The insight: Understanding practice variation in ECMO candidacy
Extracorporeal membrane oxygenation (ECMO) offers a potential lifeline to newborns with severe congenital anomalies of the kidneys and urinary tract (CAKUT). But which patients should receive it and the criteria used to make this call vary widely, and survival depends heavily on the type of CAKUT. Obstructive disease with ECMO support, for example, carries survival rates approaching 70%, while survival in intrinsic renal disease drops to 40%.
Researchers at Children’s Health℠ set out to understand why. They recently led the first multicenter survey examining how ECMO candidacy decisions are made for neonates with severe CAKUT. The study included 42 centers from the Children’s Hospitals Neonatal Consortium (CHNC) Network in the U.S. and a few internationally from the PediECMO Network.
"We were seeing survival rates that suggested these babies could benefit – but there was no common framework for deciding who should get that chance." says Syed Ahmed, M.D., Neonatologist at Children's Health, Assistant Professor at UT Southwestern and first author of the study.
What they found makes the case for why that framework is long overdue.
Why it matters: The cost of inconsistent criteria
Without consistent criteria, clinicians are making high-stakes decisions without a shared evidence base to draw from. Factors like pulmonary hypoplasia severity and long-term renal prognosis can shift outcomes significantly, and most published evidence hasn’t yet captured those distinctions. “Our goal is to be able to counsel families to help them be as informed as possible about options in the medical care offered and potential outcomes” says Keri A. Drake, M.D., Pediatric Nephrologist at Children's Health and Assistant Professor at UT Southwestern. ECMO candidacy for neonates with CAKUT remains highly individualized, even among experienced centers, and prenatal markers like anhydramnios are being interpreted inconsistently from one center to another. That inconsistency points to an opportunity: better defining how these markers should inform candidacy decisions in the first place.
Key details: Survey findings
A cross-sectional survey of 99 physicians across 42 institutions participating in the Children's Hospitals Neonatal Consortium (CHNC) captured how centers are currently approaching ECMO candidacy for neonates with CAKUT. Participating centers spanned the U.S. and several international sites.
Most centers (66%) determine ECMO eligibility on a case-by-case basis. Only 12% reported having a formal protocol.
Physicians largely agreed on ECMO candidacy for hypothetical case scenarios of obstructive disease (91%), but support dropped sharply for bilateral renal agenesis (11%).
Only 11% of physicians reported using anhydramnios as an absolute contraindication.
Disease heterogeneity (79%) and prognostic uncertainty (66%) were the most frequently cited barriers to implementing ECMO in this population.
"What surprised us was the degree of variation we found," says Dr. Ahmed. "We expected more agreement around some of the most severe diagnoses and thought prenatal markers would play a larger role in decision-making. Instead, practices varied in ways we hadn't anticipated."
"We know ECMO can be successful in some of these patients.” adds Abhishek Makkar, M.D., Neonatologist at Children’s Health and Associate Professor at UT Southwestern and senior author of the study. “The challenge is knowing which patients are most likely to benefit, and today there's still significant variation in how centers make that determination."
Advanced management of severe neonatal CAKUT at Children’s Health
Caring for newborns with severe CAKUT often requires simultaneous consideration of pulmonary status, renal prognosis and the potential need for kidney replacement therapy. At Children's Health, these decisions are made through a multidisciplinary process that brings together neonatology, pediatric nephrology, ECMO specialists and other disciplines early in the course of care.
Early nephrology involvement: Newborns with severe CAKUT are evaluated by nephrology early to help inform prognosis and treatment decisions.
Continuum of care: Coordinated support begins with prenatal consultation and extends through hospitalization and long-term follow-up.
Neonatal kidney support: Specialized kidney replacement therapies, including neonatal-specific dialysis systems, support newborns with severe renal dysfunction.
Recognized ECMO expertise: Children's Health has earned recognition from the Extracorporeal Life Support Organization (ELSO) as a Platinum-Level Center of Excellence, reflecting outcomes that exceed international benchmarks.
Defined candidacy criteria: Children's Health has established internal criteria for ECMO candidacy in neonates with obstructive renal disease.
Children's Health is also helping advance the evidence base needed to guide these decisions going forward.
"This study gives us a clearer picture of where variation exists and the questions that still need to be answered," says Dr. Makkar. "That creates an opportunity to build the evidence base needed to develop more consistent guidance for ECMO candidacy in this population." The group is currently leading an additional multicenter study via the CHNC network with 18 sites to obtain long-term outcomes data.
Learn more about ECMO and neonatal care at Children's Health.
