Outcomes Associated With Left Ventricular Assist Devices Among Recipients With and Without End-stage Renal Disease

Abstract

IMPORTANCE Left ventricular assist devices (LVADs) are widely used both as a bridge to heart transplant and as destination therapy in advanced heart failure. Although heart failure is common in patients with end-stage renal disease (ESRD), little is known about outcomes after LVAD implantation in this population.OBJECTIVE To determine the utilization of and outcomes associated with LVADs in nationally representative cohorts of patients with and without ESRD. DESIGN, SETTING AND PARTICIPANTS We described 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. We compared Medicare beneficiaries with ESRD to a 5% sample of Medicare beneficiaries without ESRD.EXPOSURES ESRD (vs no ESRD) among patients who underwent LVAD placement. MAIN OUTCOMES AND MEASURESThe primary outcome was survival after LVAD placement.RESULTS Among the patients with ESRD, the mean age was 58.4 (12.1) years and 62.0% (96) were male. Among those without ESRD, the mean age was 62.2 (12.6) years and 75.1% (196) were male. From 2003 to 2013, 155 Medicare beneficiaries with ESRD (median and interquartile range [IQR] days from ESRD onset to LVAD placement were 1655 days [453-3050 days]) and 261 beneficiaries without ESRD in the Medicare 5% sample received an LVAD. During a median follow-up of 762 days (IQR, 92-3850 days), 127 patients (81.9%) with and 95 (36.4%) without ESRD died. more than half of 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 2125 days (IQR, 565-3850 days) for those without ESRD. With adjustment for demographics, comorbidity and time period, patients with ESRD had a markedly increased adjusted risk of death (hazard ratio, 36.3; 95% CI, 15.6-84.5), especially in the first 60 days after LVAD placement. CONCLUSIONS AND RELEVANCEPatients with ESRD at the time of LVAD placement had an extremely poor prognosis, with most surviving for less than 3 weeks. This information may be crucial in supporting shared decision-making around treatments for advanced heart failure for patients with ESRD.

Implantable Ventricular Assist Device Use and Outcomes in People With End‐Stage Renal Disease

“…Bansal et al recently published an analysis of circulatory support use in people with ESRD from 2003 to 2013, based on Medicare claims 28. However, unlike our analysis, that analysis included both external circulatory support devices ( ICD‐9‐CM 37.62 and 37.65) and implantable VADs 28, 29.…”

“…Bansal et al recently published an analysis of circulatory support use in people with ESRD from 2003 to 2013, based on Medicare claims 28. However, unlike our analysis, that analysis included both external circulatory support devices ( ICD‐9‐CM 37.62 and 37.65) and implantable VADs 28, 29. Thus, temporary circulatory support devices were included, which have different indications and outcomes than durable VADs, including placement in dire circumstances such as acute cardiogenic shock or cardiopulmonary arrest 30.…”

Commentary: Understanding the relationship between acute kidney injury and durable ventricular assist device implantation: Is it a preoperative or postoperative event?

“…Although the benefits are substantial, the complexity of the operation in the setting of advanced heart failure is challenging and can result in significant end-organ dysfunction, complicating the perioperative course and long-term survival. Whereas numerous studies have examined the outcome of durable VAD implantation in the setting of renal dysfunction or dialysis, [1][2][3][4] few have focused on the impact of durable VAD implantation on the incidence of new acute kidney injury.…”

Key Updates in Cardio-Nephrology from 2018: Springboard to a Bright Future

“…Bansal et al reported on a United States Renal Data System dataset on patients with end stage kidney disease that underwent placement of left ventricular assist devices. After adjustment for several relevant confounders, the adjusted risk of death was markedly increased (HR = 36.3; 95% CI 15.6–84.5), with most subjects surviving for less than 3 weeks [23]. In contrast, Walther et al [24] reported an HR of 2.3 (95% CI 1.4–3.8) in their analysis of the National Inpatient Sample for the same question.…”