Implantable Ventricular Assist Device Use and Outcomes in People With End‐Stage Renal Disease

Abstract

BackgroundPeople with end‐stage renal disease (ESRD) are at risk for advanced heart failure, but little is known about use and outcomes of durable mechanical circulatory support in this setting. We examined use and outcomes of implantable ventricular assist devices (VADs) in a national ESRD cohort.Methods and ResultsWe performed a retrospective cohort study of Medicare beneficiaries with ESRD who underwent implantable VAD placement from 2006 to 2014. We examined in‐hospital and 1‐year mortality, all‐cause and cause‐specific hospitalizations, and heart/kidney transplantation outcomes. We investigated as predictors demographic factors, time‐period of VAD implantation, primary or post‐cardiotomy implantation, and duration of ESRD before VAD implantation. We identified 96 people with ESRD who underwent implantable VAD placement. At time of VAD implantation, 74 (77.1%) were receiving hemodialysis, 10 (10.4%) were receiving peritoneal dialysis and 12 (12.5%) had renal transplant. Time from incident ESRD to VAD implantation was median 4.0 (interquartile range 1.1, 8.2) years. Mortality during the implantation hospitalization was 40.6%. Within 1 year of implantation 61.5% of people had died. On multivariable analysis, males had half the mortality risk of females. Lower mortality risk was also seen with VAD implantation in a primary setting, and with more recent year of implantation, but these results did not reach statistical significance.ConclusionsMedicare beneficiaries with ESRD are undergoing durable VAD implantation, often several years after incident ESRD, although in low numbers. Mortality is high among these patients, highlighting the need for investigations to improve treatment selection and management.

Renal Function in Patients with or without a Left Ventricular Assist Device Implant During Listing for a Heart Transplant

“…There is evidence that a substantial association of poor kidney function with mortality only occurs in those patients who have eGFR values below 45 mL/min/1.73 m 2 , but not in patients with eGFR values above 45 mL/min/1.73 m 2 [ 29 ]. However, mortality is exceptionally high in patients with pre-existing end-stage renal disease, despite LVAD implantation [ 30 , 31 ]. Regarding the association between pretransplant eGFR values and posttransplant mortality, eGFR values <30 have been particularly associated with higher mortality after heart transplantation [ 32 ].…”

The use of direct oral anticoagulants in patients with ventricular assist devices: Is there hope for Factor Xa inhibition?

“…Additionally, randomized trials of apixaban versus warfarin in AF have excluded patients with significant pre‐existing renal dysfunction 7 . While patients with end‐stage renal failure or those requiring permanent dialysis are usually excluded form durable mechanical support owing to poorer outcomes, 39 approximately one third of patients undergoing VAD implantation experience acute kidney injury postoperatively and 13% require temporary renal replacement therapy 40 . As such DOACs may not be appropriate for this subpopulation, however, further investigation is warranted.…”

Nephrology Considerations in the Management of Durable and Temporary Mechanical Circulatory Support

“…16 Persons requiring pre-implantation dialysis, particularly those on dialysis classified as having kidney failure with replacement therapy (KFRT), have especially high mortality after LVAD implantation. [18][19][20][21] The other widely assessed kidney biomarker, proteinuria, also relates strongly with adverse LVAD outcomes. 22,23 The relationship of pre-implantation kidney dysfunction with changes in kidney function following LVAD implantation is variable.…”

“…28 Individuals with advanced CKD-including KFRT-have received devices. 18,19 These individuals have lower survival than those without KFRT, although many achieved >1 year survival. 18…”