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The impact of preoperative kidney replacement therapy on kidney outcome and survival in patients with left ventricular assist device. Ren Fail 2023; 45:2157285. [PMID: 36763000 PMCID: PMC9930763 DOI: 10.1080/0886022x.2022.2157285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Left ventricular assist device (LVAD) has been highlighted as a new treatment option in the end-stage heart failure (HF). Kidney outcome after LVAD in severe cardiorenal syndrome (CRS) patients requiring kidney replacement therapy (KRT) is unclear. We investigated the impact of preoperative KRT on kidney function and survival in LVAD patients with severe CRS. A total of 50 patients followed up for at least 1 year after LVAD implantation was analyzed. The primary outcomes were estimated glomerular filtration rate and survival rate. Patients were divided into two groups depending on in-hospital KRT before LVAD implantation: the control group (n = 33) and the KRT group (n = 17). Postoperative KRT was performed for 76.5% of patients in the KRT group, and all of them discontinued KRT before discharge. There were no statistically significant differences in the degree of eGFR decline in survivors according to preoperative KRT. Although there were no statistically significant differences in the degree of eGFR decline in survivors regardless of preoperative KRT, old age (β -0.94, p < 0.01), preexisting chronic kidney disease (β -21.89, p < 0.01), and high serum creatinine (β -13.95, p < 0.01) were identified as independent predictors of post-LVAD eGFR decline. Mortality rate was higher, and more patients progressed to end-stage kidney disease in KRT group than control group. However, LVAD still can be considered as the treatment option in end-stage HF patients with severe CRS requiring KRT, especially in those with young age and previous normal kidney function.
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Roehm B, Hedayati S, Vest AR, Gulati G, Miao J, Tighiouart H, Weiner DE, Inker LA. Long-Term Changes in Estimated Glomerular Filtration Rate in Left Ventricular Assist Device Recipients: A Longitudinal Joint Model Analysis. J Am Heart Assoc 2023; 12:e025993. [PMID: 36734339 PMCID: PMC9973635 DOI: 10.1161/jaha.122.025993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 09/28/2022] [Indexed: 02/04/2023]
Abstract
Background Advanced kidney disease is often a relative contraindication to left ventricular assist device (LVAD) implantation because of concerns for poor outcomes including worsening kidney disease. Data are lacking on long-term changes and sex-based differences in estimated glomerular filtration rate (eGFR), with published data limited by potential bias introduced by the competing risks of death and heart transplantation. Methods and Results We conducted a longitudinal analysis of 288 adults receiving durable continuous-flow LVADs from January 2010 to December 2017 at a single center. A joint model was constructed to evaluate change in eGFR over 2 years, the prespecified primary outcome, adjusted for the competing risks of death and heart transplantation. Median baseline eGFR was 60 mL/min per 1.73 m2 (interquartile range 42-78). At 2 years, 74 patients died and 104 received a heart transplant. In unadjusted analysis, LVAD recipients had a modest initial increase in eGFR of ≈2 mL/min per 1.73 m2 within the first 6 months after implantation, followed by a decrease in eGFR below baseline values at 1 and 2 years. Men experienced an eGFR decline of 5 to 10 mL/min per 1.73 m2 over the first year which then stabilized, while women had an ≈5 mL/min per 1.73 m2 increase in eGFR within the first 6 months followed by decline towards baseline eGFR levels (interaction P=0.005). Conclusions Estimated GFR remains relatively stable in most patients following LVAD implantation. Larger studies are needed to investigate sex-based differences in eGFR and to evaluate eGFR trajectory and mortality in LVAD recipients with lower eGFR.
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Affiliation(s)
- Bethany Roehm
- Division of NephrologyUniversity of Texas Southwestern Medical CenterDallasTX
| | - Susan Hedayati
- Division of NephrologyUniversity of Texas Southwestern Medical CenterDallasTX
| | | | | | | | - Hocine Tighiouart
- Tufts Medical CenterInstitute for Clinical Research and Health Policy StudiesBostonMA
- Tufts University, Tufts Clinical and Translational Science InstituteBostonMA
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Pellicori P, Kalra PR, Clark AL, Friday JM, Cleland JGF. Chronic kidney disease (CKD) and CKD-ism in heart failure - what a mess! Eur J Heart Fail 2022; 24:2196-2198. [PMID: 36130835 DOI: 10.1002/ejhf.2696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/18/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Andrew L Clark
- Department of Cardiology, Hull University Hospitals Trust, Castle Hill Hospital, Kingston-Upon-Hull, UK
| | - Jocelyn M Friday
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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Stencel J, Rajapreyar I, Samson R, Le Jemtel T. Comprehensive and Safe Decongestion in Acutely Decompensated Heart Failure. Curr Heart Fail Rep 2022; 19:364-374. [PMID: 36045314 DOI: 10.1007/s11897-022-00573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF THE REVIEW Progressive intravascular, interstitial, and alveolar fluid overload underlies the transition from compensated to acutely decompensated heart failure and loop diuretics are the mainstay of treatment. Adverse effects and resistance to loop diuretics received much attention while the contribution of a depressed cardiac output to diuretic resistance was downplayed. RECENT FINDINGS Analysis of experience with positive inotropic agents, especially dobutamine, indicates that enhancement of cardiac output is not consistently associated with increased renal blood flow. However, urinary output and renal sodium excretion increase likely due to dobutamine-mediated decrease in renal and systemic reduced activation of sympathetic nervous- and renin-angiotensin-aldosterone system. Mechanical circulatory support with left ventricular assist devices ascertained the contribution of low cardiac output to diuretic resistance and the pathogenesis and progression of kidney disease in acutely decompensated heart failure. Diuretic resistance commonly occurs in acutely decompensated heart failure. However, failure to resolve fluid overload despite high doses of loop diuretics should alert to the presence of a low cardiac output state.
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Affiliation(s)
- Jason Stencel
- Tulane University School of Medicine, New Orleans, LA, USA.
| | | | - Rohan Samson
- Rudd Heart and Lung Center, University of Louisville Health, Louisville, KY, USA
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Atkins J, Hess NR, Fu S, Read JM, Hajj JM, Ramu B, Silverman DN, Inampudi C, Van Bakel AB, Hashmi ZA, Pope NH, Witer LP, Kanwar MK, Sauer AJ, Houston BA, Kilic A, Tedford RJ. Outcomes in LVAD Patients Undergoing Simultaneous Heart-Kidney Transplantation. J Card Fail 2022; 28:1584-1592. [PMID: 35597511 DOI: 10.1016/j.cardfail.2022.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/20/2022] [Accepted: 04/30/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Multiple studies have shown better outcomes for simultaneous heart kidney transplant (sHKT) compared with isolated orthotopic heart transplant (iOHT) in recipients with chronic kidney disease (CKD). However, outcomes in patients supported by durable LVAD have not been well studied. METHODS Patients with durable LVADs and stage 3 or greater CKD (eGFR <60ml/min/1.73m2) undergoing iOHT or sHKT between 2008-2020 were identified from the United Network for Organ Sharing (UNOS) registry. Kaplan Meier survival analysis with associated log-rank test was conducted to compare post-transplant survival. Multivariable modeling was used in order to identify risk adjusted predictors of one-year posttransplant mortality. RESULTS 4375 patients were identified, 366 underwent sHKT and 4009 iOHT. The frequency of sHKT increased over the study period. One-year post-transplant survival was worse in sHKT compared with iOHT (80.3% vs 88.3%, p<0.001), and persisted up to 5 years post-transplant (p=0.001). sHKT recipients were more likely to require dialysis after transplant and had longer hospital length of stay (p<0.001). Multivariable analysis showed sHKT remained an independent risk factor for mortality at 1 year (OR 1.58, p=0.002). CONCLUSIONS HKT is becoming more common in patients with durable LVADs. Compared with iOHT, sHKT have worse short and long-term survival are more likely to require posttransplant dialysis.
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Affiliation(s)
- Jessica Atkins
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sheng Fu
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Jacob M Read
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Jennifer M Hajj
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Bhavadharini Ramu
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Daniel N Silverman
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Chakradhari Inampudi
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Adrian B Van Bakel
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Z A Hashmi
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Nicholas H Pope
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Lucas P Witer
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, The University of Kansas School of Medicine, Kansas City, Kansas
| | - Brian A Houston
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC.
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Bartfay SE, Kolsrud O, Wessman P, Dellgren G, Karason K. The trajectory of renal function following mechanical circulatory support and subsequent heart transplantation. ESC Heart Fail 2022; 9:2464-2473. [PMID: 35441491 PMCID: PMC9288773 DOI: 10.1002/ehf2.13943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/25/2022] [Accepted: 04/04/2022] [Indexed: 12/25/2022] Open
Abstract
Aim Patients with advanced heart failure (HF) frequently suffer from renal insufficiency. The impact of durable mechanical circulatory support (MCS) and subsequent heart transplantation (HTx) on kidney function is not well described. Methods and results We studied patients with advanced HF who received durable MCS as bridge to transplantation (BTT) and underwent subsequent HTx at our centre between 1996 and 2018. Glomerular filtration rate (GFR) was measured by 51Cr‐EDTA or iohexol clearance during heart failure work‐up; 3–6 months after MCS; and 1 year after HTx. Chronic kidney disease (CKD) was classified according to KDIGO criteria based on estimated GFR. A total of 88 patients (46 ± 15 years, 84% male) were included, 63% with non‐ischaemic heart disease. The median duration of MCS‐treatment was 172 (IQR 116–311) days, and 81 subjects were alive 1 year after HTx. Measured GFR increased from 54 ± 19 during HF work‐up to 60 ± 16 mL/min/1.73 m2 after MCS (P < 0.001) and displayed a slight but nonsignificant decrease to 57 ± 22 mL/min/1.73 m2 1 year after HTx (P = 0.38). The trajectory of measured GFR did not differ between pulsatile and continuous flow (CF) pumps. Among patients 35–49 years and those who were treated in the most recent era (2012–2018), measured GFR increased following MCS implantation and subsequent HTx. Estimated GFR displayed a similar course as did measured GFR. Conclusions In patients with advanced heart failure, measured GFR improved after MCS with no difference between pulsatile and CF‐pumps. The total study group showed no further increase in GFR following HTx, but in certain subgroups, including patients aged 35–54 years and those treated during the latest era (2012–2018), renal function appeared to improve after transplant.
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Affiliation(s)
- Sven-Erik Bartfay
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Oscar Kolsrud
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Wessman
- Centre of Registers Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Dellgren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristjan Karason
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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Lamba HK, Musfee FI, Chatterjee S, Nair AP, Civitello AB, Simpson L, Frazier OH, Letsou GV. The influence of preoperative dialysis on survival after continuous-flow left ventricular assist device implantation. Interact Cardiovasc Thorac Surg 2021; 34:470-477. [PMID: 34966937 PMCID: PMC8860431 DOI: 10.1093/icvts/ivab357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/28/2021] [Accepted: 11/23/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Dialysis is considered a contraindication to continuous-flow left ventricular assist device (CF-LVAD) implantation. We evaluated clinical outcomes and survival in carefully selected, low-risk patients with renal failure who required dialysis before CF-LVAD implantation. METHODS We extracted medical record data of patients who underwent CF-LVAD placement at our centre between 1 January 2006 and 31 August 2017, with 2 clinical scenarios: those who required long-term (>14 days) dialysis and those who required short-term (≤14 days) dialysis immediately before implantation. Demographic, clinical and intraoperative characteristics and survival outcomes were assessed. RESULTS Of 621 patients who underwent CF-LVAD implantation during the study period, 31 underwent dialysis beforehand. Of these, 17 required long-term dialysis (13 haemodialysis, 4 peritoneal dialysis), and 14 underwent short-term haemodialysis. Compared with the long-term dialysis patients, the short-term dialysis patients were more likely to be Interagency Registry for Mechanically Assisted Circulatory Support profile 1–2 (92.9% vs 70.6%; P < 0.001), to have needed preoperative mechanical circulatory support (78.6% vs 70.6%; P < 0.01) and to have higher in-hospital mortality (85.7% vs 29.4%; P = 0.01). Patients stable on long-term dialysis had acceptable overall survival and markedly better 6-month and 1-year survival than those with short-term dialysis before implantation (64.7% vs 14.3% and 58.8% vs 7.1%, respectively; P < 0.001). CONCLUSIONS Carefully selected patients who are stable on long-term dialysis have acceptable survival rates after CF-LVAD implantation. Patients with acute renal failure had much poorer outcomes than those with chronic end-stage renal disease.
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Affiliation(s)
- Harveen K Lamba
- Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - Fadi I Musfee
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UT Health School of Public Health, Houston, TX, USA
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Ajith P Nair
- Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - Andrew B Civitello
- Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - Leo Simpson
- Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - O H Frazier
- Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - George V Letsou
- Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, TX, USA
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8
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Gambaro A, Lombardi G, Onorati F, Gottin L, Ribichini FL. Heart, kidney and left ventricular assist device: a complex trio. Eur J Clin Invest 2021; 51:e13662. [PMID: 34347897 DOI: 10.1111/eci.13662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/24/2021] [Accepted: 08/03/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart failure (HF) is a complex syndrome affecting the whole body, kidneys included. The left ventricular assist device (LVAD) is a valid option for patients with very severe HF. Focusing on renal function, LVAD implantation could theoretically reverse the detrimental effects of HF syndrome on kidneys. However, implanting an LVAD is a high-risk surgical procedure, and LVAD patients have higher risk of bleeding, device thrombosis, strokes, renal impairment, multi-organ failure and infections. Furthermore, an LVAD has its own particular effects on the renal system. METHODS In this review, we provide a comprehensive overview of the complex interaction between LVAD and the kidneys from the pathophysiological and clinical perspectives. An analysis of the different effects of pulsatile-flow and continuous-flow LVAD is provided. RESULTS Despite their limitations, creatinine-based estimated glomerular filtration rate (eGFR) formulas help to stratify patients by their post-LVAD placement prognosis. Poor basal renal function, the onset of acute kidney injury or the need for renal replacement therapy after LVAD implantation negatively influences a patient's prognosis. LVAD can also prompt an improvement in renal function, however, with some counterintuitive effects on a patient's prognosis. CONCLUSION It is still hard to say whether different trends in eGFR depend on different renal conditions before LVAD placement, on a patient's better overall status or on a particular patient management strategy before and/or after the device's implantation. Steps should be taken to solve this question because finding the best candidates for LVAD implantation is of paramount importance to ensure the best outcomes.
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Affiliation(s)
- Alessia Gambaro
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gianmarco Lombardi
- Division of Nephrology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Leonardo Gottin
- Unit of Cardiothoracic Anesthesia and Intensive Care, Department of Emergencies and Intensive Care, University of Verona, Verona, Italy
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Chen CY, Montez-Rath ME, May LJ, Maeda K, Hollander SA, Rosenthal DN, Krawczeski CD, Sutherland SM. Hemodynamic Predictors of Renal Function After Pediatric Left Ventricular Assist Device Implantation. ASAIO J 2021; 67:1335-1341. [PMID: 34860188 PMCID: PMC8647769 DOI: 10.1097/mat.0000000000001460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although renal function often improves after pediatric left ventricular assist device (LVAD) implantation, recovery is inconsistent. We aimed to identify hemodynamic parameters associated with improved renal function after pediatric LVAD placement. A single-center retrospective cohort study was conducted in patients less than 21 years who underwent LVAD placement between June 2004 and December 2015. The relationship between hemodynamic parameters and estimated glomerular filtration rate (eGFR) was assessed using univariate and multivariate modeling. Among 54 patients, higher preoperative central venous pressure (CVP) was associated with eGFR improvement after implantation (p = 0.012). However, 48 hours postimplantation, an increase in CVP from baseline was associated with eGFR decline over time (p = 0.01). In subgroup analysis, these associations were significant only for those with normal pre-ventricular assist device renal function (p = 0.026). In patients with preexisting renal dysfunction, higher absolute CVP values 48 and 72 hours after implantation predicted better renal outcome (p = 0.005). Our results illustrate a complex relationship between ventricular function, volume status, and renal function. Additionally, they highlight the challenge of using CVP to guide management of renal dysfunction in pediatric heart failure. Better methods for evaluating right heart function and volume status are needed to improve our understanding of how hemodynamics impact renal function in this population.
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Affiliation(s)
- Chiu-Yu Chen
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Lindsay J May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Seth A Hollander
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Catherine D Krawczeski
- Division of Pediatric Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Scott M Sutherland
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Okoh AK, Kassotis J, Shah AM, Siddiqui E, Dhaduk N, Hirji S, Gold J, Mehta H, Ruberwa J, Soliman F, Tayal R, Russo MJ, Lee LY. Change in Renal Function and Its Impact on Survival in Chronic Kidney Disease Patients Bridged to Heart Transplantation With a Left Ventricular Assist Device. ASAIO J 2021; 67:1204-1210. [PMID: 33769354 DOI: 10.1097/mat.0000000000001384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The study investigates the incidence of change in renal function and its impact on survival in renal dysfunction patients who were bridged to heart transplantation with a left ventricular assist device (BTT-LVAD). BTT-LVAD patients with greater than or equal to moderately reduced renal function (estimated glomerular filtration rate [eGFR] ≤ 60 ml/min/1.73 m2) at the time of listing between 2008 and 2018 were identified from a prospectively maintained database of the United Network for Organ Sharing. Patients with a baseline eGFR less than or equal to 15 ml/min/1.73 m2 or on dialysis were excluded. Patients were divided into three groups based on percent change ([Pretransplant eGFR - listing eGFR/listing glomerular filtration rate (GFR)] × 100) in eGFR: Improvement greater than or equal to 10%, no change, decline greater than or equal to 10%, and their operative outcomes were compared. Posttransplant survival was estimated and compared among the three groups with the Kaplan-Meier survival curves and the log-rank test. Cox proportional hazards modeling was used to identify predictors of posttransplant survival. Out of 14,395 LVAD patients, 1,622 (11%) met the inclusion criteria. At the time of transplant, 900 (55%) had reported an improvement in eGFR greater than or equal to 10%, 436 (27%) had no change, and 286 (18%) experienced a decline greater than or equal to 10%. Postoperatively, the incidence of dialysis was higher in the decline than in the unchanged or improved groups (22% vs. 12% vs. 12%; p = 0.002). After a median follow-up of 5 years, there was no difference in posttransplant survival among the stratified groups (improved eGFR: 24.8%, unchanged eGFR: 23.2%, declined eGFR: 20.3%; p = 0.680). On Cox proportional hazard modeling, independent predictors of worse survival were: [hazard ratio: 95% CI; p] history of diabetes (1.43 [1.13-1.81]; p = 0.002) or tobacco use (1.40 [1.11-1.79]; p = 0.005) and ischemic time greater than 4 hours (1.36 [1.03-1.76]; p = 0.027). More than half of the patients with compromised renal function who undergo BTT-LVAD demonstrate an improvement in renal function at the time of transplant. A 10% change in GFR while listed was not associated with worse posttransplant survival.
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Affiliation(s)
- Alexis K Okoh
- From the Heart and Lung Research Center, Department of Medicine, Rutgers Health, Newark Beth Israel Medical Center, Newark, New Jersey
- Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - John Kassotis
- Department of Medicine, Division of Cardiology, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Aakash M Shah
- From the Heart and Lung Research Center, Department of Medicine, Rutgers Health, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Emaad Siddiqui
- From the Heart and Lung Research Center, Department of Medicine, Rutgers Health, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Nehal Dhaduk
- From the Heart and Lung Research Center, Department of Medicine, Rutgers Health, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Sameer Hirji
- Department of Surgery, Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin Gold
- From the Heart and Lung Research Center, Department of Medicine, Rutgers Health, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Harsh Mehta
- From the Heart and Lung Research Center, Department of Medicine, Rutgers Health, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Joseph Ruberwa
- From the Heart and Lung Research Center, Department of Medicine, Rutgers Health, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Fady Soliman
- Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Rajiv Tayal
- From the Heart and Lung Research Center, Department of Medicine, Rutgers Health, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Mark J Russo
- Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Leonard Y Lee
- Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey
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Abstract
Rationale & Objective Nearly half the patients with heart failure have chronic kidney disease. Implantation of a left ventricular assist device (LVAD) improves kidney function in some but not all patients, and lack of improvement is associated with worse outcomes. Preimplantation factors that predict change in kidney function after LVAD placement are not well described. Study Design Single-center observational study. Setting & Participants Consecutive patients undergoing LVAD implantation. Predictors 48 diverse preimplantation variables including demographic, clinical, laboratory, hemodynamic, and echocardiographic variables. Outcomes The primary outcome was change in estimated glomerular filtration rate (eGFR) at 1 month after implantation. Secondary outcomes included eGFR changes at 3, 6, and 12 months. Analytic Approach Univariable and multivariable linear regression. Results Among 131 patients, average age was 60 ± 13 years, 83% were men, 47% had pre-existing chronic kidney disease, and mean preimplantation eGFR was 57 ± 23 mL/min/1.73 m2. At 1-month following LVAD implantation, eGFR improved in 98 (75%) patients. Variables associated with 1-month increases in eGFR were younger age, absence of diabetes mellitus (DM), use of inotropes, lower implantation eGFR, and higher implantation serum urea nitrogen, alanine aminotransferase, bilirubin, and creatinine levels. In multivariable models, younger age (β = 7.14 mL/min/1.73 m2 per SD; 95% CI, 3.17-11.10), lower eGFR (β = 7.72 mL/min/1.73 m2 per SD; 95% CI, 3.10-12.34), and absence of DM (β = 10.36 mL/min/1.73 m2; 95% CI, 2.99-17.74) were each independently associated with 1-month improvement in eGFR. Only younger age and lower eGFR were associated with improvements in eGFR at later months. Limitations Single-center study. Loss to follow-up from heart transplantation and death over duration of study. Conclusions Only younger age, lower eGFR, and absence of DM were associated with improvement in eGFR at 1 month. Thus, prediction of eGFR change at 1 month and beyond is limited by using preimplantation variables.
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Jawaid O, Gaddy A, Omar HR, Guglin M. Ventricular Assist Devices and Chronic Kidney Replacement Therapy: Technology and Outcomes. Adv Chronic Kidney Dis 2021; 28:37-46. [PMID: 34389136 DOI: 10.1053/j.ackd.2021.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/12/2020] [Accepted: 01/04/2021] [Indexed: 11/11/2022]
Abstract
Heart failure and kidney failure are very common conditions, precipitating and exacerbating each other. Left ventricular assist devices (LVADs) represent a relatively new technology for treatment of advanced heart failure. Kidney dysfunction, if present, makes candidate selection for LVADs challenging and contributes to multiple complications while the patients are on an LVAD support. Although kidney function generally improves after LVAD implantation, some patients develop acute and then chronic kidney disease sometimes requiring kidney replacement therapies (KRTs). Overall, chronic KRT in LVAD recipients is feasible and well tolerated, but routine technique of blood pressure monitoring should be adjusted to the continuous blood flow. Both hemodialysis and peritoneal dialysis can be used. Unique challenges for chronic KRT posed by the presence of LVAD are discussed in this review.
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Impact of Renal Dysfunction on Outcomes after Left Ventricular Assist Device: A Systematic Review. INTERNATIONAL JOURNAL OF HEART FAILURE 2021; 3:69-77. [PMID: 36263113 PMCID: PMC9536719 DOI: 10.36628/ijhf.2020.0030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/18/2020] [Accepted: 09/29/2020] [Indexed: 01/05/2023]
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Husain-Syed F, Gröne HJ, Assmus B, Bauer P, Gall H, Seeger W, Ghofrani A, Ronco C, Birk HW. Congestive nephropathy: a neglected entity? Proposal for diagnostic criteria and future perspectives. ESC Heart Fail 2020; 8:183-203. [PMID: 33258308 PMCID: PMC7835563 DOI: 10.1002/ehf2.13118] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/13/2020] [Accepted: 10/31/2020] [Indexed: 12/12/2022] Open
Abstract
Venous congestion has emerged as an important cause of renal dysfunction in patients with cardiorenal syndrome. However, only limited progress has been made in differentiating this haemodynamic phenotype of renal dysfunction, because of a significant overlap with pre-existing renal impairment due to long-term hypertension, diabetes, and renovascular disease. We propose congestive nephropathy (CN) as this neglected clinical entity. CN is a potentially reversible subtype of renal dysfunction associated with declining renal venous outflow and progressively increasing renal interstitial pressure. Venous congestion may lead to a vicious cycle of hormonal activation, increased intra-abdominal pressure, excessive renal tubular sodium reabsorption, and volume overload, leading to further right ventricular (RV) stress. Ultimately, renal replacement therapy may be required to relieve diuretic-resistant congestion. Effective decongestion could preserve or improve renal function. Congestive acute kidney injury may not be associated with cellular damage, and complete renal function restoration may be a confirmatory diagnostic criterion. In contrast, a persistently low renal perfusion pressure might induce renal dysfunction and histopathological lesions with time. Thus, urinary markers may differ. CN is mostly seen in biventricular heart failure but may also occur secondary to pulmonary arterial hypertension and elevated intra-abdominal pressure. An increase in central venous pressure to >6 mmHg is associated with a steep decrease in glomerular filtration rate. However, the central venous pressure range that can provide an optimal balance of RV and renal function remains to be determined. We propose criteria to identify cardiorenal syndrome subgroups likely to benefit from decongestive or pulmonary hypertension-specific therapies and suggest areas for future research.
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Affiliation(s)
- Faeq Husain-Syed
- Department of Internal Medicine II, Division of Nephrology, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392, Giessen, Germany.,Department of Internal Medicine II, Division of Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392, Giessen, Germany.,International Renal Research Institute of Vicenza, Via Rodolfi, 37-36100, Vicenza, Italy
| | - Hermann-Josef Gröne
- Department of Pharmacology, University of Marburg, Karl-von-Frisch-Strasse, 35043, Marburg, Germany
| | - Birgit Assmus
- Department of Internal Medicine I, Division of Cardiology and Angiology, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392, Giessen, Germany
| | - Pascal Bauer
- Department of Internal Medicine I, Division of Cardiology and Angiology, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392, Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine II, Division of Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392, Giessen, Germany.,Member of the German Centre for Lung Research (DZL), Universities of Giessen and Marburg Lung Centre (UGMLC), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine II, Division of Nephrology, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392, Giessen, Germany.,Department of Internal Medicine II, Division of Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392, Giessen, Germany.,Member of the German Centre for Lung Research (DZL), Universities of Giessen and Marburg Lung Centre (UGMLC), Giessen, Germany.,Institute for Lung Health (ILH), Justus Liebig Medical University, Ludwigstrasse 23, 35390, Giessen, Germany.,The Cardio-Pulmonary Institute, Aulweg 130, 35392, Giessen, Germany.,Department of Lung Development and Remodeling, Max Planck Institute for Heart and Lung Research, Ludwigstrasse 43, 61231, Bad Nauheim, Germany
| | - Ardeschir Ghofrani
- Department of Internal Medicine II, Division of Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392, Giessen, Germany.,Member of the German Centre for Lung Research (DZL), Universities of Giessen and Marburg Lung Centre (UGMLC), Giessen, Germany.,Department of Pulmonology, Kerckhoff Heart, Rheuma and Thoracic Centre, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.,Department of Medicine, Imperial College London, London, UK
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Via Rodolfi, 37-36100, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Via Rodolfi, 37-36100, Vicenza, Italy.,Department of Medicine (DIMED), Università di Padova, Via Giustiniani, 2-35128, Padua, Italy
| | - Horst-Walter Birk
- Department of Internal Medicine II, Division of Nephrology, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392, Giessen, Germany
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15
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Improvement in Kidney Function After Ventricular Assist Device Implantation and Its Influence on Thromboembolism, Hemorrhage, and Mortality. ASAIO J 2020; 66:268-276. [PMID: 30883405 DOI: 10.1097/mat.0000000000000989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Although heart transplantation remains the gold standard for management of heart failure, ventricular assist devices (VAD) have emerged as viable alternatives. VAD implantation improves kidney function. However, whether the improvement is sustained or associated with improved outcomes is unclear. Herein we assess kidney function improvement, predictors of improvement, and associations with thromboembolism, hemorrhage, and mortality in VAD patients. Kidney function was defined using chronic kidney disease (CKD) stages: stage 1 (glomerular filtration rate [eGFR] ≥ 90 ml/min/1.73 m), stage 2 (eGFR 60-90 ml/min/1.73 m), stage 3a (eGFR 45-59 ml/min/1.73 m), stage 3b (eGFR 30-44 ml/min/1.73 m), stage 4 (eGFR 15-30 ml/min/1.73 m), and stage 5 (eGFR < 15 ml/min/1.73 m). Improvement in kidney function was defined as an improvement in eGFR that resulted in a CKD stage change to one of lesser severity. Kidney function improved post implant, and was maintained over 1 year for all patients, except those with baseline stage 5 CKD. Younger age at implantation (OR 0.93, 95% CI: 0.90-0.96, P < 0.0001) was associated with sustained improvement in kidney function. Poor kidney function was associated increased mortality but not with thromboembolism or hemorrhage. Compared to patients with baseline eGFR > 45 ml/min/1.73 m; patients with eGFR < 45 ml/min/1.73 m had a higher mortality risk (HR 3.32, 95% CI: 1.10-9.98, p = 0.03 for stage 3b; HR 4.07, 95% CI: 1.27-13.1, p = 0.02 for stage 4; and HR 4.01, 95% CI: 1.17-13.7, p = 0.03 for stage 5 CKD). Kidney function was not associated with thromboembolism or hemorrhage, and sustained improvement was not associated with lower risk of death. However, poor kidney function at implantation was associated with an increased risk of mortality.
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Ribeiro RVP, Alvarez JS, Fukunaga N, Yu F, Adamson MB, Foroutan F, Cusimano RJ, Yau T, Ross H, Alba AC, Billia F, Badiwala MV, Rao V. Redo sternotomy versus left ventricular assist device explant as risk factors for early mortality following heart transplantation. Interact Cardiovasc Thorac Surg 2020; 31:603-610. [DOI: 10.1093/icvts/ivaa180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/19/2020] [Accepted: 07/26/2020] [Indexed: 01/06/2023] Open
Abstract
Abstract
OBJECTIVES
There is an increasing proportion of patients with a previous sternotomy (PS) or durable left ventricular assist device (LVAD) undergoing heart transplantation (HT). We hypothesized that patients with LVAD support at the time of HT have a lower risk than patients with PS and may have a comparable risk to patients with a virgin chest (VC).
METHODS
This is a single-centre retrospective cohort study of all adults who underwent primary single-organ HT between 2002 and 2017. Multivariable Cox regression analyses were performed to compare 30-day and 1-year mortality between transplanted patients with a VC (VC-HT), a PS (PS-HT) or an LVAD explant (LVAD-HT).
RESULTS
Three hundred seventy-nine patients were analysed (VC-HT: 196, PS-HT: 94, LVAD-HT: 89). A larger proportion of patients in the LVAD-HT group were males (83%), had blood group O (52%), non-ischaemic aetiology (70%) and sensitization (67%). The PS-HT group had a higher frequency of patients with congenital heart disease (30%) and PSs compared to LVAD-HT patients (P < 0.001). PS-HT and LVAD-HT patients required a longer bypass time (P < 0.001) and showed a greater estimated blood loss (P < 0.001). Postoperatively, LVAD-HT required haemodialysis more frequently than the VC-HT group (P = 0.031). Multivariable analyses found that PS-HT patients had increased 30-day mortality compared to VC-HT [hazard ratio (HR) 2.63, 95% confidence interval (CI) 1.15–6.01; P = 0.022] while LVAD-HT did not (HR 2.17, 95% CI 0.96–4.93; P = 0.064). At 1-year, neither PS-HT nor LVAD-HT groups were significantly associated with increased mortality compared to VC-HT.
CONCLUSIONS
Transplants in recipients with PS-HT demonstrated increased early mortality compared to VC-HT patients. Although LVAD explant is often technically challenging, this population demonstrated similar mortality compared to those VC-HT patients. The chronic and perioperative support provided by the LVAD may play a favourable role in early patient outcomes compared to other redo sternotomy patients.
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Affiliation(s)
- Roberto Vanin Pinto Ribeiro
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Juglans Souto Alvarez
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Naoto Fukunaga
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Frank Yu
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mitchell Brady Adamson
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Farid Foroutan
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Robert James Cusimano
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Terrence Yau
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Heather Ross
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ana Carolina Alba
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Filio Billia
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mitesh Vallabh Badiwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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17
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Austin D, McCanny P, Aneman A. Post-operative renal failure management in mechanical circulatory support patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:833. [PMID: 32793678 PMCID: PMC7396231 DOI: 10.21037/atm-20-1172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) occurs commonly in patients requiring mechanical circulatory support (MCS) after cardiothoracic surgery. The prognostic implications of AKI in this patient group relate closely to the pathophysiology and risk factors associated with the underlying disease; pre-operative, intra-operative, and post-operative variables; hemodynamic factors; and type of support device used. General approaches to AKI management, including prevention strategies, medical management, and hemodynamic support, are also applicable in patients requiring MCS. Approaches to renal replacement therapy vary depend on patient factors, device-specific factors, and local preferences and experience. In this invited narrative review, we discuss the pathophysiology, risk factors, and prognostic implications of AKI in post-operative adult patients following institution of MCS. Management strategies for AKI are presented with a focus on those supported with either extracorporeal membrane oxygenation or a ventricular assist device.
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Affiliation(s)
- Danielle Austin
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Peter McCanny
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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18
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Kirklin JK, Pagani FD, Goldstein DJ, John R, Rogers JG, Atluri P, Arabia FA, Cheung A, Holman W, Hoopes C, Jeevanandam V, John R, Jorde UP, Milano CA, Moazami N, Naka Y, Netuka I, Pagani FD, Pamboukian SV, Pinney S, Rogers JG, Selzman CH, Silverstry S, Slaughter M, Stulak J, Teuteberg J, Vierecke J, Schueler S, D'Alessandro DA. American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support. J Thorac Cardiovasc Surg 2020; 159:865-896. [DOI: 10.1016/j.jtcvs.2019.12.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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19
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The mid-term effect of left ventricular assist devices on renal functions. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:320-328. [PMID: 32082879 DOI: 10.5606/tgkdc.dergisi.2019.17568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/31/2019] [Indexed: 11/21/2022]
Abstract
Background In this study, we aimed to investigate the mid-term effects of left ventricular assist devices on kidney functions. Methods Between January 2015 and December 2017, a total of 61 patients (53 males, 8 females; mean age 46.4±11.2 years; range, 20 to 67 years) who underwent left ventricular assist device implantation were retrospectively analyzed. Glomerular filtration rate was evaluated preoperatively and at 24 and 48 h, at one week, and at one, three, and six months postoperatively. According to the preoperative glomerular filtration rates, the patients were divided into three groups: glomerular filtration rates ?60 mL/min/1.73 m2 ( Group 1 ), g lomerular f iltration rates 61-90 mL/min/1.73 m2 (Group 2), and glomerular filtration rates >90 mL/min/1.73 m2 (Group 3). Results In all groups, the glomerular filtration rate significantly increased at one week and one month postoperatively, compared to preoperative values (p<0.001 and p<0.01, respectively). However, the glomerular filtration values at six months significantly decreased, compared to the values at one week and one month postoperatively (p<0.001 and p<0.001, respectively). The most significant drop to preoperative values was observed in Group 3 (p=0.02) at three months and it dropped below the preoperative level at six months (p<0.001). Conclusion Our study results suggest that left ventricular assist devices can significantly increase the glomerular filtration rate in short-term, irrespective of baseline values. However, this improvement may recede later, particularly in patients with normal renal functions, and it may even disappear following the third postoperative month.
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20
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Jha AK, Lata S. Kidney transplantation and cardiomyopathy: Concepts and controversies in clinical decision-making. Clin Transplant 2020; 34:e13795. [PMID: 31991012 DOI: 10.1111/ctr.13795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/21/2019] [Accepted: 01/24/2020] [Indexed: 11/30/2022]
Abstract
Increasing comorbidities and an aging population have led to a tremendous increase in the burden of both kidney and cardiac dysfunction. Concomitant cardiomyopathy exposes the patients with kidney disease to further physiological, hemodynamic, and pathologic alterations. Kidney transplantation imposes lesser anesthetic and surgical complexities compared to another solid organ transplant. The surgical decision-making remains an unsettled issue in these conditions. The surgical choices, techniques, and sequences in kidney transplant and cardiac surgery depend on the pathophysiological perturbations and perioperative outcomes. The absence of randomized controlled trials eludes us from suggesting definite management protocol in patients with end-stage kidney disease with cardiomyopathy. Nevertheless, in this review, we extracted data from published literature to understand the pathophysiologic interactions between end-stage renal diseases with cardiomyopathy and also proposed the management algorithm in this challenging scenario. The proposed management algorithm would ensure consensus across all stakeholders involved in decision-making. Our simplistic evidence-based approach would augur future randomized trials and would further ensure refinement in our management approach after the emergence of more definitive evidence.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suman Lata
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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21
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Kirklin JK, Pagani FD, Goldstein DJ, John R, Rogers JG, Atluri P, Arabia FA, Cheung A, Holman W, Hoopes C, Jeevanandam V, John R, Jorde UP, Milano CA, Moazami N, Naka Y, Netuka I, Pagani FD, Pamboukian SV, Pinney S, Rogers JG, Selzman CH, Silverstry S, Slaughter M, Stulak J, Teuteberg J, Vierecke J, Schueler S, D'Alessandro DA. American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support. J Heart Lung Transplant 2020; 39:187-219. [PMID: 31983666 DOI: 10.1016/j.healun.2020.01.1329] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - James K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala.
| | | | - Daniel J Goldstein
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | | | | | | | | | | | - Anson Cheung
- University of British Columbia, Vancouver, British Columbia, Canada
| | - William Holman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Charles Hoopes
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | | | | | - Ulrich P Jorde
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | | | - Nader Moazami
- Langone Medical Center, New York University, New York, NY
| | - Yoshifumi Naka
- Columbia University College of Physicians & Surgeons, New York, NY
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Salpy V Pamboukian
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | | | | | | | | | | | - John Stulak
- Mayo Clinic College of Medicine and Science, Rochester, Minn
| | | | | | | | - Stephan Schueler
- Department for Cardiothoracic Surgery, Newcastle upon Tyne Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - David A D'Alessandro
- Department of Cardiothoracic Surgery, Massachusetts General Hospital, Boston, Mass
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22
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Quader M, Goodreau AM, Johnson RM, Wolfe LG, Feldman GM. Impact of renal function recovery utilizing left ventricular assist device support. J Card Surg 2019; 35:100-107. [DOI: 10.1111/jocs.14320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Mohammed Quader
- Department of Surgery, Division of Cardio‐thoracic Surgery Virginia Commonwealth University Richmond Virginia
| | - Adam M. Goodreau
- Department of Surgery, Division of Cardio‐thoracic Surgery Virginia Commonwealth University Richmond Virginia
| | - Ryan M. Johnson
- Department of Surgery, Division of Cardio‐thoracic Surgery Virginia Commonwealth University Richmond Virginia
| | - Luke G. Wolfe
- Department of Surgery, Division of Cardio‐thoracic Surgery Virginia Commonwealth University Richmond Virginia
| | - George M. Feldman
- Department of Medicine, Division of Nephrology Virginia Commonwealth University Richmond Virginia
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Grosman-Rimon L, Hui SG, Freedman D, Elbaz-Greener G, Cherney D, Rao V. Biomarkers of Inflammation, Fibrosis, and Acute Kidney Injury in Patients with Heart Failure with and without Left Ventricular Assist Device Implantation. Cardiorenal Med 2019; 9:108-116. [PMID: 30699407 DOI: 10.1159/000494090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 09/27/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Renal dysfunction or renal failure is a common complication in left ventricular assist device (LVAD) recipients and is associated with reduced survival. To date, serum creatinine and glomerular filtration rate (GFR) are used for the evaluation of kidney function. However, serum creatinine and GFR have limitations. The objective of our study is to assess the levels of kidney biomarkers in LVAD recipients compared to heart failure patients and healthy controls and to examine their association with conventional clinical biomarkers. METHODS The biomarkers neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), plasminogen activator inhibitor-1 (PAI-1), and adiponectin were assessed in 51 participants: 19 heart failure patients, 16 LVAD recipients, and 16 healthy controls. Linear regressions were performed to assess whether demographic and clinical variables predict the levels of biomarkers that are associated with acute kidney injury and the risk of chronic kidney disease. RESULTS The levels of NGAL and adiponectin were higher in LVAD recipients and patients with heart failure as compared with healthy controls. The levels of PAI-1 and KIM-1 were not elevated in LVAD recipients. The results of linear regression analysis indicated that when controlling for the effect of CRP and BNP, 40.1% of the variance in NGAL levels can be explained by GFR (R2 = 0.401, F = 5.56, p = 0.005), while CRP can explain 35.3% of the variance in adiponectin levels (R2 = 0.353, F = 4.55, p = 0.01), when controlling for the effect of BNP and GFR. CONCLUSIONS The levels of NGAL and adiponectin were augmented in LVAD recipients, suggesting that renal functions were not restored with circulatory support. Larger studies should assess the predictability of these biomarkers of renal dysfunction in LVAD recipients.
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Affiliation(s)
- Liza Grosman-Rimon
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Genevieve Hui
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Danit Freedman
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gabby Elbaz-Greener
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - David Cherney
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada,
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24
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Zaleska-Kociecka M, Dabrowski M, Stepinska J. Acute kidney injury after transcatheter aortic valve replacement in the elderly: outcomes and risk management. Clin Interv Aging 2019; 14:195-201. [PMID: 30718946 PMCID: PMC6345183 DOI: 10.2147/cia.s149916] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aortic stenosis is the most common cause of valve replacement in Europe and North America with prevalence increasing with age. Transcatheter valve replacement (TAVR) represents an alternative for surgical valve replacement of severely stenotic valves. Despite lower risk of acute kidney injury compared to that associated with surgery, this complication remains prevalent in patients undergoing TAVR. There is a paucity of data confirming the relation of acute kidney injury with high morbidity and mortality, especially when superimposed on chronic kidney disease, which is a frequent comorbidity in the elderly with severe aortic stenosis. As there is no consensus on the prevention of acute kidney injury in patients undergoing TAVR, identification and limitation of risk factors are crucial. In this review, we aim to discuss the key aspects of acute kidney injury diagnosis, risk assessment, and outcomes in TAVR patients, and to point out gaps in current knowledge.
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Affiliation(s)
| | - Maciej Dabrowski
- Interventional Cardiology and Angiology Clinic, Institute of Cardiology, Warsaw, Poland
| | - Janina Stepinska
- Cardiac Intensive Therapy Clinic, Institute of Cardiology, Warsaw, Poland,
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The Physiological Rationale for Incorporating Pulsatility in Continuous-Flow Left Ventricular Assist Devices. Cardiol Rev 2018; 26:294-301. [DOI: 10.1097/crd.0000000000000202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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26
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Friedland-Little JM, Hong BJ, Gossett JG, Deshpande SR, Law S, Hollifield KA, Cantor RS, Koehl D, Kindel SJ, Turrentine MW, Davies RR. Changes in renal function after left ventricular assist device placement in pediatric patients: A Pedimacs analysis. J Heart Lung Transplant 2018; 37:1218-1225. [PMID: 30293616 DOI: 10.1016/j.healun.2018.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/21/2018] [Accepted: 06/21/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Renal dysfunction (RD) is prevalent among pediatric patients with advanced heart failure. Data are limited regarding changes in renal function after left ventricular assist device (LVAD) placement in this population. METHODS Pediatric LVAD recipients enrolled in the Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) between September 19, 2012 and June 30, 2016 were included. Longitudinal changes in renal function were analyzed for the entire cohort as well as subgroups stratified by patient and device characteristics. Logistic regression was used to attempt to identify factors associated with lack of improvement in renal function after LVAD placement. Post-LVAD outcomes were assessed using the Kaplan‒Meier method. RESULTS Data from 247 patients from 39 centers were analyzed. Baseline RD (estimated glomerular filtration rate [eGFR] <90 ml/min/1.73 m2) was present in 150 (61%) patients. Overall, eGFR improved post-LVAD, peaking at 1 month post-implant. There was an inverse relationship between baseline eGFR and the degree of improvement at 1 month. Degree of improvement in eGFR at 1 month was not impacted by device type, age, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, or diagnosis. Failure to normalize renal function at 1 week was correlated with persistent RD at 1 month. Post-implant outcomes did not differ among patients stratified by pre-implant renal function. CONCLUSIONS Renal function improves post-LVAD placement in pediatric patients regardless of age, diagnosis, illness severity, or device type, with improvement most pronounced in patients with baseline RD. Identifying patients with irreversible renal dysfunction before LVAD placement remains difficult. Pre-LVAD renal function does not appear to impact survival to transplant.
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Affiliation(s)
| | - Borah J Hong
- Heart Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jeffrey G Gossett
- Division of Pediatric Cardiology, University of California at San Francisco, San Francisco, California, USA
| | - Shriprasad R Deshpande
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sabrina Law
- Division of Pediatric Cardiology, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA
| | - Kathryn A Hollifield
- Kirklin Institute for Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryan S Cantor
- Kirklin Institute for Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Devin Koehl
- Kirklin Institute for Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Steven J Kindel
- Division of Pediatric Cardiology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mark W Turrentine
- Division of Cardiothoracic Surgery, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
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Schmack B, Grossekettler L, Weymann A, Schamroth J, Sabashnikov A, Raake PW, Popov AF, Mansur A, Karck M, Schwenger V, Ruhparwar A. Prognostic relevance of hemodialysis for short-term survival in patients after LVAD implantation. Sci Rep 2018; 8:8546. [PMID: 29867122 PMCID: PMC5986780 DOI: 10.1038/s41598-018-26515-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/14/2018] [Indexed: 01/01/2023] Open
Abstract
End-stage heart failure (HF) is associated with renal failure (RF). This study aimed to determine the prognostic influence of RF and post-operative hemodialysis on short-term survival following left ventricular assist device (LVAD) implantation. This retrospective study includes 68 patients undergoing LVAD treatment. Kidney function was recorded prior to LVAD implantation, immediately afterwards and after 30 days, noting the need for hemodialysis. Median pre-operative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) classification was 3.47 ± 1.08. 30 days after implantation there was a significant improvement of estimated glomerular filtration rate (eGFR) and reduction of blood urea nitrogen (BUN). Of pre-operative RF parameters, BUN was associated with increased mortality and need for early post-operative hemodialysis. Post-operative hemodialysis was associated with significantly lower short-term survival, while pre-operative hemodialysis did not impact mortality. Post-operative acute kidney injury (AKI) requiring hemodialysis can be regarded as a strong negative prognostic marker for short-term survival. The absence of a clear correlation between most routine RF parameters and survival or the need for early post-operative hemodialysis calls into question the predictive value of pre-operative RF. The negative association of only post-operative hemodialysis on short-term survival emphasises the impact of the occurrence of AKI.
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Affiliation(s)
- Bastian Schmack
- Department of Cardiac Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Leonie Grossekettler
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, University Hospital Oldenburg, Oldenburg, Germany
| | - Joel Schamroth
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Philip W Raake
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Aron F Popov
- Department of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University, Frankfurt am Main, Germany
| | - Ashham Mansur
- University Medical Center, University of Goettingen, Department of Anesthesiology, Emergency and Intensive Care Medicine, Goettingen, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Vedat Schwenger
- Department of Internal Medicine I, Section Nephrology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital of Heidelberg, Heidelberg, Germany
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Anjum A, Kurihara C, Critsinelis A, Kawabori M, Sugiura T, Civitello AB, Etheridge WB, Delgado RM, Simpson L, George JK, Nair AP, Frazier OH, Morgan JA. Acute kidney injury after implantation of a left ventricular assist device: a comparison of axial-flow (HeartMate II) and centrifugal-flow (HeartWare HVAD) devices. J Artif Organs 2018; 21:285-292. [DOI: 10.1007/s10047-018-1047-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/08/2018] [Indexed: 12/17/2022]
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29
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Nijenhuis VJ, Peper J, Vorselaars VMM, Swaans MJ, De Kroon T, Van der Heyden JAS, Rensing BJWM, Heijmen R, Bos WJW, Ten Berg JM. Prognostic Value of Improved Kidney Function After Transcatheter Aortic Valve Implantation for Aortic Stenosis. Am J Cardiol 2018. [PMID: 29525062 DOI: 10.1016/j.amjcard.2018.01.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is associated with acute kidney injury (AKI), but can also improve the kidney function (IKF). We assessed the effects of kidney function changes in relation to baseline kidney function on 2-year clinical outcomes after TAVI. In total, 639 consecutive patients with aortic stenosis who underwent TAVI were stratified into 3 groups according to the ratio of serum creatinine post- to pre-TAVI: IKF (≤0.80; n = 95 [15%]), stable kidney function (0.80 to 1.5; n = 477 [75%]), and AKI (≥1.5; n = 67 [10%]). Different AKI risk scores were compared using receiving-operator characteristics. Median follow-up was 24 (8 to 44) months. At 3 months, the increase in estimated glomerular filtration rate in the IKF group remained, and the decreased estimated glomerular filtration rate in the AKI group recovered. Compared with a stable kidney function, AKI showed a higher 2-year mortality rate (adjusted hazard ratio [HR] 3.69, 95% confidence interval [CI] 2.43 to 5.62) and IKF a lower mortality rate (adjusted hazard ratio 0.53, 95% CI 0.30 to 0.93). AKI also predicted major and life-threatening bleeding (adjusted odds ratio 2.94, 95% CI 1.27 to 6.78). Independent predictors of AKI were chronic kidney disease and pulmonary hypertension. Independent predictors of IKF were female gender, a preserved kidney function, absence of atrial fibrillation, and hemoglobin level. Established AKI risk scores performed moderately and did not differentiate between AKI and IKF. In conclusion, AKI is transient and is independently associated with a higher mortality rate, whereas IKF is sustained and is associated with a lower mortality rate. These effects are independent of baseline kidney function. Further studies are warranted to investigate the role of IKF and generate a dedicated prediction model.
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Affiliation(s)
| | - Joyce Peper
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Thom De Kroon
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Benno J W M Rensing
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Robin Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Willem-Jan W Bos
- Department of Internal Medicine and Nephrology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jurrien M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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30
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Miyamoto T, Karimov JH, Fukamachi K. Effects of continuous and pulsatile flows generated by ventricular assist devices on renal function and pathology. Expert Rev Med Devices 2018; 15:171-182. [DOI: 10.1080/17434440.2018.1437346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Jamshid H. Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
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31
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Ross DW, Stevens GR, Wanchoo R, Majure DT, Jauhar S, Fernandez HA, Merzkani M, Jhaveri KD. Left Ventricular Assist Devices and the Kidney. Clin J Am Soc Nephrol 2018; 13:348-355. [PMID: 29070522 PMCID: PMC5967423 DOI: 10.2215/cjn.04670417] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Left ventricular assist devices (LVADs) are common and implantation carries risk of AKI. LVADs are used as a bridge to heart transplantation or as destination therapy. Patients with refractory heart failure that develop chronic cardiorenal syndrome and CKD often improve after LVAD placement. Nevertheless, reversibility of CKD is hard to predict. After LVAD placement, significant GFR increases may be followed by a late return to near baseline GFR levels, and in some patients, a decline in GFR. In this review, we discuss changes in GFR after LVAD placement, the incidence of AKI and associated mortality after LVAD placement, the management of AKI requiring RRT, and lastly, we review salient features about cardiorenal syndrome learned from the LVAD experience. In light of the growing number of patients using LVADs as a destination therapy, it is important to understand the effect of these devices on the kidney. Additional research and long-term data are required to better understand the relationship between the LVAD and the kidney.
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Affiliation(s)
- Daniel W. Ross
- Division of Kidney Diseases and Hypertension, Department of Medicine
| | | | - Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Department of Medicine
| | | | | | - Harold A. Fernandez
- Department of Cardiothoracic Surgery, Hofstra Northwell School of Medicine, Northwell Health, North Shore University Hospital, Manhasset, New York
| | - Massini Merzkani
- Division of Kidney Diseases and Hypertension, Department of Medicine
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Department of Medicine
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32
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Roehm B, Vest AR, Weiner DE. Left Ventricular Assist Devices, Kidney Disease, and Dialysis. Am J Kidney Dis 2018; 71:257-266. [DOI: 10.1053/j.ajkd.2017.09.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/20/2017] [Indexed: 12/19/2022]
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33
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Bansal N, Hailpern SM, Katz R, Hall YN, Kurella Tamura M, Kreuter W, O'Hare AM. Outcomes Associated With Left Ventricular Assist Devices Among Recipients With and Without End-stage Renal Disease. JAMA Intern Med 2018; 178:204-209. [PMID: 29255896 PMCID: PMC5801100 DOI: 10.1001/jamainternmed.2017.4831] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Left ventricular assist devices (LVADs) are widely used both as a bridge to heart transplant and as destination therapy in advanced heart failure. Although heart failure is common in patients with end-stage renal disease (ESRD), little is known about outcomes after LVAD implantation in this population. OBJECTIVE To determine the utilization of and outcomes associated with LVADs in nationally representative cohorts of patients with and without ESRD. DESIGN, SETTING AND PARTICIPANTS We described LVAD utilization and outcomes among Medicare beneficiaries after ESRD onset (defined as having received maintenance dialysis or a kidney transplant) from 2003 to 2013 based on Medicare claims linked to data from the United States Renal Data System (USRDS), a national registry for ESRD. We compared Medicare beneficiaries with ESRD to a 5% sample of Medicare beneficiaries without ESRD. EXPOSURES ESRD (vs no ESRD) among patients who underwent LVAD placement. MAIN OUTCOMES AND MEASURES The primary outcome was survival after LVAD placement. RESULTS Among the patients with ESRD, the mean age was 58.4 (12.1) years and 62.0% (96) were male. Among those without ESRD, the mean age was 62.2 (12.6) years and 75.1% (196) were male. From 2003 to 2013, 155 Medicare beneficiaries with ESRD (median and interquartile range [IQR] days from ESRD onset to LVAD placement were 1655 days [453-3050 days]) and 261 beneficiaries without ESRD in the Medicare 5% sample received an LVAD. During a median follow-up of 762 days (IQR, 92-3850 days), 127 patients (81.9%) with and 95 (36.4%) without ESRD died. more than half of patients with ESRD (80 [51.6%]) compared with 11 (4%) of those without ESRD died during the index hospitalization. The median time to death was 16 days (IQR 2-447 days) for patients with ESRD compared with 2125 days (IQR, 565-3850 days) for those without ESRD. With adjustment for demographics, comorbidity and time period, patients with ESRD had a markedly increased adjusted risk of death (hazard ratio, 36.3; 95% CI, 15.6-84.5), especially in the first 60 days after LVAD placement. CONCLUSIONS AND RELEVANCE Patients with ESRD at the time of LVAD placement had an extremely poor prognosis, with most surviving for less than 3 weeks. This information may be crucial in supporting shared decision-making around treatments for advanced heart failure for patients with ESRD.
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Affiliation(s)
- Nisha Bansal
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Susan M Hailpern
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Ronit Katz
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Yoshio N Hall
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University, Palo Alto, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - William Kreuter
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Ann M O'Hare
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle.,Kaiser Permanente Washington Research Institute, Seattle, Washington.,Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Mohamedali B, Bhat G. The Influence of Pre-Left Ventricular Assist Device (LVAD) Implantation Glomerular Filtration Rate on Long-Term LVAD Outcomes. Heart Lung Circ 2017; 26:1216-1223. [DOI: 10.1016/j.hlc.2017.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/19/2016] [Accepted: 01/03/2017] [Indexed: 01/15/2023]
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Verma S, Bassily E, Leighton S, Mhaskar R, Sunjic I, Martin A, Rihana N, Jarmi T, Bassil C. Renal Function and Outcomes With Use of Left Ventricular Assist Device Implantation and Inotropes in End-Stage Heart Failure: A Retrospective Single Center Study. J Clin Med Res 2017; 9:596-604. [PMID: 28611860 PMCID: PMC5458657 DOI: 10.14740/jocmr3039w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 12/29/2022] Open
Abstract
Background Left ventricular assist device (LVAD) and inotrope therapy serve as a bridge to transplant (BTT) or as destination therapy in patients who are not heart transplant candidates. End-stage heart failure patients often have impaired renal function, and renal outcomes after LVAD therapy versus inotrope therapy have not been evaluated. Methods In this study, 169 patients with continuous flow LVAD therapy and 20 patients with continuous intravenous inotrope therapy were analyzed. The two groups were evaluated at baseline and at 3 and 6 months after LVAD or inotrope therapy was started. The incidence of acute kidney injury (AKI), need for renal replacement therapy (RRT), BTT rate, and mortality for 6 months following LVAD or inotrope therapy were studied. Results between the groups were compared using Mann-Whitney U test and Chi-square with continuity correction or Fischer’s exact at the significance level of 0.05. Results Mean glomerular filtration rate (GFR) was not statistically different between the two groups, with P = 0.471, 0.429, and 0.847 at baseline, 3 and 6 months, respectively. The incidence of AKI, RRT, and BTT was not statistically different. Mortality was less in the inotrope group (P < 0.001). Conclusion Intravenous inotrope therapy in end-stage heart failure patients is non-inferior for mortality, incidence of AKI, need for RRT, and renal function for 6-month follow-up when compared to LVAD therapy. Further studies are needed to compare the effectiveness of inotropes versus LVAD implantation on renal function and outcomes over a longer time period.
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Affiliation(s)
- Sean Verma
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Emmanuel Bassily
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Shane Leighton
- Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida, Tampa, FL, USA
| | - Rahul Mhaskar
- Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida, Tampa, FL, USA
| | - Igor Sunjic
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Angel Martin
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Nancy Rihana
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Tambi Jarmi
- Department of Nephrology and Hypertension, University of South Florida, Tampa, FL, USA
| | - Claude Bassil
- Department of Nephrology and Hypertension, University of South Florida, Tampa, FL, USA
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Daimee UA, Kutyifa V. Left ventricular assist devices in patients with renal dysfunction: where are we heading? Expert Rev Med Devices 2017; 14:413-415. [PMID: 28521533 DOI: 10.1080/17434440.2017.1330148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Usama A Daimee
- a The Heart Research Follow-Up Program and Cardiology Division , University of Rochester Medical Center , Rochester , NY , USA
| | - Valentina Kutyifa
- a The Heart Research Follow-Up Program and Cardiology Division , University of Rochester Medical Center , Rochester , NY , USA
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37
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Bridge to durable left ventricular assist device for refractory cardiogenic shock. J Thorac Cardiovasc Surg 2017; 153:752-762.e5. [DOI: 10.1016/j.jtcvs.2016.10.085] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/27/2016] [Accepted: 10/20/2016] [Indexed: 11/19/2022]
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Abstract
Ventricular assist device patients (VAD) are at increased risk for thromboembolism. Biomarkers of hemolysis, such as lactate dehydrogenase (LDH) and poorly controlled international normalized ratio (INR) has been identified as predictors of thromboembolism. Patients aged 19 years and older who had a continuous flow VAD placed from 2006 to 2012 were included in this study (N = 115). We assessed the relationship of LDH elevation (≥600 IU/L) at different time points and thromboembolism. Over the 51.3 person-years of follow-up, a total of 23 first thromboembolic events occurred. Patients with elevated LDH on the day of VAD implantation had an increased risk for thromboembolism (hazard ratio [HR]: 4.72, 95% confidence interval [CI]: 1.44-15.4; p = 0.01). There was an increased risk of thromboembolism with early LDH elevation within the first month post-VAD (HR: 4.95, 95% CI: 1.69-14.4; p = 0.003) and estimated glomerular filtration rate <30 before VAD implantation (HR: 4.74, 95% CI: 1.12-20.1; p = 0.0346), whereas there was a decreased risk with good anticoagulation control (HR: 0.30, 95% CI: 0.10-0.86; p = 0.0247). Our study is the first to highlight the association between LDH elevation on the day of implantation and post-VAD thromboembolism. This study details the increased risk of thromboembolism with early LDH elevation and the importance of maintaining time in therapeutic INR range.
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39
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Sajgalik P, Grupper A, Edwards BS, Kushwaha SS, Stulak JM, Joyce DL, Joyce LD, Daly RC, Kara T, Schirger JA. Current Status of Left Ventricular Assist Device Therapy. Mayo Clin Proc 2016; 91:927-40. [PMID: 27378038 DOI: 10.1016/j.mayocp.2016.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 04/22/2016] [Accepted: 05/03/2016] [Indexed: 02/05/2023]
Abstract
Congestive heart failure (HF) remains a serious burden in the Western World. Despite advances in pharmacotherapy and resynchronization, many patients have progression to end-stage HF. These patients may be candidates for heart transplant or left ventricular assist device (LVAD) therapy. Heart transplants are limited by organ shortages and in some cases by patient comorbidities; therefore, LVAD therapy is emerging as a strategy of bridge to transplant or as a destination therapy in patients ineligible for transplant. Patients initially ineligible for a transplant may, in certain cases, become eligible for transplant after physiologic improvement with LVAD therapy, and a small number of patients with an LVAD may have sufficient recovery of myocardial function to allow device explantation. This clinically oriented review will describe (1) the most frequently used pump types and aspects of the continuous-flow physiology and (2) the clinical indications for and the shift toward the use of LVADs in less sick patients with HF. Additionally, we review complications of LVAD therapy and project future directions in this field. We referred to the Interagency Registry for Mechanically Assisted Circulatory Support, landmark trials, and results from recently published studies as major sources in obtaining recent outcomes, and we searched for related published literature via PubMed. This review focuses primarily on clinical practice for primary care physicians and non-HF cardiologists in the United States.
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Affiliation(s)
- Pavol Sajgalik
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Internal Medicine, Cardioangiology, International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Avishay Grupper
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Brook S Edwards
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - David L Joyce
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Lyle D Joyce
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Richard C Daly
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Tomas Kara
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Internal Medicine, Cardioangiology, International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - John A Schirger
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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40
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Flores S, Rhodes Proctor Short S, Basu RK. Acute kidney injury in pediatric heart transplantation and extracorporeal cardiac support therapies. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2015.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Outcomes in Patients with Severe Preexisting Renal Dysfunction After Continuous-Flow Left Ventricular Assist Device Implantation. ASAIO J 2016; 62:261-7. [DOI: 10.1097/mat.0000000000000330] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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May LJ, Montez-Rath ME, Yeh J, Axelrod DM, Chen S, Maeda K, Almond CSD, Rosenthal DN, Hollander SA, Sutherland SM. Impact of ventricular assist device placement on longitudinal renal function in children with end-stage heart failure. J Heart Lung Transplant 2015; 35:449-56. [PMID: 26653933 DOI: 10.1016/j.healun.2015.10.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/21/2015] [Accepted: 10/30/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although ventricular assist devices (VADs) restore hemodynamics in those with heart failure, reversibility of end-organ dysfunction with VAD support is not well characterized. Renal function often improves in adults after VAD placement, but this has not been comprehensively explored in children. METHODS Sixty-three children on VAD support were studied. Acute kidney injury (AKI) was defined by Kidney Disease: Improving Global Outcomes criteria. Estimated glomerular filtration rate (eGFR) was determined by the Schwartz method. Generalized linear mixed-effects models compared the pre-VAD and post-VAD eGFR for the cohort and sub-groups with and without pre-VAD renal dysfunction (pre-VAD eGFR < 90 ml/min/1.73 m(2)). RESULTS The pre-VAD eGFR across the cohort was 84.0 ml/min/1.73 m(2) (interquartile range [IQR] 62.3-122.7), and 55.6% (34 of 63) had pre-VAD renal dysfunction. AKI affected 60.3% (38 of 63), with similar rates in those with and without pre-existing renal dysfunction. Within the cohort, the nadir eGFR occurred 1 day post-operatively (62.9 ml/min/1.73 m(2); IQR, 51.2-88.9 ml/min/1.73 m(2); p < 0.001). By Day 5, however, the eGFR exceeded the baseline (99.0 ml/min/1.73 m(2); IQR, 59.3-146.7 ml/min/1.73 m(2); p = 0.03) and remained significantly higher through the first post-operative week. After adjusting for age, gender, and AKI, the eGFR continued to increase throughout the entire 180-day study period (β = 0.0025; 95% confidence interval, 0.0015-0.0036; p < 0.001). Patients with pre-VAD renal dysfunction experienced the greatest improvement in the eGFR (β = 0.0051 vs β = 0.0013, p < 0.001). CONCLUSIONS Renal dysfunction is prevalent in children with heart failure undergoing VAD placement. Although peri-operative AKI is common, renal function improves substantially in the first post-operative week and for months thereafter. This is particularly pronounced in those with pre-VAD renal impairment, suggesting that VADs may facilitate recovery and maintenance of kidney function in children with advanced heart failure.
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Affiliation(s)
- Lindsay J May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Justin Yeh
- Division of Pediatric Cardiology, Department of Pediatrics, University of California San Diego, La Jolla, California
| | - David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Katsuhide Maeda
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - Christopher S D Almond
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Seth A Hollander
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Scott M Sutherland
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Gaffey AC, Phillips EC, Howard J, Hung G, Han J, Emery R, Goldberg L, Acker MA, Woo YJ, Atluri P. Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation. Ann Thorac Surg 2015; 100:542-9. [DOI: 10.1016/j.athoracsur.2015.02.093] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 02/24/2015] [Accepted: 02/27/2015] [Indexed: 11/29/2022]
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Abstract
The left ventricular assist device (LVAD) has become an established treatment option for patients with refractory heart failure. Many of these patients experience chronic kidney disease (CKD) due to chronic cardiorenal syndrome type II, which is often alleviated quickly following LVAD implantation. Nevertheless, reversibility of CKD remains difficult to predict. Interestingly, initial recovery of GFR appears to be transient, being followed by gradual but significant late decline. Nevertheless, GFR often remains elevated compared to preimplant status. Larger GFR increases are followed by a proportionally larger late decline. Several explanations for this gradual decline in renal function after LVAD therapy have been proposed, yet a definitive answer remains elusive. Mortality predictors of LVAD implantation are the occurrence of either postimplantation acute kidney injury (AKI) or preimplant CKD. However, patient outcomes continue to improve as LVAD therapy becomes more widespread, and adverse events including AKI appear to decline. In light of a growing destination therapy population, it is important to understand the cumulative effects of long-term LVAD support on kidney function. Additional research and passage of time are required to further unravel the intricate relationships between the LVAD and the kidney.
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Affiliation(s)
- T R Tromp
- University Medical Center Utrecht, POB 85500, 3508 GA, Utrecht, The Netherlands,
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The Use of Pediatric Ventricular Assist Devices in Children's Hospitals From 2000 to 2010: Morbidity, Mortality, and Hospital Charges. Pediatr Crit Care Med 2015; 16:522-8. [PMID: 25850863 DOI: 10.1097/pcc.0000000000000401] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The use of ventricular assist devices has increased dramatically in adult heart failure patients. However, the overall use, outcome, comorbidities, and resource utilization of ventricular assist devices in pediatric patients have not been well described. We sought to demonstrate that the use of ventricular assist devices in pediatric patients has increased over time and that mortality has decreased. DESIGN A retrospective study of the Pediatric Health Information System database was performed for patients 20 years old or younger undergoing ventricular assist device placement from 2000 to 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four hundred seventy-five pediatric patients were implanted with ventricular assist devices during the study period: 69 in 2000-2003 (era 1), 135 in 2004-2006 (era 2), and 271 in 2007-2010 (era 3). Median age at ventricular assist device implantation was 6.0 years (interquartile range, 0.5-13.8), and the proportion of children who were 1-12 years old increased from 29% in era 1 to 47% in era 3 (p = 0.002). The majority of patients had a diagnosis of cardiomyopathy; this increased from 52% in era 1 to 72% in era 3 (p = 0.003). Comorbidities included arrhythmias (48%), pulmonary hypertension (16%), acute renal failure (34%), cerebrovascular disease (28%), and sepsis/systemic inflammatory response syndrome (34%). Two hundred forty-seven patients (52%) underwent heart transplantation and 327 (69%) survived to hospital discharge. Hospital mortality decreased from 42% in era 1 to 25% in era 3 (p = 0.004). Median hospital length of stay increased (37 d [interquartile range, 12-64 d] in era 1 vs 69 d [interquartile range, 35-130] in era 3; p < 0.001) and median adjusted hospital charges increased ($630,630 [interquartile range, $227,052-$853,318] in era 1 vs $1,577,983 [interquartile range, $874,463-$2,280,435] in era 3; p < 0.001). Factors associated with increased mortality include age less than 1 year (odds ratio, 2.04; 95% CI, 1.01-3.83), acute renal failure (odds ratio, 2.1; 95% CI, 1.26-3.65), cerebrovascular disease (odds ratio, 2.1; 95% CI, 1.25-3.62), and extracorporeal membrane oxygenation (odds ratio, 3.16; 95% CI, 1.79-5.60). Ventricular assist device placement in era 3 (odds ratio, 0.3; 95% CI, 0.15-0.57) and a diagnosis of cardiomyopathy (odds ratio, 0.5; 95% CI, 0.32-0.84), were associated with decreased mortality. Large-volume centers had lower mortality (odds ratio, 0.55; 95% CI, 0.34-0.88), lower use of extracorporeal membrane oxygenation, and higher charges. CONCLUSIONS The use of ventricular assist devices and survival after ventricular assist device placement in pediatric patients have increased over time, with a concomitant increase in resource utilization. Age under 1 year, certain noncardiac morbidities, and the use of extracorporeal membrane oxygenation are associated with worse outcomes. Lower mortality was seen at larger volume ventricular assist device centers.
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Mao H, Katz N, Kim JC, Day S, Ronco C. Implantable left ventricular assist devices and the kidney. Blood Purif 2014; 37:57-66. [PMID: 24525434 DOI: 10.1159/000357970] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The use of left ventricular assist devices (LVADs) in treating patients with advanced heart failure restores cardiac output resulting in improved perfusion to multiple organ systems with important clinical benefits. Renal pathophysiology during LVAD support remains an evolving, poorly understood, and potentially dynamic problem. Changes in renal function after LVAD placement have been investigated in multiple studies with contradictory results. Renal dysfunction is common prior to LVAD placement, which complicates postoperative clinical outcomes. The purpose of this review is to assess the latest information regarding the effects of LVADs on renal function with regard to hemodynamics, physiology, pathology and clinical issues prior to and after placement of the devices. The review should then aid in identifying patients best suited to benefit from this technology and to refine the therapy to reduce associated risks.
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Affiliation(s)
- Huijuan Mao
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
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Gupta P, Carlson J, Wells D, Selakovich P, Robertson MJ, Gossett JM, Fontenot EE, Steiner MB. Relationship between renal function and extracorporeal membrane oxygenation use: a single-center experience. Artif Organs 2014; 39:369-74. [PMID: 25296564 DOI: 10.1111/aor.12379] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The effects of extracorporeal membrane oxygenation (ECMO) support on renal function in children with critical illness are unknown. The objective of this study was to investigate the impact of ECMO on renal function among children in different age groups. We performed a single-center retrospective observational study in critically ill children ≤ 18 years supported on ECMO for refractory cardiac or pulmonary failure (2006-2012). The patient population was divided into four age groups for the purpose of comparisons. The Acute Kidney Injury Network's (AKIN's) validated, three-tiered staging system for acute kidney injury was used to categorize the degree of worsening renal function. Data on patient demographics, baseline characteristics, renal function parameters, dialysis, ultrafiltration, duration of mechanical cardiac support, and mortality were collected. Comparisons of baseline characteristics, duration of mechanical cardiac support, and renal function were made between the four age groups. During the study period, 311 patients qualified for inclusion, of whom 289 patients (94%) received venoarterial (VA) ECMO, 12 (4%) received venovenous (VV) ECMO, and 8 (3%) received both VV and VA ECMO. A total of 109 patients (36%) received ultrafiltration on ECMO, 58 (19%) received hemodialysis, and 51 (16%) received peritoneal dialysis. There was a steady and sustained improvement in renal function in all age groups during the ECMO run, with the maximum and longest-sustained improvement occurring in the oldest age group. Proportions of patients in different AKIN stages remained similar in the first 7 days after ECMO initiation. We demonstrate that renal dysfunction improves early after ECMO support. Irrespective of the underlying disease process or patient age, renal function improves in children with pulmonary or cardiac failure who are placed on ECMO.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Division of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Abstract
Cardiac and renal diseases often coexist. Treatment may prove difficult as early diagnosis and effective therapy may be hindered by a lack of robust markers of disease activity. However, several candidate molecules are now available which may help elucidate the complexities of organ cross-talk, enabling effective therapies. We discuss the available data on the commonly studied biomarkers of acute kidney injury with reference to the cardiorenal syndrome. Furthermore, we propose how the use of biomarkers as a panel may provide information which can guide therapy. Although this is a relatively new field, advances are rapid, and such options may well be available to the clinician soon.
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Affiliation(s)
- Lui G Forni
- Department of Critical Care, Western Sussex Hospitals Foundation Trust, Worthing, UK
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Sumida M, Doi K, Kinoshita O, Kimura M, Ono M, Hamasaki Y, Matsubara T, Ishii T, Yahagi N, Nangaku M, Noiri E. Perioperative plasma neutrophil gelatinase-associated lipocalin measurement in patients who undergo left ventricular assist device implantation surgery. Circ J 2014; 78:1891-9. [PMID: 24931412 DOI: 10.1253/circj.cj-14-0008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Perioperative complication of end-organ injury including acute kidney injury (AKI) is a frequent and severe problem for patients undergoing left ventricular assist device (LVAD) implantation. This study evaluated an emerging AKI biomarker, plasma neutrophil gelatinase-associated lipocalin (NGAL), in a LVAD implantation cohort. METHODS AND RESULTS Of 31 LVAD implantation patients enrolled to this study, 17 (55%) patients were diagnosed as having AKI. Six AKI patients showed severe AKI requiring renal replacement therapy (RRT). Plasma NGAL values in the AKI-with-RRT group (n=6) were significantly higher than that in other patients, although the AKI-without-RRT (n=11) group showed a similar level of plasma NGAL to that of the non-AKI group (n=14). Multiple logistic regression analysis revealed that plasma NGAL measured at pre-operation and central venous pressure at pre-operation and 12 h after surgery independently discriminated against postoperative RRT requirement. In the AKI-with-RRT group, plasma NGAL decreased before termination of RRT in 4 patients who eventually showed renal recovery, although no decline of plasma NGAL was observed in 2 patients who showed no recovery of renal function. Removal of blood NGAL by continuous hemodiafiltration was shown to be 70-75% lower than that of creatinine. CONCLUSIONS Measurement of perioperative plasma NGAL is useful for predicting severe AKI requiring RRT and renal recovery in patients who have had LVAD implantation surgery. Further investigation is necessary to confirm these findings because this study examined a low number of patients.
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Affiliation(s)
- Maki Sumida
- Department of Nephrology and Endocrinology, The University of Tokyo
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