Bhandari, Sujata

ABSTRACT Introduction Extracorporeal membrane oxygenation (ECMO) is a life‐saving intervention for refractory cardiopulmonary failure. Despite advancements reducing complications, ECMO remains associated with acute kidney injury (AKI), often requiring kidney replacement therapy (KRT). Studies report up to 45% of ECMO patients needing KRT, significantly increasing mortality. A prior meta‐analysis suggested a declining mortality trend in recent years. Methodology Following PRISMA guidelines, PubMed, MEDLINE, EMBASE, and Cochrane Library were searched (2000–2024) for randomized and observational studies on adult ECMO patients requiring KRT. Data extraction covered study characteristics, patient demographics, ECMO type, KRT timing, and clinical outcomes. Quality was assessed using the Newcastle–Ottawa Scale. Statistical analyses were performed using RevMan 5.4.1 under a random‐effects model, with mortality as the primary outcome. Result A total of 24 studies (6347 patients) met the inclusion criteria, including 23 observational studies and one RCT. The mean age of ECMO + KRT patients was 51 years in observational studies and 61.2 years in the RCT, with cardiogenic shock as the most common ECMO indication. Meta‐analysis showed a significantly higher mortality in ECMO + KRT patients (RR: 1.86, 95% CI: 1.63–2.12, p < 0.001), with infections and bleeding as key contributors. Subgroup analysis revealed no significant survival difference based on KRT timing, while Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) was associated with worse outcomes than Veno‐venous extracorporeal membrane oxygenation (VV‐ECMO). The RCT reported 61.9% mortality at 30 days in ECMO + KRT patients. Conclusion KRT during ECMO is associated with increased mortality, likely due to the severity of illness and complications like infections and bleeding. The optimal timing of KRT initiation remains unclear, and no significant survival benefit was found for early KRT. Further large‐scale RCTs are needed to optimize management strategies.