Advertisement
Canadian Journal of Cardiology

Transcatheter Aortic Valve Replacement Outcomes in Patients With Native vs Transplanted Kidneys: Data From an International Multicenter Registry

Published:January 18, 2019DOI:https://doi.org/10.1016/j.cjca.2019.01.003

      Abstract

      Background

      Chronic kidney disease (CKD) has a negative impact on outcomes after transcatheter aortic valve replacement (TAVR). Data on outcomes in renal transplant recipients (RTRs) undergoing TAVR are scarce. We compared the outcomes in RTRs undergoing TAVR with matched patients who have native kidneys and similar kidney function.

      Methods

      This retrospective cohort study used data from 16 TAVR centres (13,941 patients). The study cohort included 216 patients (72 RTRs and 144 matched controls).

      Results

      The mean estimated glomerular filtration rate (eGFR) was 39.2 ± 23.6 vs 44.5 ± 23.6 mL/min for RTRs and control patients (P = 0.149), with a similar CKD stage distribution. After TAVR, the eGFR declined among RTRs but remained stable for up to 1 year in controls (P = 0.021). Long-term hemodialysis was required in 19 (26.4%) RTRs and 20 (13.8%) controls (hazard ratio [HR] = 2.09 95% confidence interval [CI], 1.03-3.86; P = 0.039) and was most often initiated during the periprocedural period (14 RTRs vs 16 controls; P = 0.039). After a median follow-up of 2.3 years, risk of death (29.2% vs 31.9%) and death/hemodialysis (40.3% vs 36.8%) was similar between the groups. The contrast volume/eGFR ratio was the strongest predictor of hemodialysis initiation (odds ratio [OR] = 1.64; 95% CI, 1.36-1.97 per 1 unit increase; P < 0.001), with a greater effect among RTRs than controls (P for interaction = 0.022).

      Conclusion

      s: TAVR appears safe in RTRs with mortality rates similar to matched patients with native kidneys. However, RTRs carry an increased risk of progressive renal impairment and need for hemodialysis initiation after TAVR. Our data highlight the importance of minimizing contrast load during TAVR, particularly in RTRs.

      Résumé

      Introduction

      La néphropathie chronique a un effet négatif sur les résultats du remplacement valvulaire aortique par cathéter (RVAC). Les données sur les résultats des receveurs d’une greffe du rein qui se prêtent à un RVAC sont rares. Nous avons comparé les résultats de receveurs d’une greffe du rein qui se prêtent à un RVAC et de patients appariés ayant encore leurs propres reins et dont la capacité fonctionnelle rénale était similaire.

      Méthodologie

      Cette étude de cohorte rétrospective a utilisé les données de 16 centres de RVAC (13 941 patients). La cohorte de l’étude comprenait 216 patients (72 receveurs d’une greffe du rein et 144 témoins appariés).

      Résultats

      Le taux de filtration glomérulaire estimé (TFGe) moyen a été de 39,2 ± 23,6 ml/min chez les receveurs d’une greffe du rein et de 44,5 ± 23,6 ml/min chez les témoins (p = 0,149), la distribution des stades de la néphropathie chronique étant similaire entre les groupes. Après le RVAC, le TFGe a diminué chez les receveurs d’une greffe du rein, mais est resté stable pendant une période maximale de 1 an chez les témoins (p = 0,021). Dix-neuf receveurs d’une greffe du rein (26,4 %) et 20 témoins (13,8 %) ont nécessité une hémodialyse à long terme (rapport des risques instantanés : 2,09; intervalle de confiance [IC] à 95 % : 1,03 – 3,86; p = 0,039); l’hémodialyse a été le plus souvent entreprise durant la période péri-procédurale (14 receveurs d’une greffe du rein et 16 témoins; p = 0,039). Après un suivi médian de 2,3 ans, le risque de décès (29,2 % vs 31,9 %) et de décès/hémodialyse (40,3 % vs 36,8 %) était similaire entre les groupes. Le rapport volume d’agent de contraste/TFGe a été le facteur de prédiction le plus robuste de l’instauration de l’hémodialyse (risque relatif approché : 1,64; IC à 95 % : 1,36 – 1,97 par palier d’augmentation de 1 unité; p < 0,001), l’effet étant plus important chez les receveurs d’une greffe du rein que chez les témoins (p pour l’interaction = 0,022).

      Conclusions

      Il semble que le RVAC soit sûr chez les receveurs d’une greffe du rein, les taux de mortalité étant semblables à ceux observés chez les patients appariés possédant encore leurs propres reins. Les receveurs d’une greffe du rein sont néanmoins exposés à un plus grand risque d’insuffisance rénale progressive et d’hémodialyse après le RVAC. Nos données soulignent l’importance de réduire au maximum le volume d’agent de contraste utilisé pendant le RVAC, particulièrement chez les receveurs d’une greffe du rein.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rattazzi M.
        • Bertacco E.
        • Del Vecchio A.
        • Puato M.
        • Faggin E.
        • Pauletto P.
        Aortic valve calcification in chronic kidney disease.
        Nephrol Dial Transplant. 2013; 28: 2968-2976
        • Ikee R.
        • Honda K.
        • Ishioka K.
        • et al.
        Differences in associated factors between aortic and mitral valve calcification in hemodialysis.
        Hypertens Res. 2010; 33: 622-626
        • Zentner D.
        • Hunt D.
        • Chan W.
        • Barzi F.
        • Grigg L.
        • Perkovic V.
        Prospective evaluation of aortic stenosis in end-stage kidney disease: a more fulminant process?.
        Nephrol Dial Transplant. 2011; 26: 1651-1655
        • Iung B.
        • Cachier A.
        • Baron G.
        • et al.
        Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery?.
        Eur Heart J. 2005; 26: 2714-2720
        • Bach D.S.
        • Siao D.
        • Girard S.E.
        • Duvernoy C.
        • McCallister Jr., B.D.
        • Gualano S.K.
        Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated operative risk.
        Circ Cardiovasc Qual Outcomes. 2009; 2: 533-539
        • Rodés-Cabau J.
        Transcatheter aortic valve implantation: current and future approaches.
        Nat Rev Cardiol. 2011; 9: 15-29
        • Leon M.B.
        • Smith C.R.
        • Mack M.
        • et al.
        Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.
        N Engl J Med. 2010; 363: 1597-1607
        • Smith C.R.
        • Leon M.B.
        • Mack M.J.
        • et al.
        Transcatheter versus surgical aortic-valve replacement in high-risk patients.
        N Engl J Med. 2011; 364: 2187-2198
        • Mack M.J.
        • Leon M.B.
        • Smith C.R.
        • et al.
        5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER1): a randomised controlled trial.
        Lancet. 2015; 385: 2477-2484
        • Reardon M.J.
        • Van Mieghem N.M.
        • Popma J.J.
        • et al.
        Surgical or transcatheter aortic-valve replacement in intermediate-risk patients.
        N Engl J Med. 2017; 376: 1321-1331
        • Gargiulo G.
        • Capodanno D.
        • Sannino A.
        • et al.
        Moderate and severe preoperative chronic kidney disease worsen clinical outcomes after transcatheter aortic valve implantation: meta-analysis of 4992 patients.
        Circ Cardiovasc Interv. 2015; 8e002220
        • Hart A.
        • Smith J.M.
        • Skeans M.A.
        • et al.
        OPTN/SRTR 2016 Annual Data Report: Kidney.
        Am J Transplant. 2018; 18: 18-113
        • Sharma A.
        • Gilbertson D.T.
        • Herzog C.A.
        • et al.
        Survival of kidney transplantation patients in the United States after cardiac valve replacement.
        Circulation. 2010; 121: 2733-2739
        • Briggs J.D.
        Causes of death after renal transplantation.
        Nephrol Dial Transplant. 2001; 16: 1545-1549
        • Fox H.
        • Büttner S.
        • Hemmann K.
        • et al.
        Transcatheter aortic valve implantation improves outcome compared to open-heart surgery in kidney transplant recipients requiring aortic valve replacement.
        J Cardiol. 2013; 61: 423-427
      1. Chronic Kidney Disease Epidemiology Collaboration. CKD-EPI equation. Available at: https://qxmd.com/calculate/egfr-using-ckd-epi. Accessed January 10, 2019.

        • Kappetein A.P.
        • Head S.J.
        • Généreux P.
        • et al.
        Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document.
        Eur Heart J. 2012; 33: 2403-2418
        • Detry M.A.
        • Ma Y.
        Analyzing repeated measurements using mixed models.
        JAMA. 2016; 315: 407-408
        • Greenland S.
        • Mansournia M.A.
        Penalization, bias reduction, and default priors in logistic and related categorical and survival regressions.
        Stat Med. 2015; 34: 3133-3143
        • Gansevoort R.T.
        • Correa-Rotter R.
        • Hemmelgarn B.R.
        • et al.
        Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention.
        Lancet. 2013; 382: 339-352
        • Nguyen T.C.
        • Babaliaros V.C.
        • Razavi S.A.
        • et al.
        Impact of varying degrees of renal dysfunction on transcatheter and surgical aortic valve replacement.
        J Thorac Cardiovasc Surg. 2013; 146: 1399-1406
        • Kawase Y.
        • Taniguchi T.
        • Morimoto T.
        • et al.
        CURRENT AS registry investigators: severe aortic stenosis in dialysis patients.
        J Am Heart Assoc. 2017; 6e004961
        • Steinmetz T.
        • Witberg G.
        • Chagnac A.
        • et al.
        Transcatheter aortic valve implantation versus conservative management in chronic kidney disease patients.
        EuroIntervention. 2018; 14: e503-e510
        • Gupta T.
        • Goel K.
        • Kolte D.
        • et al.
        Association of chronic kidney disease with in-hospital outcomes of transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2017; 10: 2050-2060
        • Ferro C.J.
        • Law J.P.
        • Doshi S.N.
        • et al.
        • UK TAVI Steering Group and the National Institute for Cardiovascular Outcomes Research
        Dialysis following transcatheter aortic valve replacement, risk factors and outcomes: an analysis from the UK TAVI (Transcatheter Aortic Valve Implantation) Registry.
        JACC Cardiovasc Interv. 2017; 10: 2040-2047
        • Avramovic M.
        • Stefanovic V.
        Health-related quality of life in different stages of renal failure.
        Artif Organs. 2012; 36: 581-589
        • Gilard M.
        • Eltchaninoff H.
        • Donzeau-Gouge P.
        • et al.
        • FRANCE 2 Investigators
        Late outcomes of transcatheter aortic valve replacement in high-risk patients: the FRANCE-2 Registry.
        J Am Coll Cardiol. 2016; 68: 1637-1647
        • Windecker S.
        • Kolh P.
        • Alfonso F.
        • et al.
        2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).
        Eur Heart J. 2014; 35: 2541-2619
        • Briguori C.
        • Visconti G.
        • Focaccio A.
        • et al.
        • REMEDIAL II Investigators
        Renal Insufficiency After Contrast Media Administration Trial II (REMEDIAL II): RenalGuard System in high-risk patients for contrast-induced acute kidney injury.
        Circulation. 2011; 124: 1260-1269
        • Marenzi G.
        • Ferrari C.
        • Marana I.
        • et al.
        Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (Induced Diuresis With Matched Hydration Compared to Standard Hydration for Contrast Induced Nephropathy Prevention) trial.
        JACC Cardiovasc Interv. 2012; 5: 90-97
        • Brar S.S.
        • Aharonian V.
        • Mansukhani P.
        • et al.
        Haemodynamic-guided fluid administration for the prevention of contrast-induced acute kidney injury: the POSEIDON randomised controlled trial.
        Lancet. 2014; 383: 1814-1823
        • Reynolds M.R.
        • Magnuson E.A.
        • Lei Y.
        • et al.
        Cost-effectiveness of transcatheter aortic valve replacement compared with surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results of the PARTNER (Placement of Aortic Transcatheter Valves) trial (Cohort A).
        J Am Coll Cardiol. 2012; 60: 2683-2692
        • Reynolds M.R.
        • Lei Y.
        • Wang K.
        • et al.
        Cost-effectiveness of transcatheter aortic valve replacement with a self-expanding prosthesis versus surgical aortic valve replacement.
        J Am Coll Cardiol. 2016; 67: 29-38
        • Sud M.
        • Tam D.Y.
        • Wijeysundera H.C.
        The economics of transcatheter valve interventions.
        Can J Cardiol. 2017; 33: 1091-1098
        • Tirado-Conte G.
        • Rodés-Cabau J.
        • Rodríguez-Olivares R.
        • et al.
        Clinical outcomes and prognosis markers of patients with liver disease undergoing transcatheter aortic valve replacement. a propensity score–matched analysis.
        Circ Cardiovasc Interv. 2018; 11e00572
        • Jafar T.H.
        • Stark P.C.
        • Schmid C.H.
        • et al.
        Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiogtensisn-converting enzyme inhibition: a patient level meta-analysis.
        Ann Intern Med. 2003; 139: 244-252