Aortic Stenosis and Aortic Valve Replacement among Patients with Chronic Kidney Disease: A Narrative Review

Abstract

Background: Aortic stenosis (AS) can present with dyspnea, angina, syncope, and palpitations and this presents a diagnostic challenge as chronic kidney disease (CKD) and other commonly found comorbid conditions may present similarly. While medical optimization is an important aspect in management, aortic valve replacement (AVR) by surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) is the definitive treatment. Patients with concomitant CKD and AS require special consideration as it is known that CKD is associated with progression of AS and poor long-term outcomes. Aims and objectives: To summarize and review current existing literature on patients with both CKD and AS regarding disease progression, dialysis method, surgical intervention, and post operative outcomes. Conclusion: The incidence of aortic stenosis increases with age but has also been independently associated with chronic kidney disease and furthermore with hemodialysis. Regular dialysis with hemodialysis vs. peritoneal dialysis and female gender have been associated with progression of AS. Management of aortic stenosis is multidisciplinary and requires planning and interventions by the “Heart-Kidney Team” to decrease risk of further inducing kidney injury among high-risk population. Both TAVR and SAVR are effective interventions for patients with severe symptomatic AS, but TAVR has been associated with better short-term renal and cardiovascular outcomes. Implications for practice: Special consideration must be taken in patients with both CKD and AS. The choice of whether to undergo hemodialysis (HD) vs. peritoneal dialysis (PD) among patients with CKD is multifactorial but studies have shown benefit regarding AS progression among those who undergo PD. The choice regarding AVR approach is likewise the same. TAVR has been associated with decreased complications among CKD patients, but the decision is multifactorial and requires a comprehensive discussion with the Heart-Kidney Team as many other factors play a role in the decision including preference, prognosis, and other risk factors.

In-Hospital Outcomes of Transcatheter Aortic Valve Replacement in Patients with Chronic and End-Stage Renal Disease: A Nationwide Database Study

“…In the Transcatheter Valve Therapy registry, Ogami et al identi ed age > 75 years, body mass index < 25 kg/m 2 , chronic obstructive pulmonary disease, diabetes, and white race as independent risk factors for ve-year mortality in patients with ESRD [13]. A multidisciplinary approach with a heart-kidney team can be bene cial for making challenging treatment decisions in this population [30].…”

Treatment of aortic stenosis in dialysis: a necessary update in a challenging population

“…Dyspnoea and chest pain can be attributable to aortic stenosis but also to conditions related to CKD, such as anaemia, protein-wasting energy syndrome and fluid overload. 14 During dialysis, the reduced preload and diastolic filling pressure lead to a decrease in the cardiac output, which can be deleterious in patients with aortic stenosis due to possible cardiac ischemia, arrhytmia and cerebral hypoperfusion. 15 Also, patients with aortic stenosis dialysis are often excluded from the renal transplant waiting list if they do not receive aortic stenosis treatment.…”

“…Specifically, patients with aortic stenosis and ESRD requiring dialysis represent a challenging population from diagnosis to treatment. Dyspnoea and chest pain can be attributable to aortic stenosis but also to conditions related to CKD, such as anaemia, protein-wasting energy syndrome and fluid overload 14 . During dialysis, the reduced preload and diastolic filling pressure lead to a decrease in the cardiac output, which can be deleterious in patients with aortic stenosis due to possible cardiac ischemia, arrhytmia and cerebral hypoperfusion 15 .…”