Aortic stenosis in chronic kidney disease: challenges in diagnosis and treatment

Abstract

Chronic kidney disease (CKD) is becoming increasingly common and is associated with development and rapid progression of aortic stenosis (AS). Patients with AS and CKD have higher mortality rates than those with AS of similar severity and normal kidney function. The diagnosis of severe AS in patients with CKD is often challenging due to alterations in haemodynamics and heart structure, and integration of data from multiple imaging modalities may be required. When indicated, the definitive treatment for severe AS is aortic valve replacement. Patients with CKD are candidates for bioprosthetic valve replacement (surgical or transcatheter aortic valve implantation) or mechanical valve replacement. However, for patients with CKD, lifetime management is complex, as patients with CKD have a higher competing risk of bioprosthetic structural valve deterioration, bleeding in the setting of systemic anticoagulation and mortality related to CKD itself. The involvement of a heart-kidney multidisciplinary team in the care of patients with CKD and severe AS is ideal to navigate the complexities of diagnosis and management decisions.

Transcatheter aortic valve implantation versus surgical aortic valve replacement in dialysis-dependent patients: a meta-analysis

“…2 As well as the increased predisposition of progressive aortic stenosis in dialysis-dependent patients, literature reports accelerated progression and a higher incidence of cardiovascular and all-cause mortality associated with aortic stenosis in dialysis versus nondialysisdependent patients. [3][4][5] Although CKD is considered a significant comorbidity for surgical intervention, compounding the preexisting significant risk of acute kidney injury (AKI), data suggest that the consideration of end-stage renal disease (ESRD) in dialysis patients should not preclude surgeons from aortic intervention, 2,6 as intervention leads to an improvement of prognosis. 7,8 The question of whether surgical aortic valve replacement (AVR) or the less invasive transcatheter aortic valve implantation (TAVI) produces better outcomes for patients on dialysis remains uncertain due to ESRD patients being excluded from all performed randomized control trials (RCTs) comparing TAVI versus AVR.…”

Valvular Prostaglandins Are Elevated in Severe Human Aortic Valve Stenosis

“…4,5 Risk factors of AVS include age, elevated LDL (low-density lipoprotein) and Lp(a; lipoprotein[a]), smoking history, hypertension, diabetes, chronic kidney disease, bone mineral disorder, and bicuspid AV. [6][7][8][9][10] There is currently no effective pharmacological intervention for AVS, and surgical valve replacement or transcatheter AV implantation are the current best treatment methods, but they may not be feasible for patients with significant comorbidities. 11 There is a growing need to better understand the underlying mechanisms of AVS to develop medical treatments and dietary recommendations, both to reduce the incidence and progression, while minimizing the need for invasive therapies.…”

Heartbeat: long-term outcomes in patients with symptomatic coronary artery spasm

“…Also in this issue of Heart is a review article on the progression and management of calcific AS in patients with chronic kidney disease 8. Evaluation of AS severity can be challenging due to altered haemodynamics, often requiring integration of data from multiple imaging modalities.…”