Safety and Efficacy of Combined Extracorporeal Co(2) Removal and Renal Replacement Therapy in Patients With Acute Respiratory Distress Syndrome and Acute Kidney Injury: The Pulmonary and Renal Support in Acute Respiratory Distress Syndrome Study*

OBJECTIVE: To assess the safety and efficacy of combining extracorporeal Co(2) removal with continuous renal replacement therapy in patients presenting with acute respiratory distress syndrome and acute kidney injury. DESIGN: Prospective human observational study. SETTINGS: Patients received volume-controlled mechanical ventilation according to the acute respiratory distress syndrome net protocol. Continuous venovenous hemofiltration therapy was titrated to maintain maximum blood flow and an effluent flow of 45 mL/kg/h with 33% predilution. PATIENTS: Eleven patients presenting with both acute respiratory distress syndrome and acute kidney injury required renal replacement therapy. INTERVENTIONS: A membrane oxygenator (0.65 m(2)) was inserted within the hemofiltration circuit, either upstream (n = 7) or downstream (n = 5) of the hemofilter. Baseline corresponded to tidal volume 6 mL/kg of predicted body weight without extracorporeal Co(2) removal. The primary endpoint was 20% reduction in Paco(2) at 20 minutes after extracorporeal Co(2) removal initiation. Tidal volume was subsequently reduced to 4 mL/kg for the remaining 72 hours. MEASUREMENTS AND MAIN RESULTS: Twelve combined therapies were conducted in the 11 patients. Age was 70 ± 9 years, Simplified Acute Physiology Score II was 69 ± 13, Sequential Organ Failure Assessment score was 14 ± 4, lung injury score was 3 ± 0.5, and Pao(2)/Fio(2) was 135 ± 41. Adding extracorporeal Co(2) removal at tidal volume 6 mL/kg decreased Paco(2) by 21% (95% CI, 17–25%), from 47 ± 11 to 37 ± 8 Torr (p < 0.001). Lowering tidal volume to 4 mL/kg reduced minute ventilation from 7.8 ± 1.5 to 5.2 ± 1.1 L/min and plateau pressure from 25 ± 4 to 21 ± 3 cm H(2)O and raised Paco(2) from 37 ± 8 to 48 ± 10 Torr (all p < 0.001). On an average of both positions, the oxygenator’s blood flow was 410 ± 30 mL/min and the Co(2) removal rate was 83 ± 20 mL/min. The oxygenator blood flow (p <0.001) and the Co(2) removal rate (p = 0.083) were higher when the membrane oxygenator was placed upstream of the hemofilter. There was no safety concern. CONCLUSIONS: Combining extracorporeal Co(2) removal and continuous venovenous hemofiltration in patients with acute respiratory distress syndrome and acute kidney injury is safe and allows efficient blood purification together with enhanced lung protective ventilation.