Acute Kidney Injury After Extracorporeal Membrane Oxygen in Children: Phenotypes and Prognosis in a Single-Center Cohort, 2020–2023

OBJECTIVES: To evaluate the association between acute kidney injury (AKI) phenotypes and major adverse kidney events at 30 days (MAKE30) after initiating extracorporeal membranous oxygenation (ECMO). DESIGN: Retrospective cohort study. SETTING: Neonatal, pediatric and cardiac critical care units at a quaternary children's hospital in the United States. PATIENTS: Children younger than 18 years requiring ECMO between January 2020 and September 2023. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Overall, 284 neonatal and pediatric ECMO patients were included (80% venoarterial, 20% venovenous). MAKE30 occurred in 97 of 284 (34%) patients with persistent renal dysfunction (i.e., estimated glomerular filtration rate < 75% of baseline) in 27 of 284 (9.5%) patients, dialysis requirement in 14 of 284 (4.9%) patients, and death in 56 of 284 (20%) patients. There were 176 of 284 (62%) patients who developed AKI, with a median (interquartile range, IQR) time from cannulation to AKI diagnosis of 2 days (IQR 0-7). AKI was classified as early if diagnosed (≤ 48 hr after cannulation) vs. late (> 48 hr after cannulation) and transient (lasting < 48 hr) vs. persistent (lasting > 48 hr). In patients with AKI, early transient AKI was present in 39 of 176 (22%) patients, early-persistent in 111 of 176 (61%) patients, late transient in 14 of 176 (8%) patients, and late persistent in 17 of 176 (9%) patients. Persistent AKI was independently associated with MAKE30 (adjusted odds ratio 2.36; 95% CI, 1.21-4.75; p = 0.013). CONCLUSIONS: In our 2020-2023 experience of pediatric ECMO, persistent AKI occurred frequently and was associated with subsequent MAKE30, whereas we failed to identify such an association in those patients with transient AKI. Further studies are needed to examine the time- and duration-based AKI phenotypes in relation to renal morbidity and patient outcomes.