Left atrial appendage closure in end-stage renal disease and hemodialysis: Data from a German multicenter registry

Advanced hemodialysis systems: Assessing inflammatory biomarkers, renal analytics, and metabolic stability in elderly patients with chronic kidney disease

BackgroundChronic kidney disease (CKD) in the elderly necessitates innovative therapeutic technologies to address systemic complications. Advanced hemodialysis systems, integrating real-time biochemical monitoring and optimized filtration, offer potential enhancements in clinical outcomes, yet their impact on inflammatory pathways and metabolic equilibrium remains underexplored.ObjectiveThis study evaluated the efficacy of a next-generation hemodialysis system in modulating inflammatory biomarkers, renal function parameters, and calcium-phosphorus homeostasis among elderly CKD patients.MethodsEighty-four elderly CKD patients were randomized into a control group (standard therapy) and an intervention group (standard therapy + advanced hemodialysis). The intervention utilized a fully automated dialysis machine with bicarbonate dialysate, precision-calibrated blood flow (180-200 mL/min), and real-time metabolic tracking. Serum levels of TNF-α, IL-6, IL-1, hs-CRP, BUN, Scr, β2-MG, calcium, phosphorus, and Ca × P were analyzed pre- and post-intervention using ELISA and biochemical assays.ResultsThe intervention group demonstrated a higher total efficacy rate (85.71% vs. 64.29%, P < 0.05). Post-treatment, significant reductions in inflammatory markers (TNF-α: 1.35 ± 0.24 vs. 4.06 ± 0.42 ng/mL; IL-6: 13.05 ± 1.52 vs. 17.62 ± 2.24 ng/L), renal toxins (BUN: 7.82 ± 1.75 vs. 10.12 ± 2.02 mmol/L; Scr: 401.32 ± 15.76 vs. 489.95 ± 16.14 μmol/L), and phosphorus (1.62 ± 0.34 vs. 2.16 ± 0.46 mmol/L) were observed (P < 0.05). Calcium levels improved (3.19 ± 0.56 vs. 2.26 ± 0.53 mmol/L), alongside stabilized Ca × P products (52.92 ± 5.05 vs. 60.34 ± 7.06 mg2/dL).ConclusionAdvanced hemodialysis systems significantly enhance therapeutic outcomes in elderly CKD patients by attenuating inflammation, restoring renal function, and optimizing calcium-phosphorus metabolism. These findings underscore the clinical value of integrating technology-driven dialysis protocols for precision care.

Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Hemodialysis: An International, Multicentric Registry

BACKGROUND

The net benefit of oral anticoagulation in patients with end-stage renal disease on hemodialysis (HD) is uncertain. In recent years, left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation; however, there is scant evidence of LAAC in patients on HD.

OBJECTIVES

This study aimed to assess the feasibility and safety of LAAC in patients on HD.

METHODS

In an international multicenter registry, patients' baseline characteristics and procedural and follow-up data were recorded from all patients on HD with atrial fibrillation who underwent LAAC.

RESULTS

A total of 147 patients from 9 centers were included. The mean age was 72.6 ± 10.4 years; the mean CHA2DS2-VASc-score was 4.6 ± 1.5, and the mean HAS-BLED-score was 4.7 ± 1.1. Antithrombotic treatment regimens prior to implantation were notably diverse, encompassing more than 12 distinct combinations. Technical successful LAA at first procedure was achieved in 144 of 147 (98%) patients and major complications were observed in 4.7% (7 of 149 procedures). The median follow-up was 427 days (Q1-Q3: 184-797 days), no device-related thrombi were detected, and peridevice leaks ≥5 mm were 1.7% at first imaging control. The most common post-implantation antithrombotic therapy was single antiplatelet therapy with 165.9 patient-years (py). During follow-up of 222.9 py, the annual stroke rate was 0.9%, reflecting an 88% relative risk reduction (P < 0.001) compared to historical data. Similarly, the annual rate of major bleeding was 4.5%, signifying a 55% relative risk reduction (P = 0.023). Throughout follow-up, 29 deaths (19.9%) were recorded.

CONCLUSIONS

LAAC in end-stage renal disease patients on HD demonstrated an acceptable safety profile, coupled with a notably low incidence of strokes. This was paralleled by low bleeding rates.

Comparative analysis of ischemic and hemorrhagic stroke hospitalization rates in end-stage kidney disease and kidney transplant patients with and without atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF) in end-stage kidney disease (ESKD) and kidney transplant (KTx) recipients presents challenges in stroke risk management. This study aimed to compare hospitalization rates for ischemic and hemorrhagic cerebrovascular events in ESKD and KTx patients with and without AF.

METHODS

Using the National Inpatient Sample (2005-2019), retrospective analysis was conducted on hospitalizations for ESKD and KTx patients with and without AF. Baseline characteristics and hospitalization rates for five cerebral ischemic conditions and one hemorrhagic condition were compared. Descriptive statistics and t-tests were employed for analysis.

RESULTS

Among ESKD patients, those with AF exhibited significantly higher hospitalization rates for ischemic stroke, including 1)Cerebral infarction due to thrombosis, embolism, occlusion (0.11% vs. 0.08%,p<0.001), 2)Cerebral infarction due to thrombosis, embolism, and unspecified occlusion (1.93% vs. 1.51%, p<0.001), 3)Artery occlusion resulting in cerebral ischemia (1.37% vs. 0.93%,p<0.001), 4)Cerebral artery occlusion resulting in cerebral ischemia (0.48% vs. 0.42%,p<0.001), while experiencing lower rates of intraoperative and postprocedural cerebrovascular infarction (0.88% vs. 0.97%,p<0.001) compared to those without AF. Conversely, KTx patients with AF showed increased hospitalizations for hemorrhagic stroke, particularly nontraumatic intracranial hemorrhage (0.79% vs. 0.56%,p<0.001), compared to those without AF. However, they did not exhibit significant differences in hospitalization rates for most ischemic conditions, except for cerebral infarction due to thrombosis, embolism, and unspecific occlusion (1.62% vs. 1.11%,p<0.001) and artery occlusion resulting in cerebral ischemia (0.84% vs. 0.52%,p<0.001).

CONCLUSION

Our findings reveal patterns in hospitalization rates between ESKD and KTx patients with AF compared to those without AF, with ESKD patients with AF exhibiting higher rates of ischemic stroke compared to ESKD patients without AF and KTx patients with AF showing increased hospitalizations for hemorrhagic stroke compared to those without AF. These findings demonstrate the impact of AF on hospitalization rates for ischemic and hemorrhagic cerebrovascular events in both ESKD and KTx patients.

Zero-contrast left atrial appendage closure, a feasible alternative for patients with a high risk of contrast-induced nephropathy: Systematic literature review and meta-analysis

BACKGROUND

Left atrial appendage closure (LAAC) is an alternative to reduce thrombotic risk in patients with nonvalvular atrial fibrillation. This procedure conventionally requires the use of a contrast agent. A significant proportion of patients who undergo this procedure have chronic kidney disease, with a high risk of contrast-induced nephropathy.

OBJECTIVE

We aimed to systematically review existing literature regarding the feasibility and safety of a zero-contrast LAAC technique.

METHODS

We searched the MEDLINE/PubMed, Embase, and Cochrane Central Register of Controlled Trials databases for studies comparing a zero-contrast LAAC technique with conventional LAAC up to April 2024. From each study, we extracted baseline characteristics, feasibility, and safety outcomes. A random model meta-analysis was used to compare outcomes between groups.

RESULTS

Five studies reporting data from 367 patients were included. A 100% successful implantation rate was reported in all the zero-contrast groups. The mean number of recaptures reached no significant difference between the groups (mean difference, -0.15; CI, -0.67 to 0.37; I2 = 0%; P = .58). The zero-contrast group had a significantly shorter fluoroscopy time (mean difference, -4.03; CI, -7.72 to -0.34; I2 = 67%; P = .03). Complications related to the procedure, peridevice leak, and device-associated thrombus rates were not significantly different between the groups.

CONCLUSION

Zero-contrast LAAC is a feasible alternative. The success and complication rates are consistent with those of conventional LAAC. Aside from the inherent benefit of zero-contrast exposure, this technique allows a reduction in fluoroscopy time.

Ten tips to manage oral anticoagulation in hemodialysis patients with atrial fibrillation

Patients with chronic kidney disease (CKD) have a high incidence and prevalence of atrial fibrillation (AF). While general treatment strategies for AF may largely be transferred to patients with mild to moderate CKD, patients with advanced CKD-particularly hemodialysis (HD) patients-with AF pose substantial therapeutical challenges to cardiologists and nephrologists. The arguably greatest dilemma is the very limited evidence on appropriate strategies for prevention of stroke and systemic embolism in HD patients with AF, since the risk for both thromboembolic events without oral anticoagulation and severe bleeding events with oral anticoagulation are substantially increased in advanced CKD, compared with the general population. Thus, the benefit to risk ratio of either vitamin K antagonists or direct oral anticoagulants is less evident in HD than in non-CKD patients with AF. As a multidisciplinary panel of clinicians, we here propose 10 tips that may help our colleagues to navigate between the risk of undertreatment-exposing CKD patients with AF to a high stroke risk-and overtreatment-exposing the very same patients to a prohibitively high bleeding risk. These tips include ideas on alternative risk stratification strategies and novel treatment approaches that are currently in clinical studies-such as factor XI inhibitors or left atrial appendage closure-and may become game-changers for HD patients with AF.

Transcatheter left atrial appendage occlusion in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative.

OBJECTIVE

This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD).

METHODS

Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies.

RESULTS

We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade.

CONCLUSIONS

Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO.

Left Atrial Appendage Closure: A Single-Center Experience in a Population With a High Prevalence of End-Stage Renal Disease

Background Left atrial appendage closure (LAAC) has emerged as an alternative approach for mitigating thrombotic risk in nonvalvular atrial fibrillation patients. However, existing registries often lack representation of the Hispanic population, motivating this study to elucidate the demographic, clinical, and procedural characteristics, specifically among Hispanic patients undergoing this procedure. Methods Adult patients who underwent percutaneous LAAC between June 2017 and July 2022 at a high-complexity hospital in Bogotá, COL, were included. Baseline and procedural characteristics are reported. For patients with available follow-up data, major bleeding, thromboembolic events, and cardiovascular mortality were assessed. A subgroup analysis was conducted for patients with end-stage renal disease on dialysis. Results We included 33 patients. Follow-up data were available for 27 patients, with a mean follow-up period of 12.4 months. The median age of the cohort was 70 years (SD 9), with 58% being women. The median CHADS2 and HAS-BLED scores were 3 points (IQR 2 to 4) and 4 points (IQR 3 to 4), respectively. The 90-day cardiovascular mortality rate was 3.7%, whereas cardioembolic episodes and major bleeding events were reported at rates of 10.8 and 14.4 per 100 patient years, respectively. The long-term outcomes of patients on dialysis were comparable to those of nondialysis patients. Conclusions Our study reinforces existing evidence supporting the safety of LAAC, particularly in a multimorbid patient population with elevated bleeding and thrombotic risks. In this high-risk cohort, LAAC emerges as a feasible alternative for reducing thromboembolic risk. Notably, patients on dialysis demonstrated comparable long-term outcomes, suggesting the procedure's viability in this subgroup as well.

Treatment strategies of the thromboembolic risk in kidney failure patients with atrial fibrillation

The incidence and prevalence of atrial fibrillation (AF) in patients affected by kidney failure, i.e. glomerular filtration rate <15 ml/min/1.73 m2, is high and probably underestimated. Numerous uncertainties remain regarding how to prevent thromboembolic events in this population because both cardiology and nephrology guidelines do not provide clear recommendations. The efficacy and safety of oral anticoagulant therapy (OAC) in preventing thromboembolism in patients with kidney failure and AF has not been demonstrated for either vitamin K antagonists (VKAs) or direct anticoagulants (DOACs). Moreover, it remains unclear which is more effective and safer, because estimated creatinine clearance <25-30 ml/min was an exclusion criterion in the randomized controlled trials (RCTs). Three RCTs comparing DOACs and VKAs in kidney failure failed to reach the primary endpoint, as they were underpowered. The left atrial appendage is the main source of thromboembolism in the presence of AF. Left atrial appendage closure (LAAC) has recently been proposed as an alternative to OAC. RCTs comparing the efficacy and safety of LAAC versus OAC in kidney failure were terminated prematurely due to recruitment failure. A recent prospective study showed a reduction in thromboembolic events in haemodialysis patients with AF and undergoing LAAC compared with patients taking or not taking OAC. We review current treatment standards and discuss recent developments in managing the thromboembolic risk in kidney failure patients with AF. The importance of shared decision-making with the multidisciplinary team and the patient to consider individual risks and benefits of each treatment option is underlined.

[Atrial fibrillation - what should be taken into account with chronic kidney disease and hemodialysis?]

CKD is a common comorbidity in patients with atrial fibrillation. The CHA2DS2-VASc score is not validated in patients with severe CKD and has a low predictive value in dialysis patients. As NOACs are partly eliminated by the kidneys the dosage has to be adapted in CKD. Recent studies indicate an acceptable safety profile for NOACs in CKD. However, larger randomized studies are still lacking. The results from prospective studies with placebo i.e., no anticoagulation therapy, are pending.

Percutaneous Left Atrial Appendage Closure in Patients with Non-Valvular Atrial Fibrillation and End-Stage Renal Disease on Hemodialysis: A Case Series

Non-valvular atrial fibrillation (NVAF) is the most common cardiac arrhythmia in the general population, and its prevalence increases among patients with chronic kidney disease (CKD) undergoing hemodialysis. This population presents high risk of both hemorrhagic and thrombotic events, with little evidence regarding the use of oral anticoagulation treatment (OAT) and multiple complications arising from it; however, stroke prevention with percutaneous left atrial appendage closure (LAAC) is an alternative to be considered. We retrospectively describe the safety and efficacy of percutaneous LAAC in eight patients with NVAF and CKD on hemodialysis during a 12-month follow-up. The mean age was 78.8 years (range 64-86; SD ± 6.7), and seven patients were male. The mean CHA2DS2-VASC and HAS-BLED scores were high, 4.8 (SD ± 1.5) and 3.8 (SD ± 1.3), respectively. Seventy-five percent of the patients were referred for this intervention due to a history of major bleeding, with gastrointestinal bleeding being the most common type, while the remaining twenty-five percent of the patients were referred because of a high risk of bleeding. The percutaneous LAAC procedure was successfully completed in 100% of the patients, with complete exclusion of the appendage without complications or leaks exceeding 5 mm. There was one death not related to the procedure four days after the intervention. Among the other seven patients, no deaths, cardioembolic events or major bleeding were reported during the follow-up period. In our sample, percutaneous LAAC appears to be a safe and effective alternative to anticoagulation in patients with NVAF and CKD on hemodialysis.

[Cardiovascular treatment in chronic kidney disease]

Patients with combined cardiac and renal diseases are particularly challenging in the routine clinical practice due to the substantial risk profile for increased morbidity and mortality. As cardiorenal patients have often been underrepresented in randomized, controlled interventional trials, guideline recommendations regarding the choice of treatment are often weaker for these individuals than for cardiovascular patients without chronic kidney disease. Furthermore, there are limitations in the approval of certain medications depending on the kidney function. This review addresses some considerations in crucial treatment areas for patients with cardiovascular diseases, whose treatment is significantly influenced by concomitant chronic kidney disease.