Dialysis Following TAVR

Study Questions:

What are the risk factors for post-transcatheter aortic valve replacement (TAVR) dialysis, and what is the impact of pre-TAVR or post-TAVR dialysis on mortality?

Methods:

The UK TAVI (Transcatheter Aortic Valve Implantation) Registry was established to report outcomes on all TAVR procedures performed within the United Kingdom (2007-2014). Data were collected prospectively on 6,464 patients with a median follow-up of 625 days. Survival analysis was based on data from 6,464 of 7,364 (88%) patients who underwent TAVR whose survival status was available through a national registry.

Results:

The proportion of patients on dialysis before TAVR remained constant over time at 1.8%. After TAVR, the proportion of patients newly needing dialysis after TAVR fell from 6.1% (2007-2008) to 2.3% (2013-2014). The risk of a new dialysis requirement after TAVR was independently associated with lower baseline renal function, year of procedure, impaired left ventricular function, diabetes, use of an Edwards valve, a non-transfemoral approach, need for open surgery, and moderate-to-severe aortic regurgitation after the procedure. A new requirement for dialysis after TAVR was associated with higher mortality at 30 days (hazard ratio, 6.44; 95% confidence interval, 4.87-8.53) and at 4 years (hazard ratio, 3.54; 95% confidence interval, 2.99-4.19; p < 0.001 for all) compared with patients without a dialysis requirement.

Conclusions:

The proportion of patients requiring dialysis after TAVR decreased over time, and post-TAVR dialysis is associated with increased mortality.

Perspective:

This large, multicenter registry study from the United Kingdom found that a new dialysis requirement after TAVR was associated with a >6-fold increased risk of mortality at 30 days compared with subjects who did not require dialysis, whereas patients already on dialysis before TAVR had a >2-fold increased risk. Although this suggests that renal failure and dialysis account for only part of the excess mortality associated with a new dialysis requirement, selection bias among patients undergoing TAVR despite an existing dialysis requirement may account for some of the difference. Although the risk of requiring dialysis after TAVR appears to be decreasing, the high associated mortality suggests that identifying potentially modifiable risk factors warrants further investigation.


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