Original Article
Plasma Free Hemoglobin Is a Predictor of Acute Renal Failure During Adult Venous-Arterial Extracorporeal Membrane Oxygenation Support

https://doi.org/10.1053/j.jvca.2016.02.011Get rights and content

Objective

Hemolysis is a common and severe complication during extracorporeal membrane oxygenation (ECMO). Increased plasma free hemoglobin (PFHb) is related to renal injury. The aim of this study was to investigate whether increased PFHb during adult venous-arterial ECMO was associated with acute renal failure (ARF).

Design

A retrospective, observational, single-center study.

Setting

Fuwai Hospital in Beijing, China.

Participants

The study comprised 84 venous-arterial ECMO patients.

Interventions

None.

Measurements and Main Results

A total of 84 consecutive adult patients (≥18 years) with cardiac diseases requiring venous-arterial ECMO support were studied retrospectively. Demographics of patients, clinical and ECMO characteristics, and PFHb level were collected within the first 3 days after ECMO. ARF was defined as a≥300% rise in serum creatinine from baseline or application of dialysis. Repeated measurement analysis of variance revealed that the main effect for the non-ARF group and ARF group in PFHb (p = 0.002) was significant. A significant main effect for time points (p<0.001) and time×group interaction (p = 0.014) in PFHb was obtained. In a multiple logistic regression model, peak PFHb during ECMO (odds ratio 1.052, 95% confidence interval 1.016-1.089, p = 0.005) was a risk factor for ARF during ECMO and patients who underwent heart transplantation (odds ratio 0.240, 95% confidence interval 0.060-0.964, p = 0.044) experienced less ARF. There was a linear correlation between peak serum creatinine and peak PFHb (Spearman’s r = 0.223, p = 0.042).

Conclusions

Increased PFHb is a predictor of ARF among adult patients on venous-arterial ECMO support.

Section snippets

Patients

Medical data of consecutive adult patients (≥18 years) with cardiac diseases and who required VA ECMO support between December 2010 and June 2015 in the Fuwai Hospital were retrospectively collected. Inclusion criteria included age≥18 years, sufficient data of PFHb and serum creatinine (SCr), and every patient with 1 ECMO run. Patients with history of kidney diseases were excluded. The authors’ institutional review board exempted this retrospective study from full review because there was no

Results

From December 2010 to June 2015 in Fuwai Hospital, 84 adult patients (age, 48.14±13.86 years; weight, 65.39±13.17 kg; male/female, 66/18) supported by VA ECMO with sufficient PFHb data were included in this retrospective study. One patient with missing PFHB was excluded. Indications of VA ECMO were found in 28 (33.3%) patients after heart transplantation, 51 (60.7%) patients after other cardiac surgery, and 5 (6%) patients with medical heart failure. The mean ECMO duration was 126.28±60.05

Discussion

Although ECMO increasingly has been used in critically ill patients with severe cardiopulmonary failure, the outcome of ECMO support has not been satisfactory. ARF as a risk factor of mortality is a severe complication during ECMO support.1 Early recognized risk factors for ARF and preventing ARF may decrease mortality of ECMO support. The initial pump speed of ECMO was a risk factor for AKI, and the red cell distribution width was a risk factor for stage 3 AKI in adult patients receiving ECMO.2

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    MV and VILI may not only affect hemodynamics and pulmonary function, but may also lead to systemic inflammation via the release of inflammatory cytokines. Additionally, generation of plasma-free hemoglobin may cause renal tubular injury during ECMO treatment [72–74]. The latter factors may explain the higher glomerular and proximal convoluted tubular injury in the Hemo group, in which most animals had oliguria and pigmenturia.

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