Left atrial appendage closure using WATCHMAN device in chronic kidney disease and end stage renal disease patients

Cardiovascular disease in chronic kidney disease

Individuals with chronic kidney disease (CKD) exhibit an increased risk for the development of cardiovascular disease (CVD) with its manifestations coronary artery disease, stroke, heart failure, arrhythmias, and sudden cardiac death. The presence of both, CVD and CKD has a major impact on the prognosis of patients. This association likely reflects the involvement of several pathophysiological mechanisms, including shared risk factors (e.g. diabetes and hypertension), as well as other factors such as inflammation, anaemia, volume overload, and the presence of uraemic toxins. Identifying and characterizing CKD is crucial for appropriate CVD risk prediction. Mitigating CVD risk in patients with CKD mandates a multidisciplinary approach involving cardiologists, nephrologists, and other health care professionals. The present State-of-the-Art Review addresses the current understanding on the pathophysiological link between CVD and CKD, clinical implications and challenges in the treatment of these patients.

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.

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.

[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.

Not to Rush-Laboratory Parameters and Procedural Complications in Patients Undergoing Left Atrial Appendage Closure

Background: As a preventive procedure, minimizing periprocedural risk is crucially important during left atrial appendage closure (LAAC). Methods: We included consecutive patients receiving LAAC at nine centres and assessed the relationship between baseline characteristics and the acute procedural outcome. Major procedural complications were defined as all complications requiring immediate invasive intervention or causing irreversible damage. Logistic regression was performed and included age and left-ventricular function. Furthermore, the association between acute complications and long-term outcomes was evaluated. Results: A total of 405 consecutive patients with a median age of 75 years (37% female) were included. 47% had a history of stroke. Median CHA2DS2-VASc score was 4 (interquartile range, 3−5) and the median HAS-BLED score was 3 (2−4). Major procedural complications occurred in 7% of cases. Low haemoglobin (OR 0.8, 95% CI 0.65−0.99 per g/dL, p = 0.040) and end-stage kidney disease (OR 13.0, CI 2.5−68.5, p = 0.002) remained significant in multivariate analysis. Anaemia (haemoglobin < 12 and < 13 g/dL in female and male patients) increased the risk of complications 2.2-fold. Conclusions: The major complication rate was low in this high-risk patient population undergoing LAAC. End-stage kidney disease and low baseline haemoglobin were independently associated with a higher major complication rate.