{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T03:23:40Z","timestamp":1790047420563,"version":"4.0.1"},"reference-count":27,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,1,16]],"date-time":"2025-01-16T00:00:00Z","timestamp":1736985600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,1,16]],"date-time":"2025-01-16T00:00:00Z","timestamp":1736985600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100017590","name":"Universit\u00e4tsklinikum Essen","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100017590","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Anesthesiol"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Acute kidney injury (AKI) is a common complication of acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) in patients receiving extracorporeal membrane oxygenation (ECMO) support, leading to requirement of continuous renal replacement therapy (CRRT) in 70% of ECMO patients. Parallel arrangement of CRRT and ECMO circuits is common in adult patients. However, CRRT may also be integrated directly into the ECMO circuit. This study compares the safety of both approaches.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This retrospective analysis included 105 patients treated with continuous veno-venous haemodiafiltration and veno-venous ECMO (Cardiohelp\u00a9) for COVID-19-induced ARDS between April 2020 and December 2021. Of these, 48 patients received a parallel connected CRRT running independently from ECMO (parallel approach), while in 57 patients, CRRT was integrated into the ECMO circuit (integrated approach) by connecting the CRRT access line to the post-oxygenator port and the CRRT return line to the pre-oxygenator position. Local protocol for risk assessment of this device combination mandated a maximum return line pressure below 250 mmHg in the CRRT system.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      At CRRT initiation, the integrated group had significantly higher median pressures in CRRT lines compared to the parallel approach group (access line 110 mmHg vs. -25 mmHg, return line 170 mmHg vs. 50 mmHg;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.01). However, median transmembrane pressures were similar between both groups (20 mmHg vs. 20 mmHg,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.16). In-hospital mortality (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.99), catheter associated infections (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.47), bacteraemia (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.96), filter clotting (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.58) and unplanned CRRT system changes (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.45) within the first 72\u00a0h of CRRT were comparable between both groups. The integrated group exhibited higher rates of bleeding events (37% vs. 23%;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.08). Thromboembolism occurred in four cases in the integrated group, while one pneumothorax was observed in the parallel group. No cases of air embolism, device associated haemolysis or blood leakage was documented.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Despite higher pressures in CRRT lines, the integrated approach provided comparable safety to the parallel approach. In case of hygienically challenging settings (such as the COVID-19 pandemic), the minimization of extracorporeal accesses and the streamlining of alarm management are decisive factors in providing intensive care medicine. Therefore, the integrated configuration of CRRT into the ECMO circuit can be advantageous in daily intensive care medicine.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12871-024-02818-w","type":"journal-article","created":{"date-parts":[[2025,1,16]],"date-time":"2025-01-16T01:05:45Z","timestamp":1736989545000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Comparison of integrated versus parallel continuous renal replacement therapy combined with veno-venous extracorporeal membrane oxygenation in patients with COVID-19 ARDS"],"prefix":"10.1186","volume":"25","author":[{"given":"Kristina","family":"Sch\u00f6nfelder","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Felix","family":"Helmenstein","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank","family":"Herbstreit","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johanna","family":"Reinold","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Kribben","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Jahn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justa","family":"Friebus-Kardash","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,1,16]]},"reference":[{"key":"2818_CR1","volume-title":"Extracorporeal life support: the ELSO red book","author":"TV Brogan","year":"2017","unstructured":"Brogan TV, Lequier L, Lorusso R, et al. Extracorporeal life support: the ELSO red book. 5th ed. Ann Arbor, MI: Extracorporeal Life Support Organisation; 2017.","edition":"5"},{"key":"2818_CR2","doi-asserted-by":"publisher","first-page":"321","DOI":"10.2147\/IJNRD.S292893","volume":"14","author":"L Foti","year":"2021","unstructured":"Foti L, Villa G, Romagnoli S, Ricci Z. Acute kidney Injury and extracorporeal membrane oxygenation: review on multiple organ support options. Int J Nephrol Renovasc Dis. 2021;14:321\u20139.","journal-title":"Int J Nephrol Renovasc Dis"},{"issue":"6","key":"2818_CR3","doi-asserted-by":"publisher","first-page":"523","DOI":"10.1111\/1744-9987.12188","volume":"18","author":"B Seczy\u0144ska","year":"2014","unstructured":"Seczy\u0144ska B, Kr\u00f3likowski W, Nowak I, Jankowski M, Szu\u0142drzy\u0144ski K, Szczeklik W. Continuous renal replacement therapy during extracorporeal membrane oxygenation in patients treated in medical intensive care unit: technical considerations \u2013 CRRT during ECMO-technical considerations. Ther Apher Dial. 2014;18(6):523\u201334.","journal-title":"Ther Apher Dial"},{"issue":"4","key":"2818_CR4","doi-asserted-by":"publisher","first-page":"413","DOI":"10.1097\/MAT.0000000000000085","volume":"60","author":"H Shum","year":"2014","unstructured":"Shum H, Kwan AMC, Chan KC, Yan WW. The use of regional citrate anticoagulation continuous venovenous hemofiltration in extracorporeal membrane oxygenation. ASAIO J. 2014;60(4):413\u20138.","journal-title":"ASAIO J"},{"issue":"6","key":"2818_CR5","doi-asserted-by":"publisher","first-page":"493","DOI":"10.1097\/MCC.0000000000000559","volume":"24","author":"M Ostermann","year":"2018","unstructured":"Ostermann M, Connor M Jr, Kashani K. Continuous renal replacement therapy during extracorporeal membrane oxygenation: why,when and how? Curr Opin Crit Care. 2018;24(6):493\u2013503.","journal-title":"Curr Opin Crit Care"},{"issue":"1","key":"2818_CR6","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1053\/j.ackd.2021.04.004","volume":"28","author":"AD Zeidman","year":"2021","unstructured":"Zeidman AD. Extracorporeal membrane oxygenation and continuous kidney replacement therapy: Technology and outcomes - A Narrative Review. Adv Chronic Kidney Dis. 2021;28(1):29\u201336.","journal-title":"Adv Chronic Kidney Dis"},{"issue":"1","key":"2818_CR7","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1186\/s13054-015-0860-6","volume":"19","author":"R Jacobs","year":"2015","unstructured":"Jacobs R, Honore PM, Spapen HD. Intertwining extracorporeal membrane oxygenation and continuous renal replacement therapy: sense or nonsense? Crit Care. 2015;19(1):145.","journal-title":"Crit Care"},{"issue":"12","key":"2818_CR8","doi-asserted-by":"publisher","first-page":"1289","DOI":"10.1038\/ki.2009.383","volume":"76","author":"MJ Santiago","year":"2009","unstructured":"Santiago MJ, S\u00e1nchez A, L\u00f3pez-Herce J, P\u00e9rez R, del Castillo J, Urbano J, et al. The use of continuous renal replacement therapy in series with extracorporeal membrane oxygenation. Kidney Int. 2009;76(12):1289\u201392.","journal-title":"Kidney Int"},{"issue":"2","key":"2818_CR9","doi-asserted-by":"publisher","first-page":"210","DOI":"10.1007\/s00134-011-2439-2","volume":"38","author":"G MacLaren","year":"2012","unstructured":"MacLaren G, Combes A, Bartlett RH. Contemporary extra-corporeal membrane oxygenation for adult respiratory failure: life support in the new era. Intensive Care Med. 2012;38(2):210\u201320.","journal-title":"Intensive Care Med"},{"issue":"6","key":"2818_CR10","doi-asserted-by":"publisher","first-page":"1084","DOI":"10.1016\/j.ejcts.2010.09.010","volume":"39","author":"AP Simons","year":"2011","unstructured":"Simons AP, Weerwind PW. Re: how to perform a haemodialysis using the arterial and venous lines of an extracorporeal life support. Eur J Cardiothorac Surg. 2011;39(6):1084\u20135.","journal-title":"Eur J Cardiothorac Surg"},{"issue":"5","key":"2818_CR11","doi-asserted-by":"publisher","first-page":"695","DOI":"10.1016\/j.aucc.2022.11.005","volume":"36","author":"J Wu","year":"2023","unstructured":"Wu J, Huang X, Mei Y, Lv J, Li W, Hu D, et al. Impact of connecting methods of continuous renal replacement therapy device on patients underwent extracorporeal membrane oxygenation: a retrospectively observational study. Aust Crit Care. 2023;36(5):695\u2013701.","journal-title":"Aust Crit Care"},{"issue":"2","key":"2818_CR12","doi-asserted-by":"publisher","first-page":"227","DOI":"10.1177\/17511437211067088","volume":"24","author":"M Raja","year":"2023","unstructured":"Raja M, Leal R, James Doyle J. Continuous renal replacement therapy in patients receiving extracorporeal membrane oxygenation therapy. J Intensive Care Soc. 2023;24(2):227\u20139.","journal-title":"J Intensive Care Soc"},{"issue":"7","key":"2818_CR13","doi-asserted-by":"publisher","first-page":"345","DOI":"10.5301\/ijao.5000597","volume":"40","author":"XL Zhou","year":"2017","unstructured":"Zhou XL, Chen YH, Wang QY. A new approach combining venoarterial extracorporeal membrane oxygenation and CRRT for adults: a retrospective study. Int J Artif Organs. 2017;40(7):345\u20139.","journal-title":"Int J Artif Organs"},{"issue":"5","key":"2818_CR14","doi-asserted-by":"publisher","first-page":"893","DOI":"10.1053\/j.jvca.2012.02.001","volume":"26","author":"D Sidebotham","year":"2012","unstructured":"Sidebotham D, Allen SJ, McGeorge A, Ibbott N, Willcox T. Venovenous extracorporeal membrane oxygenation in adults: practical aspects of circuits, cannulae, and procedures. J Cardiothorac Vasc Anesth. 2012;26(5):893\u2013909.","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"2818_CR15","doi-asserted-by":"crossref","unstructured":"Costa AM, Halfwerk F, Wiegmann B, Neidlin M, Arens J. Trends, advantages and disadvantages in combined extracorporeal lung and kidney support from a Technical Point of View. Front Med Technol 2022:4:909990.","DOI":"10.3389\/fmedt.2022.909990"},{"issue":"4","key":"2818_CR16","doi-asserted-by":"publisher","first-page":"407","DOI":"10.1097\/MAT.0b013e3182579218","volume":"58","author":"GM Fleming","year":"2012","unstructured":"Fleming GM, Askenazi DJ, Bridges BC, Cooper DS, Paden ML, Selewski DT, et al. A multicenter international survey of renal supportive therapy during ECMO: the kidney intervention during extracorporeal membrane oxygenation (KIDMO) group. ASAIO J. 2012;58(4):407\u201314.","journal-title":"ASAIO J"},{"issue":"11","key":"2818_CR17","doi-asserted-by":"publisher","first-page":"899","DOI":"10.1159\/000522398","volume":"51","author":"M Thy","year":"2022","unstructured":"Thy M, Augustin P, Tran-Dinh A, Montravers P, de Tymowski C. Renal replacement therapy for patients requiring extracorporeal membrane oxygenation: a Multicenter International Survey. Blood Purif. 2022;51(11):899\u2013906.","journal-title":"Blood Purif"},{"issue":"4","key":"2818_CR18","doi-asserted-by":"publisher","first-page":"967","DOI":"10.1016\/j.ejcts.2009.10.007","volume":"37","author":"S Rubin","year":"2010","unstructured":"Rubin S, Poncet A, Wynckel A, Baehrel B. How to perform a haemodialysis using the arterial and venous lines of an extracorporeal life support. Eur J Cardiothorac Surg. 2010;37(4):967\u20138.","journal-title":"Eur J Cardiothorac Surg"},{"issue":"1","key":"2818_CR19","doi-asserted-by":"publisher","first-page":"387","DOI":"10.1186\/s13054-016-1570-4","volume":"20","author":"JE Millar","year":"2016","unstructured":"Millar JE, Jonathon P, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care. 2016;20(1):387.","journal-title":"Crit Care"},{"issue":"9","key":"2818_CR20","doi-asserted-by":"publisher","first-page":"497","DOI":"10.1056\/NEJM198102263040901","volume":"304","author":"DE Chenoweth","year":"1981","unstructured":"Chenoweth DE, Cooper SW, Hugli TE, Stewart RW, Blackstone EH, Kirklin JW. Complement activation during cardiopulmonary bypass: evidence for generation of C3a and C5a anaphylatoxins. N Engl J Med. 1981;304(9):497\u2013503.","journal-title":"N Engl J Med"},{"issue":"10","key":"2818_CR21","doi-asserted-by":"publisher","first-page":"3542","DOI":"10.1161\/01.CIR.96.10.3542","volume":"96","author":"P Bruins","year":"1997","unstructured":"Bruins P, Te Velthuis H, Yazdanbakhsh AP, Jansen PG, van Hardevelt FW, de Beaumont EM, et al. Activation of the complement system during and after cardiopulmonary bypass surgery: postsurgery activation involves C-reactive protein and is associated with postoperative arrhythmia. Circulation. 1997;96(10):3542\u20138.","journal-title":"Circulation"},{"issue":"21","key":"2818_CR22","doi-asserted-by":"publisher","first-page":"12081","DOI":"10.3390\/ijms222112081","volume":"22","author":"Y Higashikuni","year":"2021","unstructured":"Higashikuni Y, Liu W, Obana T, Sata M. Pathogenic basis of Thromboinflammation and Endothelial Injury in COVID-19: current findings and therapeutic implications. Int J Mol Sci. 2021;22(21):12081.","journal-title":"Int J Mol Sci"},{"issue":"6","key":"2818_CR23","doi-asserted-by":"publisher","first-page":"485","DOI":"10.1177\/026765910001500603","volume":"15","author":"JW Mulholland","year":"2000","unstructured":"Mulholland JW, Massey W, Shelton JC. Investigation and quantification of the blood trauma caused by the combined dynamic forces experienced during cardiopulmonary bypass. Perfusion. 2000;15(6):485\u201394.","journal-title":"Perfusion"},{"issue":"6","key":"2818_CR24","doi-asserted-by":"publisher","first-page":"675","DOI":"10.1186\/s13054-014-0675-x","volume":"18","author":"H Chen","year":"2014","unstructured":"Chen H, Yu R, Yin N, Zhou JX. Combination of extracorporeal membrane oxygenation and continuous renal replacement therapy in critically ill patients: a systematic review. Crit Care. 2014;18(6):675.","journal-title":"Crit Care"},{"issue":"1","key":"2818_CR25","doi-asserted-by":"publisher","first-page":"48","DOI":"10.1097\/MAT.0000000000000441","volume":"63","author":"C de Tymowski","year":"2017","unstructured":"de Tymowski C, Augustin P, Houissa H, Allou N, Montravers P, Delzongle A, et al. CRRT connected to ECMO: managing high pressures. ASAIO J. 2017;63(1):48\u201352.","journal-title":"ASAIO J"},{"issue":"2","key":"2818_CR26","first-page":"127","volume":"16","author":"A Crosswell","year":"2014","unstructured":"Crosswell A, Roodenburg O. Vascular access site influences circuit life in continuous renal replacement therapy. Crit Care Resusc. 2014;16(2):127\u201330.","journal-title":"Crit Care Resusc"},{"issue":"3","key":"2818_CR27","doi-asserted-by":"publisher","first-page":"332","DOI":"10.1097\/MAT.0000000000001003","volume":"66","author":"M Giani","year":"2020","unstructured":"Giani M, Scaravilli V, Stefanini F, Valsecchi G, Rona R, Grasselli G, et al. Continuous renal replacement therapy in venovenous extracorporeal membrane oxygenation: a retrospective study on regional citrate anticoagulation. ASAIO J. 2020;66(3):332\u20138.","journal-title":"ASAIO J"}],"container-title":["BMC Anesthesiology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12871-024-02818-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12871-024-02818-w\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12871-024-02818-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,1,16]],"date-time":"2025-01-16T01:05:50Z","timestamp":1736989550000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcanesthesiol.biomedcentral.com\/articles\/10.1186\/s12871-024-02818-w"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1,16]]},"references-count":27,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["2818"],"URL":"https:\/\/doi.org\/10.1186\/s12871-024-02818-w","relation":{},"ISSN":["1471-2253"],"issn-type":[{"value":"1471-2253","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,1,16]]},"assertion":[{"value":"3 September 2024","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 November 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"16 January 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"5.2 The study was conducted according to the guidelines of the Declaration of Helsinki and was approved by the Ethics Committee of the University Hospital Essen (-21-9897-BO). Informed consent was obtained from all subjects involved in the study.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"28"}}