Complications and Hospital Resource Utilization Associated with ECMO in COVID-19 ARDS with Acute Kidney Injury: Insights from United States National Inpatient Sample, 2020–2022

Q: What are the key findings of this study?

ECMO use was not associated with statistically significantly lower adjusted in-hospital mortality (aOR 0.96, 95% CI 0.81-1.12; p=0.61) compared with IMV alone in COVID-19 ARDS complicated by AKI.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: COVID-19-associated acute respiratory distress syndrome (ARDS) complicated by acute kidney injury (AKI) requiring invasive mechanical ventilation (n=198395). Intervention: Extracorporeal membrane oxygenation (ECMO) plus invasive mechanical ventilation (IMV) vs. Invasive mechanical ventilation (IMV) alone. Primary outcome: In-hospital mortality (OR 0.96, 95% CI 0.81-1.12, p=0.61).

Q: What does this research mean for the field?

In patients with COVID-19-associated ARDS complicated by acute kidney injury, ECMO use is not associated with significantly lower in-hospital mortality compared with invasive mechanical ventilation alone, but is associated with increased complications and resource utilization. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Antony J Arumairaj; Poojaben Dhorajiya; Dili Dhanani; Joshua P. Reddy; Abhishek Kumar Mariswamy Arun Kumar; Fatema Ali Asgar Tashrifwala; Vipulkumar Prajapati; Sireesha Palkamsetti; Dheera Tamvada; Digantkumar Patel; Divya Korpu; Jayesh Mittal

doi:10.3390/healthcare14203490

October 17, 2026HealthcareOpen Access

Complications and Hospital Resource Utilization Associated with ECMO in COVID-19 ARDS with Acute Kidney Injury: Insights from United States National Inpatient Sample, 2020–2022

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Key result

ECMO shows no in-hospital mortality benefit over mechanical ventilation alone in COVID-19 ARDS with AKI.

OR 0.96
95% CI 0.81-1.12
P=0.61
n=198,395

Why the study?

Although AKI is a common complication of COVID-19-associated ARDS, the impact of ECMO on outcomes in this high-risk population remained unclear.

Does extracorporeal membrane oxygenation (ECMO) plus invasive mechanical ventilation reduce in-hospital mortality compared to invasive mechanical ventilation alone in hospitalized adults with COVID-19-associated ARDS complicated by acute kidney injury?

Key Points

To assess whether extracorporeal membrane oxygenation (ECMO) improves in-hospital mortality and affects complication rates and healthcare resource utilization among patients with COVID-19-associated ARDS complicated by acute kidney injury.
Conducted a retrospective, survey-weighted study utilizing the National Inpatient Sample (2020–2022) analyzing a weighted estimate of 198,395 adult hospitalizations with COVID-19-associated ARDS and AKI requiring invasive mechanical ventilation (IMV).
Compared outcomes between patients treated with IMV alone (weighted n=193,665) and those managed with IMV plus ECMO (weighted n=4730) using multivariable regression and propensity score matching.
Adjusted in-hospital mortality did not differ significantly between ECMO and IMV-only cohorts (55.9% vs. 66.3% unadjusted; aOR 0.96, 95% CI 0.81–1.12; p = 0.61; propensity-matched OR 0.86, 95% CI 0.69–1.07; p = 0.179).
Patients receiving ECMO had significantly longer hospital stays (44.5 vs. 21.4 days; adjusted mean difference 18.45 days, 95% CI 15.6–21.2; p < 0.001) and higher total hospital charges ($1,501,206 vs. $370,330; adjusted mean difference $1,002,610, 95% CI $880,695–$1,124,525; p < 0.001).

Study Design

Type

Cohort (n=198,395)

Multicenter

Yes

Structured PICO

Does extracorporeal membrane oxygenation (ECMO) plus invasive mechanical ventilation reduce in-hospital mortality compared to invasive mechanical ventilation alone in hospitalized adults with COVID-19-associated ARDS complicated by acute kidney injury?

P

Population

198,395 weighted US adult hospitalizations (39,679 unweighted records) for COVID-19-associated ARDS complicated by AKI requiring invasive mechanical ventilation from 2020 to 2022.

E

Exposure

Extracorporeal membrane oxygenation (peripheral venoarterial [VA]-ECMO or peripheral venovenous [VV]-ECMO) combined with invasive mechanical ventilation (IMV)

C

Comparator

Invasive mechanical ventilation (IMV) alone without ECMO

O

Outcome

In-hospital mortalityhard clinical

Main Result

Odds Ratio: 0.96 (95% CI 0.81–1.12)

Absolute Event Rate: 55.9% vs 66.3%

p-value: p=0.61

In US adults hospitalized with COVID-19 ARDS and concurrent AKI on mechanical ventilation, ECMO was not associated with lower adjusted in-hospital mortality but was linked to substantially higher rates of renal replacement therapy, severe bleeding/thrombotic complications, longer hospital stays, and over $1 million in additional hospital charges.

Limitations

Discharge-level administrative database (NIS) cannot identify repeat admissions, verify long-term outcomes, or establish temporal relationships between ECMO initiation and complications/AKI onset.
Subject to ICD-10 coding inaccuracies and lacks granular physiologic, laboratory, and clinical severity data (e.g., PaO2/FiO2 ratio, serum creatinine, KDIGO stage, SOFA score, ventilator settings, ECMO duration/cannulation details).
Substantial baseline differences indicate strong treatment-selection and referral effects, leaving residual confounding, referral bias, indication bias, and immortal-time/survivor bias.
Absence of formal adjustment for multiple comparisons across numerous exploratory secondary outcomes increases the risk of type I error.
Discharge-level administrative database (NIS) lacks longitudinal follow-up, repeat admission tracking, and timing of AKI onset, ECMO initiation, and complications.
Reliance on ICD-10 codes without clinical/physiologic verification (lacks PaO2/FiO2, PEEP, creatinine, KDIGO stage, SOFA score, lactate, vasopressor dose, and ECMO duration).
Residual confounding, treatment-selection bias, referral bias, and survivor/immortal-time bias despite multivariable adjustment and propensity score matching.
No formal adjustment for multiple comparisons across secondary outcomes.

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Implication

ECMO should not yet change practice in COVID-19 ARDS with AKI; leaves open the need for randomized trials to clarify net benefit.

Abstract

BACKGROUND: Acute kidney injury (AKI) is a common complication of COVID-19-associated acute respiratory distress syndrome (ARDS), yet the impact of extracorporeal membrane oxygenation (ECMO) on outcomes in this high-risk population remains unclear. METHODS: We performed a retrospective, survey-weighted study using the National Inpatient Sample (NIS) database from 2020-2022 to compare outcomes among adults hospitalized with COVID-19-associated ARDS and AKI managed with invasive mechanical ventilation (IMV) alone versus IMV and ECMO. The primary outcome was in-hospital mortality, while secondary outcomes included renal replacement therapy (RRT), complications, hospital length of stay (LOS), and healthcare utilization. RESULTS: Among 198,395 hospitalizations with COVID-19 ARDS complicated by AKI, 4730 received IMV and ECMO. ECMO use was not associated with statistically significantly lower adjusted in-hospital mortality (adjusted odds ratio [aOR] 0.96, 95% CI 0.81-1.12). However, ECMO was associated with greater odds of RRT, intracranial hemorrhage, disseminated intravascular coagulation, cardiogenic shock, vasopressor use, tracheostomy, acute liver failure, deep vein thrombosis, ischemic stroke and ICU-acquired weakness. ECMO was also associated with longer LOS and higher hospitalization charges. CONCLUSIONS: Among hospitalizations with COVID-19-associated ARDS and AKI, ECMO was not associated with statistically significantly lower adjusted in-hospital mortality but was associated with markedly higher complication burden, longer hospitalization, and substantially greater healthcare resource utilization.

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Cite This Study

Arumairaj et al. (2026) conducted a cohort in COVID-19-associated acute respiratory distress syndrome (ARDS) complicated by acute kidney injury (AKI) requiring invasive mechanical ventilation (n=198,395). Extracorporeal membrane oxygenation (ECMO) plus invasive mechanical ventilation (IMV) vs. Invasive mechanical ventilation (IMV) alone was evaluated on In-hospital mortality (OR 0.96, 95% CI 0.81-1.12, p=0.61). ECMO use was not associated with statistically significantly lower adjusted in-hospital mortality (aOR 0.96, 95% CI 0.81-1.12; p=0.61) compared with IMV alone in COVID-19 ARDS complicated by AKI.

synapsesocial.com/papers/6aee6b8671a75948062209c2 https://doi.org/10.3390/healthcare14203490

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Complications and Hospital Resource Utilization Associated with ECMO in COVID-19 ARDS with Acute Kidney Injury: Insights from United States National Inpatient Sample, 2020–2022

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Complications and Hospital Resource Utilization Associated with ECMO in COVID-19 ARDS with Acute Kidney Injury: Insights from United States National Inpatient Sample, 2020–2022

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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