal membrane oxygenation for respiratory failure in newborns. Ann Thorac Surg 50(5):720–723

    Article  CAS  Google Scholar 

  10. Zwischenberger JB, Nguyen TT, Upp JR, Jr., Bush PE, Cox CS Jr, Delosh T et al (1994) Complications of neonatal extracorporeal membrane oxygenation. Collective experience from the Extracorporeal Life Support Organization. J Thorac Cardiovasc Surg 107(3):838–48; discussion 48–9

  11. Hansrivijit P, Lertjitbanjong P, Thongprayoon C, Cheungpasitporn W, Aeddula NR, Salim SA et al (2019) Acute kidney injury in pediatric patients on extracorporeal membrane oxygenation: a systematic review and meta-analysis. Medicines (Basel) 6(4)

  12. Fleming GM, Sahay R, Zappitelli M, King E, Askenazi DJ, Bridges BC et al (2016) The incidence of acute kidney injury and its effect on neonatal and pediatric extracorporeal membrane oxygenation outcomes: a multicenter report from the kidney intervention during extracorporeal membrane oxygenation study group. Pediatr Crit Care Med 17(12):1157–1169

    Article  Google Scholar 

  13. Zwiers AJ, de Wildt SN, Hop WC, Dorresteijn EM, Gischler SJ, Tibboel D et al (2013) Acute kidney injury is a frequent complication in critically ill neonates receiving extracorporeal membrane oxygenation: a 14-year cohort study. Crit Care 17(4):R151

    Article  Google Scholar 

  14. Villa G, Katz N, Ronco C (2015) Extracorporeal membrane oxygenation and the kidney. Cardiorenal Med 6(1):50–60

    Article  Google Scholar 

  15. Gu M, Mei XL, Zhao YN (2021) A review on extracorporeal membrane oxygenation and kidney injury. J Biochem Mol Toxicol 35(3):e22679

    Article  CAS  Google Scholar 

  16. Bridges BC, Selewski DT, Paden ML, Cooper DS, Zappitelli M, Fleming GM et al (2012) Acute kidney injury in neonates requiring ECMO. NeoReviews 13(7):e428

    Article  Google Scholar 

  17. Basu RK, Devarajan P, Wong H, Wheeler DS (2011) An update and review of acute kidney injury in pediatrics. Pediatr Crit Care Med 12(3):339–347

    Article  Google Scholar 

  18. Gbadegesin R, Zhao S, Charpie J, Brophy PD, Smoyer WE, Lin JJ (2009) Significance of hemolysis on extracorporeal life support after cardiac surgery in children. Pediatr Nephrol 24(3):589–595

    Article  Google Scholar 

  19. Lee SA, Cozzi M, Bush EL, Rabb H (2018) Distant organ dysfunction in acute kidney injury: a review. Am J Kidney Dis 72(6):846–856

    Article  Google Scholar 

  20. Husain-Syed F, Slutsky AS, Ronco C (2016) Lung-kidney cross-talk in the critically Ill patient. Am J Respir Crit Care Med 194(4):402–414

    Article  CAS  Google Scholar 

  21. Flori HR, Church G, Liu KD, Gildengorin G, Matthay MA (2011) Positive fluid balance is associated with higher mortality and prolonged mechanical ventilation in pediatric patients with acute lung injury. Crit Care Res Pract 2011:854142

    Google Scholar 

  22. Seguin J, Albright B, Vertullo L, Lai P, Dancea A, Bernier PL et al (2014) Extent, risk factors, and outcome of fluid overload after pediatric heart surgery. Crit Care Med 42(12):2591–2599

    Article  Google Scholar 

  23. Swaniker F, Kolla S, Moler F, Custer J, Grams R, Barlett R et al (2000) Extracorporeal life support outcome for 128 pediatric patients with respiratory failure. J Pediatr Surg 35(2):197–202

    Article  CAS  Google Scholar 

  24. Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R (2001) Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 107(6):1309–1312

    Article  CAS  Google Scholar 

  25. Selewski DT, Cornell TT, Lombel RM, Blatt NB, Han YY, Mottes T et al (2011) Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Med 37(7):1166–1173

    Article  CAS  Google Scholar 

  26. Sutherland SM, Zappitelli M, Alexander SR, Chua AN, Brophy PD, Bunchman TE et al (2010) Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 55(2):316–325

    Article  Google Scholar 

  27. Fleming GM, Askenazi DJ, Bridges BC, Cooper DS, Paden ML, Selewski DT et al (2012) A multicenter international survey of renal supportive therapy during ECMO: the Kidney Intervention During Extracorporeal Membrane Oxygenation (KIDMO) group. ASAIO J 58(4):407–414

    Article  CAS  Google Scholar 

  28. Selewski DT, Askenazi DJ, Bridges BC, Cooper DS, Fleming GM, Paden ML et al (2017) The impact of fluid overload on outcomes in children treated with extracorporeal membrane oxygenation: a multicenter retrospective cohort study. Pediatr Crit Care Med 18(12):1126–1135

    Article  Google Scholar 

  29. Gorga S, Lima L, Askenazi D, Bridges B, Cooper D, Paden M et al (2021) 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. Publish Ahead of Print

  30. Kellum JA, Lameire N, Group KAGW (2013) Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care 17(1):204

    Article  Google Scholar 

  31. Selewski DT, Charlton JR, Jetton JG, Guillet R, Mhanna MJ, Askenazi DJ et al (2015) Neonatal acute kidney injury. Pediatrics 136(2):e463–e473

    Article  Google Scholar 

  32. Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL, Investigators A (2017) Epidemiology of acute kidney injury in critically Ill children and young adults. N Engl J Med 376(1):11–20

    Article  Google Scholar 

  33. Schisterman EF, Cole SR, Platt RW (2009) Overadjustment bias and unnecessary adjustment in epidemiologic studies. Epidemiology 20(4):488–495

    Article  Google Scholar 

  34. Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A et al (2009) Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 37(2):666–688

    Article  Google Scholar 

  35. Carcillo JA, Davis AL, Zaritsky A (1991) Role of early fluid resuscitation in pediatric septic shock. JAMA 266(9):1242–1245

    Article  CAS  Google Scholar 

  36. Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP et al (2020) Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med 21(2):e52–e106

    Article  Google Scholar 

  37. Fong KM, Au SY, Ng GWY, Leung AKH (2020) Positive fluid balance and mortality in adult patients treated with extracorporeal membrane oxygenation: a retrospective study. J Intensive Care Soc 21(3):210–220

    Article  Google Scholar 

  38. Gist KM, Misfeldt A, Sahay RD, Gorga SM, Askenazi DJ, Bridges BC et al (2021) Acute kidney injury and fluid overload in pediatric extracorporeal cardio-pulmonary resuscitation: a multicenter retrospective cohort study. ASAIO J

  39. Schmidt M, Bailey M, Kelly J, Hodgson C, Cooper DJ, Scheinkestel C et al (2014) Impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation. Intensive Care Med 40(9):1256–1266

    Article  CAS  Google Scholar 

  40. Staudacher DL, Gold W, Biever PM, Bode C, Wengenmayer T (2017) Early fluid resuscitation and volume therapy in venoarterial extracorporeal membrane oxygenation. J Crit Care 37:130–135

    Article  Google Scholar 

  41. Malbrain M, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O et al (2018) Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy. Ann Intensive Care 8(1):66

    Article  Google Scholar 

  42. Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ et al (2014) Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther 46(5):361–380

    Article  Google Scholar 

  43. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B et al (2006) Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 354(24):2564–2575

    Article  CAS  Google Scholar 

  44. Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC et al (2017) Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med 43(2):155–170

    Article  Google Scholar 

  45. Alobaidi R, Basu RK, DeCaen A, Joffe AR, Lequier L, Pannu N et al (2020) Fluid accumulation in critically Ill children. Crit Care Med 48(7):1034–1041

    CAS  Google Scholar 

  46. Meyer RJ, Brophy PD, Bunchman TE, Annich GM, Maxvold NJ, Mottes TA et al (2001) Survival and renal function in pediatric patients following extracorporeal life support with hemofiltration. Pediatr Crit Care Med 2(3):238–242

    Article  Google Scholar 

  47. Gist KM, Selewski DT, Brinton J, Menon S, Goldstein SL, Basu RK (2020) Assessment of the independent and synergistic effects of fluid overload and acute kidney injury on outcomes of critically Ill children. Pediatr Crit Care Med 21(2):170–177

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Pediatrics, Children’s Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA

    Megan M. SooHoo, M. Hank Williams, Robert Hyslop, Shannon Buckvold & John S. Kim

  2. University of Colorado-Denver Campus, Denver, CO, 80045, USA

    Ananya Shah

  3. Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA

    Anthony Mayen

  4. Department of Pediatrics, Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Rajit K. Basu

  5. Department of Biostatistics and Epidemiology, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA

    John T. Brinton

  6. Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA

    Katja M. Gist

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  1. Megan M. SooHoo
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Contributions

MHW and SB created the fluid management algorithm. MMS, JKS, and KMG designed the study. MMS, AS, AM, MHW, RH, and KMG acquired the data. JTB and KMG did the statistical analysis. MMS, JTB, and KMG analyzed and interpreted the data. MMS, AS, JTB, and KMG drafted the manuscript. MMS, MHW, RH, SB, RKB, JSK, and KMG substantively revised the manuscript. All authors reviewed the manuscript and approved the final report.

Corresponding author

Correspondence to Megan M. SooHoo.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the Colorado Multiple Institutional Review Board with a waiver of informed consent (COMIRB protocol 14–1516, approval date 11/18/2014). Procedures were followed in accordance to the Helsinki Declaration of 1975.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Communicated by Gregorio Milani

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SooHoo, M.M., Shah, A., Mayen, A. et al. Effect of a standardized fluid management algorithm on acute kidney injury and mortality in pediatric patients on extracorporeal support. Eur J Pediatr 182, 581–590 (2023). https://doi.org/10.1007/s00431-022-04699-y

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