Outcomes of extracorporeal membrane oxygenation in immunocompromised versus immunocompetent intensive care unit patients: a systematic review and meta-analysis study

Abstract

Background
Immunocompromised individuals who develop severe respiratory failure have elevated death rates. Therefore, as the number of persons hospitalized to critical care units (ICUs) rises, it is essential to comprehend the impacts of Extracorporeal Membrane Oxygenation (ECMO) in this susceptible group.


Objective
To compare survival and clinical outcomes between immunocompromised and immunocompetent patients receiving ECMO and to identify subgroups of immunocompromised patients who may benefit most from ECMO support.


Methods

A thorough query was performed in the PubMed, Cochrane Library, Web of Science, and Scopus databases until September 2025. Studies were eligible if they directly compared ECMO outcomes between immunocompromised and immunocompetent patient groups. Data quality was assessed using the ROBINS-I tool, and pooled analyses were performed using Review Manager and STATA 18. Dichotomous outcomes were pooled using odds ratios (ORs), while continuous outcomes were summarized using mean differences (MDs) with their corresponding 95% confidence intervals (CIs). Interstudy heterogeneity was quantified using the I
2
statistic. When substantial heterogeneity was detected, sensitivity analyses were conducted to investigate potential sources of variability.



Results

Seven retrospective studies with an overall population of 4,557 patients satisfied our eligibility criteria. Immunocompromised individuals had considerably worse results relative to immunocompetent patients. Overall survival (OR: 0.58 [95% CI: 0.46 to 0.72];
p
 < 0.00001) and survival to hospital discharge (OR: 0.40 [95% CI: 0.26 to 0.64];
p
 < 0.0001) were both lower. Additionally, a lower proportion of immunocompromised individuals were successfully withdrawn from ECMO (OR: 0.51 [95% CI: 0.39 to 0.67];
p
 < 0.00001). No substantial variations were seen in ECMO duration or hospital length of stay. Subgroup analysis revealed particularly poor outcomes among patients with hematological malignancies, with only 4% survival and a 16% ECMO weaning rate.



Conclusions
Although immunocompromised patients generally experience poorer outcomes with ECMO, a subset, specifically those with autoimmune diseases, HIV, a history of solid organ transplants, and solid tumors, still achieve meaningful recovery. Therefore, immunocompromised status alone should not automatically exclude patients from ECMO consideration.