Renal injury and recovery in pediatric patients after ventricular assist device implantation and cardiac transplant

Abstract

Background The use of ventricular assist devices (VADs) in children with heart failure may be of particular benefit to those with accompanying renal failure, as improved renal function is seen in some, but not all recipients. We hypothesized that persistent renal dysfunction at 7 days and/or 1 month after VAD implantation would predict chronic kidney disease (CKD) 1 year after heart transplantation (HT). Methods Linkage analysis of all VAD patients enrolled in both the PEDIMACS and PHTS registries between 2012 and 2016. Persistent acute kidney injury (P‐AKI), defined as a serum creatinine ≥1.5× baseline, was assessed at post‐implant day 7. Estimated glomerular filtration rate (eGFR) was determined at implant, 30 days thereafter, and 12 months post‐HT. Pre‐implant eGFR, eGFR normalization (to ≥90 mL/min/1.73 m2), and P‐AKI were used to predict post‐HT CKD (eGFR <90 mL/min/1.73 m2). Results The mean implant eGFR was 85.4 ± 46.5 mL/min/1.73 m2. P‐AKI was present in 19/188 (10%). Mean eGFR at 1 month post‐VAD implant was 131.1 ± 62.1 mL/min/1.73 m2, significantly increased above baseline (P < 0.001). At 1 year post‐HT (n = 133), 60 (45%) had CKD. Lower pre‐implant eGFR was associated with post‐HT CKD (OR 0.99, CI: 0.97‐0.99, P = 0.005); P‐AKI was not (OR 0.96, CI: 0.3‐3.0, P = 0.9). Failure to normalize renal function 30 days after implant was highly associated with CKD at 1 year post‐transplant (OR 12.5, CI 2.8‐55, P = 0.003). Conclusions Renal function improves after VAD implantation. Lower pre‐implant eGFR and failure to normalize renal function during the support period are risk factors for CKD development after HT.

Acute kidney injury and chronic kidney disease after combined heart‐liver transplant in patients with congenital heart disease: A retrospective case series

“…In the 5 patients who reached the 1‐year end‐point, we found that CKD to be more prevalent, occurring in 20% of patients at 1 year compared to 10% of HT patients 3 . Although interpretation of this finding is limited by the small sample size, this pattern may be explained by the marginal preoperative renal function observed in these patients, as evidenced by the high prevalence of CKD before transplantation.…”

“…18 In the 5 patients who reached the 1-year end-point, we found that CKD to be more prevalent, occurring in 20% of patients at 1 year compared to 10% of HT patients. 3 Although interpretation of this finding is limited by the small sample size, this pattern may be explained by the marginal preoperative renal function observed in these patients, as evidenced by the high prevalence of CKD before transplantation. In contrast to our finding that AKI is comparatively rare after CHLT, we found that CKD was more prevalent in these patients, occurring in 20% of patients at 1 year compared with 10% of HT patients.…”

“…Although studies in the CHLT population are rare, 1 isolated heart and liver transplants are independently associated with AKI and CKD development 3 . AKI occurs in up to 72% of pediatric HT recipients, and 5% develop CKD 1 year after transplantation 4 .…”

ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association

“…12 Post-VAD outcomes have been shown to be worse if the patient has renal dysfunction prior to VAD implantation. 16,27 Congestive hepatopathy resultant from HF has also been associated with both morbidity and mortality post-VAD. Elevated ALT/AST values are reported in up to 22% to 25% of patients, and abnormal bilirubin in 40% to 45% of patients at the time of VAD.…”

A coordinated approach to improving pediatric heart transplant waitlist outcomes: A summary of the ACTION November 2019 waitlist outcomes committee meeting

“…Currently, around 13% children and 25% of infants on the HT waitlist will not survive to transplantation 2 . Among those who do survive to transplant, waitlist characteristics, including waitlist duration, available mechanical support options, and renal injury all contribute to post‐transplant outcomes 3‐8 . The waitlist phase of care has received considerable attention recently, including the recent publication of an International Society for Heart & Lung Transplantation (ISHLT) consensus statement on donor organ acceptability and other important papers 9‐19 …”