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Nair N, Mahesh B, Du D. The Long-Term Survival of LVAD Patients-A TriNetX Database Analysis. J Clin Med 2024; 13:4096. [PMID: 39064136 PMCID: PMC11278369 DOI: 10.3390/jcm13144096] [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: 06/10/2024] [Revised: 07/03/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Donor shortage limits the utilization of heart transplantation, making it available for only a fraction of the patients on the transplant waiting list. Therefore, continuous-flow left ventricular assist devices (CF-LVADs) have evolved as a standard of care for end-stage heart failure. It is imperative therefore to investigate long-term survival in this population. Methods: This study assesses the impact of demographics, infections, comorbidities, types of cardiomyopathies, arrhythmias, and end-organ dysfunction on the long-term survival of LVAD recipients. The TriNetX database comprises de-identified patient information across healthcare organizations. The log-rank test assessed post-implant survival effects, while Cox regression was used in the univariate analysis to obtain the Hazard Ratio (HR). All analyses were conducted using the Python programming language and the lifelines library. Results: This study identified CMV, hepatitis A exposure, atrial fibrillation, paroxysmal ventricular tachycardia, ischemic cardiomyopathy, renal dysfunction, diabetes, COPD, mitral valve disease, and essential hypertension as risk factors that impact long-term survival. Interestingly, hypokalemia seems to have a protective effect and gender does not affect survival significantly. Conclusions: This is the first report of a detailed long-term survival assessment of the LVAD population using a decoded database.
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Affiliation(s)
- Nandini Nair
- Department of Medicine, Division of Cardiology, Penn State Health/PSUCOM, 500 University Drive, Hershey, PA 17033, USA
| | - Balakrishnan Mahesh
- Department of Surgery, Division of Cardiothoracic Surgery, Penn State Health/PSUCOM, 500 University Drive, Hershey, PA 17033, USA;
| | - Dongping Du
- Department of Industrial, Manufacturing and Systems Engineering, Texas Tech University (TTU), Lubbock, TX 79409, USA;
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Idrovo A, Hollander SA, Neumayr TM, Bell C, Munoz G, Choudhry S, Price J, Adachi I, Srivaths P, Sutherland S, Akcan-Arikan A. Long-term kidney outcomes in pediatric continuous-flow ventricular assist device patients. Pediatr Nephrol 2024; 39:1289-1300. [PMID: 37971519 DOI: 10.1007/s00467-023-06190-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Continuous-flow ventricular assist devices (CF-VADs) are used increasingly in pediatric end-stage heart failure (ESHF) patients. Alongside common risk factors like oxidant injury from hemolysis, non-pulsatile flow constitutes a unique circulatory stress on kidneys. Post-implantation recovery after acute kidney injury (AKI) is commonly reported, but long-term kidney outcomes or factors implicated in the evolution of chronic kidney disease (CKD) with prolonged CF-VAD support are unknown. METHODS We studied ESHF patients supported > 90 days on CF-VAD from 2008 to 2018. The primary outcome was CKD (per Kidney Disease Improving Global Outcomes (KDIGO) criteria). Secondary outcomes included AKI incidence post-implantation and CKD evolution in the 6-12 months of CF-VAD support. RESULTS We enrolled 134 patients; 84/134 (63%) were male, median age was 13 [IQR 9.9, 15.9] years, 72/134 (54%) had preexisting CKD at implantation, and 85/134 (63%) had AKI. At 3 months, of the 91/134 (68%) still on a CF-VAD, 34/91 (37%) never had CKD, 13/91 (14%) developed de novo CKD, while CKD persisted or worsened in 49% (44/91). Etiology of heart failure, extracorporeal membrane oxygenation use, duration of CF-VAD, AKI history, and kidney replacement therapy were not associated with different CKD outcomes. Mortality was higher in those with AKI or preexisting CKD. CONCLUSIONS In the first multicenter study to focus on kidney outcomes for pediatric long-term CF-VAD patients, preimplantation CKD and peri-implantation AKI were common. Both de novo CKD and worsening CKD can happen on prolonged CF-VAD support. Proactive kidney function monitoring and targeted follow-up are important to optimize outcomes.
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Affiliation(s)
- Alexandra Idrovo
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA.
- Renal Section, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Seth A Hollander
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tara M Neumayr
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School, St. Louis, MO, USA
- Division of Nephrology, Department of Pediatrics, Washington University School, St. Louis, MO, USA
| | - Cynthia Bell
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Genevieve Munoz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School, St. Louis, MO, USA
| | - Swati Choudhry
- Pediatrics, Cardiology Section, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Jack Price
- Pediatrics, Cardiology Section, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Department of Pediatrics, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Poyyapakkam Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA
| | - Scott Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ayse Akcan-Arikan
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA
- Department of Pediatrics Critical Care Section, Baylor College of Medicine, Texas Children's, Houston, TX, USA
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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
PURPOSE OF REVIEW Despite attention to racial disparities in outcomes for heart failure (HF) and other chronic diseases, progress against these inequities has been gradual at best. The disparities of COVID-19 and police brutality have highlighted the pervasiveness of systemic racism in health outcomes. Whether racial bias impacts patient access to advanced HF therapies is unclear. RECENT FINDINGS As documented in other settings, racial bias appears to operate in HF providers' consideration of patients for advanced therapy. Multiple medical and psychosocial elements of the evaluation process are particularly vulnerable to bias. SUMMARY Reducing gaps in access to advanced therapies will require commitments at multiple levels to reduce barriers to healthcare access, standardize clinical operations, research the determinants of patient success and increase diversity among providers and researchers. Progress is achievable but likely requires as disruptive and investment of immense resources as in the battle against COVID-19.
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Affiliation(s)
- Raymond C Givens
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
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Pal N, Stansfield J, Mukhopadhyay N, Nelson M. Marginal Improvement in Survival Post-Heart Transplantation in Patients With Prior Left Ventricular Assist Device: A Temporal Analysis of United Network of Organ Sharing Registry. J Cardiothorac Vasc Anesth 2020; 34:392-400. [DOI: 10.1053/j.jvca.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/26/2019] [Accepted: 10/02/2019] [Indexed: 11/11/2022]
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