Complications and Hospital Resource Utilization Associated with ECMO in COVID-19 ARDS with Acute Kidney Injury: Insights from United States National Inpatient Sample, 2020–2022

Abstract

Highlights What are the main findings? The use of extracorporeal membrane oxygenation (ECMO) was not associated with lower adjusted in-hospital mortality compared with invasive mechanical ventilation (IMV) alone in patients with COVID-19-associated acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI). The patients who were on ECMO had a higher need for renal replacement therapy (RRT) and a longer hospital stay than those on IMV for COVID-19 ARDS with AKI. What are the implications of the main findings? ECMO was used in a highly selected population of patients with COVID-19 ARDS and AKI, emphasizing the importance of careful patient selection. The increased requirement for RRT among patients on ECMO emphasizes the need for early nephrology involvement and renal-protective strategies in this high-risk population. Abstract Background: Acute kidney injury (AKI) is a common complication of COVID-19-associated acute respiratory distress syndrome (ARDS), yet the impact of extracorporeal membrane oxygenation (ECMO) on outcomes in this high-risk population remains unclear. Methods: We performed a retrospective, survey-weighted study using the National Inpatient Sample (NIS) database from 2020–2022 to compare outcomes among adults hospitalized with COVID-19-associated ARDS and AKI managed with invasive mechanical ventilation (IMV) alone versus IMV and ECMO. The primary outcome was in-hospital mortality, while secondary outcomes included renal replacement therapy (RRT), complications, hospital length of stay (LOS), and healthcare utilization. Results: Among 198,395 hospitalizations with COVID-19 ARDS complicated by AKI, 4730 received IMV and ECMO. ECMO use was not associated with statistically significantly lower adjusted in-hospital mortality (adjusted odds ratio [aOR] 0.96, 95% CI 0.81–1.12). However, ECMO was associated with greater odds of RRT, intracranial hemorrhage, disseminated intravascular coagulation, cardiogenic shock, vasopressor use, tracheostomy, acute liver failure, deep vein thrombosis, ischemic stroke and ICU-acquired weakness. ECMO was also associated with longer LOS and higher hospitalization charges. Conclusions: Among hospitalizations with COVID-19-associated ARDS and AKI, ECMO was not associated with statistically significantly lower adjusted in-hospital mortality but was associated with markedly higher complication burden, longer hospitalization, and substantially greater healthcare resource utilization.