In extreme-, high- and intermediate-risk patients with chronic kidney disease (CKD) undergoing transcatheter aortic valve replacement (TAVR) using balloon-expandable transcatheter heart valves (THV), progression to end-stage renal disease (ESRD) requiring hemodialysis (HD) is extremely rare follow TAVR.
Data regarding TAVR outcomes in patients with CKD remain unclear. Early data from the PARTNER (Placement of Aortic Transcatheter Valves) 1 trial reported progression to ESRD requiring HD in only 24% of patients undergoing TAVR, suggesting that a proportion of patients see improvement in their cardiorenal syndrome after TAVR.
Robert J. Cubeddu, MD, of the Cleveland Clinic Weston, Florida, and co-investigators sought to further describe renal outcomes in patients receiving balloon-expandable TAVR. The authors compiled data in a post hoc analysis from the patients in the PARTNER 1, 2 and 2 S3 trials. They analyzed 5,190 patients with who underwent TAVR using balloon-expandable valves between 2007 and 2014. They reported their results in a manuscript published in the Sept. 22 issue of the Journal of the American College of Cardiology.
Stage 2 or worse CKD was present in 91% of patients pre-TAVR. CKD worsened post-TAVR in a minority of patients (23% stage 1, 10% stage 2, 11% stage 3A, 6.2% stage 3B and 0.82% stage 4). In total, progression to stage 5 CKD occurred in only 0.035% of patients post-TAVR (within 7 days). Higher baseline estimated glomerular filtration rate (eGFR) (p<0.0001) and transfemoral approach (p=0.0002) were associated with a higher post-TAVR eGFR. Pre-existing obesity, diabetes, left ventricular hypertrophy and mitral regurgitation were associated with a lower post-TAVR eGFR. With regard to mortality, lower risk-adjusted baseline and post-TAVR eGFR were associated with higher early mortality (p<0.0001), but not late mortality. Higher contrast use was not associated with a significant decrease in eGFR post-TAVR.
Benjamin Z. Galper, MD, of the Mid-Atlantic Permanente Medical Group, McLean, Virginia, and co-authors wrote an accompanying editorial to the study. They acknowledge the significance and prevalence of CKD in patients with symptomatic severe aortic stenosis. Furthermore, they cite smaller studies that have demonstrated an association with worsening renal function and mortality in TAVR. They agree that a larger heterogenous study of TAVR patients could provide further insight into this topic. The findings of this study support TAVR in CKD patients, with the overwhelming majority demonstrating stable or improving renal function post-TAVR. They conclude that this study could change the treatment paradigm of how physicians approach TAVR in CKD patients.
Cubeddu RJ, Asher CR, Lowry AM, et al. Impact of Transcatheter Aortic Valve Replacement on Severity of Chronic Kidney Disease. J Am Coll Cardiol 2020;76:1410-21.
Galper BZ, Goldsweig AM, Bhatt DL. TAVR and the Kidney: Is This the Beginning of a Beautiful Friendship? J Am Coll Cardiol 2020;76:1422-4.
Photo Credit: Kristoffer Lindskov Hansen, Michael Bachmann Nielsen and Caroline Ewertsen / CC BY (https://creativecommons.org/licenses/by/4.0)Kristoffer Lindskov Hansen, Michael Bachmann Nielsen and Caroline Ewertsen / CC BY (https://creativecommons.org/licenses/by/4.0). Available from: https://upload.wikimedia.org/wikipedia/commons/5/5b/Ultrasonography_of_chronic_renal_disease_caused_by_glomerulonephritis.jpg