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.
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Patient-related variables
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Pretreatment factors
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Hypoperfusion, loss of
autoregulation Hypoxia
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Nephrotoxic drugs Systemic
inflammation
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ECMO-related variables
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Hemodynamic factors
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Blood flow alterations
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Hormonal factors
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Renin-angiotensin-aldosterone
dysregulation ANP downregulation
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ECMO-related
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Blood shear stress
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Systemic inflammation
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Exposure to a non-self membrane
Blood/air interface
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Organ crosstalk
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Cardio-renal syndrome
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Circuit-related factors
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Hypermyoglobinemia
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Embolism
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Hemolysis
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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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