Epidemiology, Risk Factors and Outcomes of AKI and CRRT in Patients on ECMO: Workgroup Statements from the Joint Acute Disease Quality Initiative (ADQI) and Extracorporeal Life Support Organization (ELSO) Consensus Conference on ECMO, AKI, fluid management and CRRT

Extracorporeal life support (ECLS), most commonly delivered as extracorporeal membrane oxygenation (ECMO), is a lifesaving therapy for refractory cardiac and respiratory failure. Acute kidney injury (AKI) is among the most frequent complications associated with ECMO, occurring in 40-80% of patients, with approximately 40-50% receiving continuous renal replacement therapy (CRRT). AKI in this setting is multifactorial, reflecting pre-ECMO shock or hemodynamic instability, systemic inflammation, hemolysis, venous congestion, non-pulsatile flow, nephrotoxic exposure, and fluid overload. Both AKI and CRRT among patients receiving ECMO are independently associated with increased mortality, prolonged duration of support, and long-term risk of chronic kidney disease (CKD). This review was developed in pursuit of the 36th Acute Disease Quality Initiative (ADQI XXXVI) consensus conference, during which international experts in nephrology, critical care, cardiology, perfusion, and extracorporeal support convened to evaluate current evidence and generate consensus statements regarding the epidemiology, prevention, and management of AKI in patients receiving ECLS. The conference emphasized harmonization of definitions, identification of modifiable risk factors, optimization of CRRT strategies, and prioritization of future research directions. We highlight key epidemiologic patterns, mechanistic drivers, CRRT utilization, short- and long-term outcomes, and research priorities. Particular attention is given to the need for standardized definitions, prospective multicenter trials, biomarker validation, and integration of nephrology expertise into ECMO programs to improve kidney-related outcomes in this high-risk population.