Table 1. Methods for combining renal replacement therapy with veno-arterial extracorporeal membrane oxygenation.
| Treatment | Specific type | Pros | Cons |
|---|---|---|---|
| CRRT | Integrated approach: with in-line haemofilter | Low cost | No pressure monitoring |
| Relatively easy to set up | External pump required to control anticoagulation | ||
| Large volumes of ultrafiltrate able to be generated | Less precise ultrafiltration | ||
| Separate anticoagulation not required | Flow turbulence, hemolysis risk | ||
| Integrated approach: CRRT device integrated to ECMO circuit | Solute removal and ultrafiltration provided | Exposure of CRRT machine to pressures outside safety range | |
| Mode of solute clearance not restricted | Risk of air entrapment | ||
| Ultrafiltration controlled | Turbulent flow and hemolysis risk | ||
| Separate anticoagulation not required | Risk of thrombus formation on additional connectors | ||
| Potential for shunt generation within ECMO circuit | |||
| Integrated approach: connection of CRRT device to oxygenator | Ultrafiltration controlled | Potential risk of interference with oxygenator | |
| Pressures maintained within safety margin of CRRT device | |||
| Parallel systems: separate CRRT and ECMO circuits | Solute removal and ultrafiltration provided | Separate vascular access required | |
| Mode of solute clearance not restricted | Additional workload in maintenance of two separate extracorporeal circuits | ||
| Precise fluid removal | Higher extracorporeal blood volume | ||
| Ability to provide CRRT independent of ECMO support | Rapid fluid shifts and hemodynamic instability | ||
| Option for separate anticoagulation strategy to maintain CRRT circuit patency | |||
| Potentially compatible with ECMO circuit | |||
| IHD | – | Reduced downtime and costs compared with CRRT | Disequilibrium syndrome |
| Hemodynamic stability | |||
| Technically more complex and demanding | |||
| PD | – | Technically simple | Mainly restricted to pediatrics patients and those on chronic PD |
| Lower cost | Specific intraperitoneal catheters required | ||
| Peritonitis risk | |||
| Impairs diaphragmatic movements, potentially prolonging ECMO wean |
CRRT, continuous renal replacement therapy; ECMO, extracorporeal membrane oxygenation; IHD, intermittent hemodialysis; PD, peritoneal dialysis.