Extracorporeal Membrane Oxygenation in Immunocompromised Patients With Acute Respiratory Distress Syndrome: A Systematic Review and Meta-analysis.

Summary

Across 17 studies (n=5,136), immunocompromised ARDS patients on ECMO had lower weaning rates and higher hospital and 6‑month mortality compared with immunocompetent patients. Risk varied substantially by immunosuppression type, highest in hematologic malignancies and relatively lower in solid organ transplant recipients.

Key Findings

• Immunocompromised patients had lower ECMO weaning rates (RR 0.77) versus immunocompetent controls.
• Hospital mortality was higher in immunocompromised patients (RR 1.38), as was 6‑month mortality (RR 1.31).
• Risk varied by IC type: hematologic malignancies (OR 3.76), autoimmune diseases (OR 2.50), and solid organ transplant (OR 1.40).
• Study quality assessed via Newcastle-Ottawa Scale; no significant publication bias detected.

Clinical Implications

ECMO candidacy and resource allocation should incorporate immunosuppression type; shared decision-making can be tailored, and trials may enrich for lower-risk IC subgroups.

Limitations

• Predominantly observational cohorts with residual confounding and selection bias
• Heterogeneity in immunosuppression definitions, ECMO indications, and management across studies

Future Directions

Prospective registries and adaptive trials should test ECMO strategies stratified by immunosuppression phenotype, incorporating frailty and infection control metrics.