Outcomes With LVADs in End-Stage Renal Disease

Study Questions:

What are the outcomes after placement of a left ventricular assist device (LVAD) in advanced heart failure (HF) inpatients with end-stage renal disease (ESRD)?

Methods:

The study authors assessed LVAD utilization and outcomes among Medicare beneficiaries after ESRD onset (defined as having received maintenance dialysis or a kidney transplant) from 2003 to 2013 based on Medicare claims linked to data from the United States Renal Data System (USRDS), a national registry for ESRD. They excluded those for whom LVAD placement had preceded ESRD onset. They compared Medicare beneficiaries with ESRD to a 5% sample of Medicare beneficiaries without ESRD. The primary outcome was survival after LVAD placement. They utilized Cox proportional hazard models to examine the association of ESRD (vs. no ESRD) with time to death after LVAD placement, adjusting for demographics, comorbid conditions during the year before cohort entry, tertile of Quan score, and time period of LVAD placement.

Results:

The final study cohort of patients, who received an LVAD, included 155 Medicare beneficiaries with ESRD (median and interquartile range [IQR] days from ESRD onset to LVAD placement were 1,655 days [453-3,050 days]) and 261 beneficiaries without ESRD in the Medicare 5% sample. Most patients (123 [79.3%]) with ESRD were receiving maintenance hemodialysis, 12 (7.7%) were receiving peritoneal dialysis, and 15 (9.7%) had a functioning kidney transplant at the time of LVAD placement. In patients with ESRD, the mean age was 58.4 (12.1) years, and 62.0% (n = 96) were male. In those without ESRD, the mean age was 62.2 (12.6) years and 75.1% (n = 196) were male. During a median follow-up of 762 days (IQR, 92-3,850 days), 127 patients (81.9%) with and 95 (36.4%) without ESRD died. More than one half of the patients with ESRD (80 [51.6%]) compared with 11 (4%) of those without ESRD died during the index hospitalization. The median time to death was 16 days (IQR, 2-447 days) for patients with ESRD compared with 2,125 days (IQR, 565-3,850 days) for those without ESRD. After adjusting for demographics, comorbidity, and time period, patients with ESRD had a markedly increased adjusted risk of death (hazard ratio, 36.3; 95% confidence interval, 15.6-84.5), especially in the first 60 days after LVAD placement, during which time 92 patients with ESRD (72.4%) and 6 patients without ESRD (6.3%) died. In adjusted analyses that included an interaction term for time from LVAD placement (p < 0.001), ESRD was a dominant risk factor for death after LVAD placement.

Conclusions:

The study coauthors concluded that patients with ESRD at the time of LVAD placement had an extremely poor prognosis, with most surviving for <3 weeks.

Perspective:

Although this is an observational study, the important findings of this paper suggest that it is time to call a moratorium on implanting LVADs in ESRD patients until it is clear which patients would possibly benefit from LVADs.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support

Keywords: Cardiac Surgical Procedures, Heart Failure, Heart-Assist Devices, Kidney Failure, Chronic, Kidney Transplantation, Medicare, Outcome Assessment (Health Care), Peritoneal Dialysis, Renal Dialysis, Renal Insufficiency, Risk Factors


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