Analysis Of Clinical Outcome Of Continuous Renal Replacement Therapy In The Treatment Of Patients Undergoing Extracorporeal Membrane Oxygenation

Background:Extracorporeal membrane oxygenation(ECMO)is an auxiliary supportive therapy for cardiopulmonary function replacement in patients with refractory cardiopulmonary failure,which is widely used in intensive care unit(ICU).Acute kidney injury(AKI)and fluid overload(FO)are common complications in patients with ECMO,which can increase the mortality of patients.Continuous renal replacement theray(CRRT)plays an important role in maintaining hemodynamic stability,fluid balance and removing toxins and inflammatory mediators.CRRT is often used in combination with ECMO.At present,there are few and controversial studies on the clinical characteristics and prognostic risk factors of CRRT in ECMO patients.The timing of CRRT application has always been the focus of research on renal diseases,but no systematic study has analyzed the impact of timing of CRRT application on prognosis in ECMO patients.Therefore,the clinical characteristics and prognostic risk factors of CRRT in ECMO patients and the timing of CRRT application were analyzed and discussed in this paperPart 1 Application of continuous renal replacement therapy in patients treated with ECMO.Objective:To analyze the clinical characteristics and prognostic risk factors of ICU patients treated with ECMO combined with CRRT.Methods:Patients admitted to the intensive care unit of Henan Provincial People’s Hospital and treated with ECMO combined with CRRT from January 2017 to January 2022 were collected.Patients were divided into survival group and death group according to hospital survival.Hospital death was defined as death occurring during hospitalization or giving up treatment due to critical condition.The general clinical features,clinical data and the worst biochemical indices recorded in 24 hours before ECMO were collected and compared between the two groups.The main outcome was hospital survival.Logistic regression analysis was used to analyze the prognostic risk factors of patients,and receiver operating characteristic curve(ROC)was drawn to evaluate the prognostic efficacy of risk factors.Result:1.General clinical features:A total of 159 patients were included,with an average age of 52.23±16.11years,including 44(27.67%)females and 115(72.33%)males;32(20.13%)survived,127(79.87%)died,and 57(35.85%)were successfully removed from ECMO.2.Comparison of baseline data between the two groups:Compared with the survival group,in the death group,the proportion of cardiopulmonary resuscitation due to respiratory cardiac arrest,acute physiology and chronic health evaluation II(APACHE II),sequential organ failure assessment(SOFA),total bile acid,arterial lactic acid,doses applied epinephrine,norepinephrine and terisopressin were higher.The percentage of successful withdrawal of ECMO,Glasgow Coma scale(GCS)and CRRT application time were lower,and the differences between the two groups were statistically significant(all P<0.05).3.Prognosis:32 patients(20.13%)survived and 127 patients(79.87%)died in ECMO combined with CRRT.The proportion of coagulation dysfunction,septic shock,multiple organ failure and the number of organ failure>3 in the death group was higher than that in the survival group,and the differences between the two groups were statistically significant(all P<0.05).4.Risk factors analysis:Multivariate Logistic regression analysis showed that ECMO withdrawal failure(OR=0.009,95%CI 0.001～0.120,P<0.001),high APACHE II score(OR=1.251,95%CI1.060～1.477,P=0.008),complicated the number of organ failure>3(OR=32.913,95%CI 1.767～612.957,P=0.019)and high arterial lactic acid(OR=1.355,95%CI 1.018～1.802,P=0.037)were independent risk factors for death in patients treated with ECMO combined CRRT.5.Predictive value of risk factors for patient death:ROC curve analysis showed that the area under the ROC curve of APACHE II score was 0.867,the sensitivity was 70.10%,and the specificity was90.60%.Summary:ECMO combined with CRRT patients had high mortality in hospital;ECMO withdrawal failure,high APACHE II score,the number of organ failure>3 and high arterial lactic acid were independent risk factors for in-hospital death.APACHE II score can predict the death of ECMO combined with CRRT.Part II Effect of the timing of continuous renal replacement therapy on prognosis of patients with extracorporeal membrane oxygenationObjective:To investigate the effect of the timing of CRRT application on the prognosis of ECMO patients.Methods:Patients admitted to the intensive care unit of Henan Provincial People’s Hospital from January 2017to January 2022 and treated with ECMO combined with CRRT were retrospectively included,and patients who were treated with CRRT before ECMO were excluded.According to the interval of CRRT starting after ECMO application,the patients were divided into the early CRRT group(≤72h)and the late CRRT group(>72h).Data collection and endpoint event definition of patients between the two groups were the same as those in the first part,and the differences in baseline data and prognosis between the early CRRT group and the late CRRT group were compared.Propensity score matching(PSM)was used to balance the baseline characteristics of the two groups and control the influence of confounding factors.Kaplan-Meier survival analysis was used to draw the survival curves of the two groups,and Log-Rank test was used to compare the differences between the two groups.Result:1.General clinical features:A total of 159 patients were screened,14 patients were excluded from CRRT application before ECMO,and 145 patients were finally included.With an average age of52.70±16.07 years old,including 117 patients(80.69%)in the early CRRT group and 28 patients(19.31%)in the late CRRT group.116 patients(80.00%)died.After matching propensity scores,a total of 40 patients were included,including 20 patients in the early CRRT group and 20 patients in the late CRRT group(50.00%).The mean age was 53.85±14.89 years old,and 31 cases(77.50%)died.2.Comparison of clinical baseline data between the early CRRT group and the late CRRT group:Compared with the late CRRT group,In the early CRRT group,the proportion of CPR due to respiratory cardiac arrest,the proportion of ECMO treatment due to respiratory cardiac arrest,the proportion of Veno-arterial mode of ECMO,the proportion of failure of ECMO withdrawal,APACHE II score,SOFA score,creatinine,uric acid,serum potassium,alanine aminotransferase,aspartate aminotransferase and arterial lactic acid were all higher.However,the proportion of Veno-venous ECMO mode,GCS score and arterial PH were all lower,with statistical significance(all P<0.05).After matching propensity score,there was no significant difference in baseline data between the early CRRT group and the late CRRT group(all P>0.05).3.Survival analysis:There was no significant difference in mortality between the early CRRT group and the late CRRT group(P=0.462).Kaplan-Meier survival curve showed that the cumulative survival rate of the late CRRT group was higher than that of the early CRRT group(χ~2=8.684,P=0.003).After matching propensity scores,there was no significant difference in mortality between the early CRRT group and the late CRRT group(P=1.000).Kaplan-Meier survival curve showed that there was no significant difference in cumulative survival between the early CRRT group and the late CRRT group(χ~2=1.300,P=0.254).Summary:Early CRRT application after ECMO treatment may not be superior to late CRRT;and the timing of CRRT application maybe has no significant effect on the prognosis of ECMO patients.Conclusions:1.Patients with ECMO combined with CRRT had high in-hospital mortality;ECMO withdrawal failure,high APACHE II score,the number of organ failure>3 and high arterial lactic acid was an independent risk factor for death of patients.2.Early application of CRRT after ECMO treatment may not be superior to late application of CRRT;and the timing of CRRT application maybe has no significant effect on the prognosis of ECMO patients.