TAVR Ups Risk of ESRD, Death for Advanced CKD Patients

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Transcatheter aortic valve replacement increases the risk of requiring renal replacement therapy and the risk of death among patients with stage 4 or 5 CKD.
Transcatheter aortic valve replacement increases the risk of requiring renal replacement therapy and the risk of death among patients with stage 4 or 5 CKD.

For patients with stage 4 to 5 chronic kidney disease (CKD), the risks of undergoing transcatheter aortic valve replacement (TAVR) may outweigh the benefits. Stage 3 CKD patients, however, appear to fare better from the procedure.

In a study, James W. Hansen, DO, of Lahey Hospital and Medical Center in Burlington, Massachusetts, and colleagues analyzed outcomes for nearly 45,000 TAVR patients by CKD stage using a transcatheter valve therapy registry 2011–2015 and Medicare database. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease equation.

The chances of renal replacement therapy (RRT) or death increased significantly more than would be expected for TAVR patients with pre-procedural eGFR below 30 mL/min/1.73m2, according to results published in JACC: Cardiovascular Interventions (2017;10:2064–2075). Researchers estimated that 1 in 6 stage 4 CKD patients (14.6%) will require dialysis and 1 in 3 will die within 1 year. A third of stage 5 patients will need RRT within 30 days and two-thirds within 1 year. In contrast, just 3.5% of stage 3 CKD patients required RRT within 1 year, marginally more than would be expected.

An increase in eGFR of just 5 mL/min/1.73m2 was associated with a 29% risk reduction for patients with pre-procedure eGFR below 60 mL/min/1.73 m2. Whether this is simply a marker or a potential therapeutic target requires investigation.

“Pre-procedure GFR should be considered when selecting CKD patients for TAVR,” the researchers wrote.

In a press release issued by the American College of Cardiology, Dr Hansen said, “While patients with more severe chronic kidney disease do have a higher rate of both death and dialysis at 30 days and one year, we're encouraged that the absolute rate of new dialysis is relatively low in stage 3 patients."

With regard to clinical implications, “Physicians should be advised that patients with severely reduced GFR who experience additional comorbidities beyond chronic kidney disease may not benefit from TAVR because of high short- and long-term hazard,” Israel Barbash, MD, and Amit Segev, MD, commented in an accompanying editorial. “If a procedure is planned, these patients should be meticulously informed of the high risk for post-procedural RRT and mortality.”

Future research should investigate whether perioperative strategies such as limiting iodinated contrast dye, appropriate hydration, and transesophageal echocardiography guidance, improves outcomes.

References

Hansen JW, Foy A, Yadav P, et al. Death and dialysis after transcatheter aortic valve replacement: An analysis of the STS/ACC TVT Registry. J Am Coll Cardiol Intv 2017;10:2064–2075. doi: 10.1016/j.jcin.2017.09.001

Barbash IM and Segev A. The plan Was to replace the valve, not the kidneys. J Am Coll Cardiol Intv 2017;10:2076-2077. doi: 10.1016/j.jcin.2017.09.006

Relatively few kidney patients need to start dialysis after undergoing TAVR Study can help patients, physicians make more informed decisions about risks [news release]. American College of Cardiology; October 16, 2017.

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