Higher Mortality Risk Linked to ESRD Requiring LVAD Implantation in New Study

A study found that patients with end stage renal/kidney disease (ESRD) who undergo left ventricular assist device (LVAD) implantation had higher 1-year mortality compared with patients with chronic kidney disease.

Patients with end stage renal/kidney disease (ESRD) had higher 1-year mortality rate vs patients with chronic kidney disease (CKD) when undergoing left ventricular assist device (LVAD) implantation, according to new study findings published in Journal of Cardiac Failure.

Study data were retrieved from the United States Renal Data System analytical files from 2006 to 2018, with December 31, 2017, as the last date of LVAD implant to include 1-year follow-up. The population included Medicare beneficiaries with ESRD who were dependent on dialysis, were 18 years and older, and underwent LVAD implantation between 2006 and 2017. Patients were excluded if they had a kidney transplant prior to LVAD implantation or were not on consistent dialysis.

A final sample size of 496 was used for patients with CKD and 95 patients with ESRD. The primary outcome was all-cause mortality during the 1-year follow-up and during index admission. Secondary outcomes included significant bleeding, pump thrombosis, hemorrhagic and ischemic stroke, sepsis, and infection of LVAD within 1 year.

Patients with ESRD were 7 years younger on average than the CKD group, and the ESRD group had more patients with hypertension (90.5% vs 38.3%), peripheral vascular disease (13.7% vs 7.3%), atherosclerotic heart disease (62.1% vs 50.6%), and diabetes (48.4% vs 20.2%).

No significant change in trend of LVAD implantation was noted in patients with ESRD, but there was an increase in patients with CKD from 90.3 to 236 per 1 million from 2006 to 2017. There were 27.4% of patients with ESRD and 16.7% of patients with CKD who died during the index admission of LVAD implantation, but mortality was higher in patients with CKD who needed kidney replacement therapy (KRT) vs patients who did not require KRT: 63.6% vs 13.4%.

All-cause 1-year mortality was higher in patients with ESRD who had LVAD implantation vs patients with CKD (49.5% vs 30.9%); 12.6% of patients with ESRD and 9.9% with CKD required heart transplants. The researchers also found a higher mortality in patients with ESRD in a 12-year follow-up.

The overall 1-year mortality among patients with ESRD and CKD when excluding patients who died during index hospitalization or underwent orthotopic heart transplant (OHT) was 36.8% and 17.6%, respectively. The median (IQR) time among patients with LVADs who survived index admission was 48 (21-98) days in patients with ESRD and 149.5 (71.5-235.5) days in patients with CKD. Mortality in patients with ESRD was still significantly higher than patients with CKD when considering newer-generation LVAD pumps.

All patients who underwent OHT in the ESRD group survived for 1 year post transplant while 14.3% of patients with CKD died following the procedure. There were no significant differences in secondary LVAD outcomes between the CKD and ESRD groups.

This study had limitations. The researchers were unable to determine details or types of implantable devices, and they were missing several key clinical parameters of preoperative patient illness that may have affected mortality. Information on LVAD intent or indication, such as bridge to transplant, bridge to recovery, or destination therapy, also could not be found, and the generalizability of results to younger populations is harder given the median age of the participants in this study.

The researchers concluded that patients with ESRD on maintenance dialysis with LVAD have an increased risk of mortality compared with patients with CKD during index admission and 1-year follow-up. Patients with CKD who required KRT during index admission experienced a higher risk of mortality vs those who did not.

“LVADs in patients with advanced CKD and ESRD should only be considered after shared decision-making between physicians and their patients and may be best utilized in ESRD patients getting stabilized for expedited dual organ transplant,” the authors wrote.

Reference

Dalia T, Chan WC, Sauer AJ, et al. Outcomes in patients with chronic kidney disease and end stage renal disease and durable left ventricular assist device: insights from United States renal data system database. J Card Fail. Published Online April 22, 2022. Doi:10.1016/j.cardfail.2022.03.355