O. Kwon1,2, E. Aguayo1,2, N. Le1, T. Coaston1, K. Tabibian1, S. Mallick1, J. Hadaya1,3, Y. Sanaiha1,3, M. Gandjian1,3, P. Benharash1,3 1Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School Of Medicine At University Of California, Los Angeles, CA, USA 2Los Angeles County Harbor-UCLA Medical Center, Department Of Surgery, Torrance, CA, USA 3Division of Cardiac Surgery, Department Of Surgery, David Geffen School Of Medicine At University Of California, Los Angeles, CA, USA
Introduction:
Chronic kidney disease (CKD) is associated with increased risks of mortality, complications, and prolonged recovery in cardiac surgery. However, its association with outcomes among those requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) is poorly understood. The present study evaluated the utilization of VA-ECMO in CKD patients and assessed outcomes across varying degrees of renal dysfunction.
Methods:
All adults (≥18 years) requiring VA-ECMO were identified using the Nationwide Readmissions Database from 2019-2021. Patients were stratified based on the presence of CKD and its stages: non-CKD, CKD1-2, and CKD3-5. Those with a diagnosis of end-stage renal disease requiring dialysis or prior renal transplant were excluded. The primary outcome was in-hospital mortality, while secondary outcomes included perioperative complications. A marginal analysis was performed to evaluate the interaction effects between CKD status and VA-ECMO indications. Entropy balancing was employed to generate balanced patient cohorts to compare outcomes across different stages of CKD.
Results:
Of an estimated 14,314 receiving VA-ECMO, 1,695 (11.8%) had underlying CKD, with 10.0% having stages 3-5. Among CKD patients, common indications for VA-ECMO included cardiogenic shock (34.4%) and postcardiotomy shock (25.5%). Following risk adjustment, CKD was independently associated with greater odds of in-hospital mortality (AOR 1.24, 95%CI 1.04-1.48) and overall complications (AOR 1.32, 95%CI 1.04-1.69). Furthermore, a notable increase in mortality and complications was observed in CKD patients undergoing VA-ECMO when cardiogenic shock was the primary indication (Figure 1A-B). Among CKD patients, other indications, such as postcardiotomy shock, non-cardiogenic shock, and thoracic transplant, were also linked to a higher overall complication rate compared to their counterparts (Figure 1B). When evaluated by severity of renal dysfunction, CKD3-5 was associated with higher odds of mortality (AOR 1.89, 95%CI 1.11-3.25) and an increased risk of stroke (AOR 2.29, 95%CI 1.03-4.68), infectious (AOR 2.22, 95%CI 1.26-3.89), and hemorrhagic (AOR 1.70, 95%CI 1.07-2.70) complications compared to CKD1-2.
Conclusion:
Renal dysfunction is an independent predictor of morbidity and mortality following VA-ECMO, particularly in late stages and when performed in the setting of cardiogenic shock. Careful patient selection, risk stratification, and optimization of perioperative care are essential to mitigate complications and improve survival in these high-risk patients requiring VA-ECMO.