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Garcia LP, Walther CP. Kidney health and function with left ventricular assist devices. Curr Opin Nephrol Hypertens 2023; 32:439-444. [PMID: 37195244 PMCID: PMC10524584 DOI: 10.1097/mnh.0000000000000896] [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: 05/18/2023]
Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) is a group of evolving therapies used for indications ranging from temporary support during a cardiac procedure to permanent treatment of advanced heart failure. MCS is primarily used to support left ventricle function, in which case the devices are termed left ventricular assist devices (LVADs). Kidney dysfunction is common in patients requiring these devices, yet the impact of MCS itself on kidney health in many settings remains uncertain. RECENT FINDINGS Kidney dysfunction can manifest in many different forms in patients requiring MCS. It can be because of preexisting systemic disorders, acute illness, procedural complications, device complications, and long-term LVAD support. After durable LVAD implantation, most persons have improvement in kidney function; however, individuals can have markedly different kidney outcomes, and novel phenotypes of kidney outcomes have been identified. SUMMARY MCS is a rapidly evolving field. Kidney health and function before, during, and after MCS is relevant to outcomes from an epidemiologic perspective, yet the pathophysiology underlying this is uncertain. Improved understanding of the relationship between MCS use and kidney health is important to improving patient outcomes.
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Affiliation(s)
- Leonardo Pozo Garcia
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Carl P. Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
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Walther CP, Benoit JS, Lamba HK, Civitello AB, Erickson KF, Mondal NK, Liao KK, Navaneethan SD. Distinctive kidney function trajectories following left ventricular assist device implantation. J Heart Lung Transplant 2022; 41:1798-1807. [PMID: 36182652 PMCID: PMC10091513 DOI: 10.1016/j.healun.2022.08.024] [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] [Received: 09/27/2021] [Revised: 05/04/2022] [Accepted: 08/31/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of this study was to assess for distinct kidney function trajectories following left ventricular assist device (LVAD) placement. Cohort studies of LVAD recipients demonstrate that kidney function tends to increase early after LVAD placement, followed by decline and limited sustained improvement. Inter-individual differences in kidney function response may be obscured. METHODS We identified continuous flow LVAD implantations in US adults (2016-2017) from INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). Primary outcomes were estimated glomerular filtration rate (eGFR) trajectories pre-implantation to ∼12 months. Latent class mixed models were applied to primary and validation samples. Clinical differences among trajectory groups were investigated. RESULTS Among 4,615 LVAD implantations, 5 eGFR trajectory groups were identified. The 2 largest groups (Groups 1 and 2) made up >80% of the cohort, and were similar to group average trajectories previously reported, with early eGFR rise followed by decline and stabilization. Three novel trajectory groups were found: worsening followed by sustained low kidney function (Group 3, 10.1%), sustained improvement (Group 4, 3.3%), and worsening followed by variation (Group 5, 1.7%). These groups differed in baseline characteristics and outcomes. Group 4 was younger and had more cardiogenic shock and pre-implantation dialysis; Group 3 had higher rates of pre-existing chronic kidney disease, along with older age. CONCLUSIONS Novel eGFR trajectories were identified in a national cohort, possibly representing distinct cardiorenal processes. Type 1 cardiorenal syndrome may have been predominant in Group 4, and parenchymal kidney disease may have been predominant in Group 3.
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Affiliation(s)
- Carl P Walther
- Department of Medicine, Baylor College of Medicine, Selzman Institute for Kidney Health, Section of Nephrology, Houston, Texas.
| | - Julia S Benoit
- Texas Institute for Measurement, Evaluation, and Statistics, University of Houston, Houston, Texas
| | - Harveen K Lamba
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Andrew B Civitello
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Advanced Heart Failure Center of Excellence, Baylor College of Medicine, Houston, Texas
| | - Kevin F Erickson
- Department of Medicine, Baylor College of Medicine, Selzman Institute for Kidney Health, Section of Nephrology, Houston, Texas; Baker Institute for Public Policy, Rice University, Houston, Texas
| | - Nandan K Mondal
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Kenneth K Liao
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sankar D Navaneethan
- Department of Medicine, Baylor College of Medicine, Selzman Institute for Kidney Health, Section of Nephrology, Houston, Texas; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
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Lakhdar S, Nassar M, Buttar C, Guzman Perez LM, Akbar S, Zafar A, Munira M. Outcomes With Left Ventricular Assist Device in End-Stage Renal Disease: A Systematic Review. Cureus 2022; 14:e24227. [PMID: 35602813 PMCID: PMC9117860 DOI: 10.7759/cureus.24227] [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] [Accepted: 04/17/2022] [Indexed: 11/30/2022] Open
Abstract
Renal dysfunction is a common comorbidity in patients with advanced heart failure who may benefit from mechanical circulatory support (MCS). Unfortunately, renal function may result after left ventricular assist device (LVAD) implantation. The purpose of this study is to examine the outcomes of advanced heart failure patients with end-stage renal disease (ESRD) requiring mechanical circulatory support as a bridge to transplant (BTT) or destination therapy (DT). We searched Medline, Embase, and Cochrane in September 2021. The following keywords were used: left ventricular assist device or LVAD and end-stage renal disease or ESRD. Our study included case reports, case series, descriptive studies, and randomized control trials. Review articles, guidelines, systematic reviews, and meta-analyses were excluded. We also excluded pediatric cases. We identified 278 articles; 92 were duplicated, 186 articles entered the screening phase, and 133 articles were excluded by title and abstract. After the full-text screening, 40 articles were excluded. This systematic review included 13 articles. Among the contraindications to LVAD implantation, a general contraindication is for patients found to have stage 4 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR): <30 mL/minute/1.73 m2), while those on dialysis are an absolute contraindication LVAD implantation. Despite the limited data and publications on LVADs in patients with ESRD, LVAD implantation as a bridge to transplantation or destination therapy may be considered in selected patients without increasing morbidity and mortality. Therefore, shared decision-making around the treatment of advanced heart failure with these patients and the care team is essential.
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Affiliation(s)
- Sofia Lakhdar
- Internal Medicine, Queens Hospital Center, New York City, USA
| | - Mahmoud Nassar
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City Health and Hospitals/Queens, New York City, USA
| | - Chandan Buttar
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City Health and Hospitals/Queens, New York City, USA
| | - Laura M Guzman Perez
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York City, USA
| | - Shahzad Akbar
- Internal Medicine, Kettering Medical Center, Dayton, USA
| | - Anoosh Zafar
- Medicine, Rawal Institute of Health Sciences, Islamabad, PAK
| | - Most Munira
- Cardilogy/Medicine, Weill Cornell Medicine, New York City, USA
- Cardiology, Queens Hospital Center, New York City, USA
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Abstract
The challenge presented by sudden cardiac death in dialysis patients is to better define risk factors and delineate multiple etiologies. Only then can therapy be tailored to the highest risk patients and the incidence of sudden cardiac death be reduced. This article details the many possible etiologies and presents a brief overview of more recent research that may in the future prove of great benefit in improving the mortality of our patients with end-stage renal disease.
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Walther CP, Winkelmayer WC, Niu J, Cheema FH, Nair AP, Morgan JA, Fedson SE, Deswal A, Navaneethan SD. Acute Kidney Injury With Ventricular Assist Device Placement: National Estimates of Trends and Outcomes. Am J Kidney Dis 2019; 74:650-658. [PMID: 31160142 DOI: 10.1053/j.ajkd.2019.03.423] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 03/12/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Ventricular assist devices (VADs) are used for end-stage heart failure not amenable to medical therapy. Acute kidney injury (AKI) in this setting is common due to heart failure decompensation, surgical stress, and other factors. Little is known about national trends in AKI diagnosis and AKI requiring dialysis (AKI-D) and associated outcomes with VAD implantation. We investigated national estimates and trends for diagnosed AKI, AKI-D, and associated patient and resource utilization outcomes in hospitalizations in which implantable VADs were placed. STUDY DESIGN Cohort study of 20% stratified sample of US hospitalizations. SETTING & PARTICIPANTS Patients who underwent implantable VAD placement in 2006 to 2015. EXPOSURE No AKI diagnosis, AKI without dialysis, AKI-D. OUTCOMES In-hospital mortality, length of stay, estimated hospitalization costs. ANALYTICAL APPROACH Multivariate logistic and linear regression using survey design methods to account for stratification, clustering, and weighting. RESULTS An estimated 24,140 implantable VADs were placed, increasing from 853 in 2006 to 3,945 in 2015. AKI was diagnosed in 56.1% of hospitalizations and AKI-D occurred in 6.5%. AKI diagnosis increased from 44.0% in 2006 to 2007 to 61.7% in 2014 to 2015; AKI-D declined from 9.3% in 2006 to 2007 to 5.2% in 2014 to 2015. Mortality declined in all AKI categories but this varied by category: those with AKI-D had the smallest decline. Adjusted hospitalization costs were 19.1% higher in those with diagnosed AKI and 39.6% higher in those with AKI-D, compared to no AKI. LIMITATIONS Administrative data; timing of AKI with respect to VAD implantation cannot be determined; limited pre-existing chronic kidney disease ascertainment; discharge weights not derived for subpopulation of interest. CONCLUSIONS A decreasing proportion of patients undergoing VAD implantation experience AKI-D, but mortality among these patients remains high. AKI diagnosis with VAD implantation is increasing, possibly reflecting changes in AKI surveillance, awareness, and coding.
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Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine.
| | | | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine
| | - Faisal H Cheema
- Division of Cardiothoracic Transplantation and Circulatory Support
| | - Ajith P Nair
- Section of Cardiology, Department of Medicine, Baylor College of Medicine
| | - Jeffrey A Morgan
- Division of Cardiothoracic Transplantation and Circulatory Support; Department of Cardiopulmonary Transplantation and Center for Cardiac Support, Texas Heart Institute
| | - Savitri E Fedson
- Section of Cardiology, Department of Medicine, Baylor College of Medicine; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center; Center for Medical Ethics and Health Policy, Baylor College of Medicine
| | - Anita Deswal
- Section of Cardiology, Department of Medicine, Baylor College of Medicine; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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Doshi R, Taha M, Pisipati S, Patel K, Al-Khafaji J, Desai R, Shah J, Gullapalli N. Impact of chronic kidney disease on in-hospital outcomes following left ventricular assist device placement: A national perspective. Heart Lung 2019; 49:48-53. [PMID: 31153604 DOI: 10.1016/j.hrtlng.2019.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/19/2019] [Accepted: 05/18/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are being increasingly utilized for the treatment of stage-D heart failure. A LVAD is a battery-operated, mechanical pump that assists in pumping blood out of the left ventricle (LV) into the aorta, thereby lowering left ventricular burden. Prevalence of chronic kidney disease (CKD) is increasing in patients receiving LVAD. OBJECTIVES The purpose of this study was to compare in-hospital mortality and hospitalization expenditure associated with CKD in patients receiving LVAD implantation. METHODS Using the National Inpatient Sample from January 2012 through September 2015, index hospitalizations for LVAD were identified. Based on kidney function, LVAD recipients were divided into three groups: Group 1 included patients with normal renal function or CKD stages I-III. Groups 2 and 3 comprised of patients with CKD stage IV/V, and end-stage renal disease on dialysis respectively. RESULTS A total of 20,656 patients received LVAD during the study period. Mean age was 56.1 years; 76.8% were men. In a fully adjusted model, in-hospital mortality was higher in group 2 (OR: 1.33, CI: 1.16-1.50) and highest in group 3 (OR: 8.95, CI: 6.90-11.61). Similarly, the length of hospitalization, and hospitalization cost were higher in group 2 and highest in group 3. CONCLUSION Despite improving outcomes in patients receiving LVAD, CKD remained a significant health problem. Worsening in-hospital outcomes paralleling the degree of kidney dysfunction were observed in patients receiving LVADs in this study.
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Affiliation(s)
- Rajkumar Doshi
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States.
| | - Mohamed Taha
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States
| | - Sailaja Pisipati
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States
| | - Krunalkumar Patel
- Department of Cardiology, North Shore University Hospital - Northwell Health, Manhasset, NY, United States
| | - Jaafar Al-Khafaji
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States
| | - Rupak Desai
- Department of Cardiology, Atlanta VA Medical Center, Decatur, GA, United States
| | - Jay Shah
- Department of Internal Medicine, Mercy St. Vincent Medical Center, Toledo, OH, United States
| | - Nageshwara Gullapalli
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States
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Rangaswami J, Soman S, McCullough P. Key Updates in Cardio-Nephrology from 2018: Springboard to a Bright Future. Cardiorenal Med 2019; 9:222-228. [DOI: 10.1159/000498916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 02/14/2019] [Indexed: 11/19/2022] Open
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