Left ventricular assist devices in patients with renal dysfunction: where are we heading?

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

BACKGROUND

There is paucity of data regarding durable LVAD outcomes in patients with chronic kidney disease (CKD) stage 3-5 and CKD stage 5 on dialysis (ESRD: end stage renal disease).

METHODS

We conducted a retrospective study of Medicare beneficiaries with ESRD and 5% sample of CKD with LVAD (2006 to 2018) to determine one-year outcomes utilizing the United States Renal Data System (USRDS) database. The LVAD implantation, comorbidities and outcomes were identified using appropriate ICD-9 and ICD-10 codes.

RESULTS

We identified 496 CKD and 95 ESRD patients who underwent LVAD implantation. The ESRD patients were younger (59 vs 66 years; p <0.001), had more Blacks (40% vs 24.6%; p=0.009), compared to the CKD group. One-year mortality (49.5% vs 30.9%; p <0.001) and index mortality (27.4% vs 16.7%; p=0.014) was higher in ESRD. Subgroup analysis showed significantly higher mortality in ESRD vs CKD 3 (49.5% vs 30.2%, adjusted p=0.009), but no significant difference in mortality between stage 3 vs 4/5 (30.2% vs 30.8%; adjusted p=0.941). There was no significant difference in secondary outcomes (bleeding, stroke, and sepsis/infection) during follow-up between two groups.

CONCLUSIONS

Patients with ESRD undergoing LVAD implantation had significantly higher index and 1-year mortality compared to CKD patients.

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

Background

People 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 Results

We 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.

Conclusions

Medicare 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.