Identifying a Population at Risk - Progression of Advanced Chronic Kidney Disease Requiring Hemodialysis Following Transcatheter Aortic Valve Replacement

Background:
Despite refinements in transcatheter aortic valve replacement (TAVR), progression of chronic kidney disease (CKD) to requiring hemodialysis (HD) remains a complication associated with an increase in mortality. Patients with at least stage 4 CKD pre-TAVR are the most vulnerable population. Identifying those within this group at highest risk for progression to HD post-TAVR carries significant clinical implications.

Methods:
In a retrospective, observational study from 2012-2018, we reviewed 1374 patients who underwent TAVR at our institution. Included were HD naïve patients with a glomerular filtration rate (GFR) <30mL/min pre-TAVR. We examined clinical characteristics (age, sex, hypertension, diabetes requiring insulin, GFR, coronary disease, atrial fibrillation (AF), peripheral artery disease (PAD), tobacco use, obesity), left ventricular ejection fraction (EF), unplanned vascular interventions and contrast dose used during TAVR. The primary outcome of interest was new requirement for HD during the TAVR hospitalization post-TAVR and defined our cohorts. Statistical analyses of outcomes were performed using multivariate binary logistic regression.

Results:
Included were 138 HD naïve patients with a pre-TAVR GFR <30mL/min. Cohort 1 included 12 patients with a pre-TAVR GFR <30mL/min who went on to require HD post-TAVR. Cohort 2 included 126 patients with a pre-TAVR GFR <30mL/min who did not require HD post-TAVR. Patients with pre-existing PAD were 15.9 times more likely to require HD post-TAVR (CI 0.008, 0.513, p=0.0098). Patients with pre-existing AF were 9.3 times more likely to require HD post-TAVR (CI 0.016, 0.731, p=0.0225). The remaining variables examined were not found to correlate with requiring HD post-TAVR.

Conclusions:
Patients with advanced CKD are at the highest risk for progression to require HD post-TAVR. Our study demonstrates that within this group, pre-existing PAD or AF were independent predictors of requiring HD during the TAVR hospitalization post-TAVR. Our study thus identifies a subset of patients who may warrant pre-TAVR contrast reduction by utilizing alternative imaging or hydration to minimize the risk of requiring HD post-TAVR.