Renal Replacement Therapy, Death Examined in CKD Patients Post TAVR in NCDR Study

Patients with chronic kidney disease (CKD) who undergo transcatheter aortic valve replacement (TAVR) have a relatively low risk of needing renal replacement therapy (RRT) or dying after the procedure. Results from a study published Oct. 16 in JACC: Cardiovascular Interventions suggest physicians will be able to make more informed decisions about recommending TAVR as an option for patients with CKD.

James W. Hansen, DO, et al., used the STS/ACC TVT Registry to gather data on 44,778 patients who underwent TAVR between November 2011 and September 2015 and were not on RRT at the start of the study. They examined the association between pre-procedure glomerular filtration rate (GFR) and rates of mortality, new RRT and/or a combination of both, from 30 days to one year post TAVR. Researchers classified patients by CKD stage at the time of the procedure. Fifty-one percent had stage 1/2 CKD, 43 percent had stage 3 CKD, 5 percent had stage 4 and only 0.46 percent had stage 5 CKD. The median patient age was 82 years.

The results show pre-procedural GFR to be associated with both mortality and new RRT in both the adjusted and unadjusted analysis. Patients who were in the later stages of CKD were found to have an increased risk of mortality and/or RRT.

“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,” states Hansen. Among patients with stage 3 CKD, only 2.2 percent had new RRT within 30 days of TAVR, whereas 3.5 percent had new RRT at one year. In comparison, less than 1 percent of those with stage 1/2 CKD started RRT after 30 days; results showed a slight increase to 1.2 percent of the subgroup population at one year.

Patients with stage 4/5 CKD had a higher risk of both RRT and death. One-third of stage 4 patients died within a year, with nearly 15 percent requiring RRT. An increase in mortality was not seen in patients with stage 5 CKD; however, more than one-third required RRT after 30 days, increasing to two-thirds at one year.

Looking ahead, the study authors suggest future studies to evaluate specific risk factors for new RRT and determine whether the relationship between the incremental GFR increase and outcome is a marker of risk or a potential target of therapy, which could be used to reduce the hazard of renal failure and need for post-procedure RRT.

In an accompanying editorial comment, Israel M. Barbash, MD, and Amit Segev, MD, FACC, agree the findings provide a reassuring message and are in agreement with another recently published study looking at TAVR patients in the U.K. They highlight that the present study “provides the physician invaluable information by identifying a small subgroup with an extremely high risk of RRT or death.” In fact, “it should be emphasized that this high risk group represents a small minority of the entire TAVR population, less than 6 percent of the patients.”

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Glomerular Filtration Rate, Risk Factors, Transcatheter Aortic Valve Replacement, Research Personnel, Israel, Renal Insufficiency, Chronic, Renal Replacement Therapy, Renal Insufficiency, Registries, Renal Dialysis

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