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Journal ArticleDOI

Acute Kidney Injury Following Aortic Valve Replacement in Patients Without Chronic Kidney Disease

TL;DR: TAVR in patients without CKD was associated with a significantly less frequent incidence of AKI compared with SAVR, and increasing severity ofAKI was incrementally associated with 5-year mortality.
About: This article is published in Canadian Journal of Cardiology.The article was published on 2021-01-01 and is currently open access. It has received 7 citations till now. The article focuses on the topics: Kidney disease & Aortic valve replacement.

Summary (3 min read)

Introduction

  • Acute kidney injury (AKI) is a common complication i patients undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), its incidence ranging up to 56% depending on the population.
  • 3,6,8 TAVR has become the preferred treatment strategy for severe aortic valve stenosis (AS) in patients at high and intermediat risk with a high prevalence of CKD3,9,10 and the incidence and clinical impact of AKI have been well documented in patients with CKD.
  • 11,12 During the past few years, the clinical practice with TAVR has shifted towards treating lower-risk patients deemed to have less frequent pre-procedural CKD.
  • Accordingly, knowledge of AKI and its impact on late outcomes in this subset of patients are essential before expanding the indication for TAVR to lower-risk patients with long life expectancy.
  • Therefore, the authors sought to investigate 1) he incidence and predictors of AKI, and 2) 5-year mortality in patients without pre-procedural CKD underwent TAVR or SAVR and 3) the impact of AKI and its severity on 5-year mortality.

Study design

  • The FinnValve registry is a nationwide registry, which includes retrospectively collected data from consecutive and unselected patients who underwent TAVR or SAVR with a bioprosthesis from 2008 to 2017 in Finland.
  • This study was approved by the Institutional Review Boards of each participating center.
  • The operative risk of the patients was evaluated according to the Society of Thoracic Surgeons (STS)18 and the EuroSCORE II19 risk scoring methods.
  • For the purpose of the current analysis, patients with baseline estimated glomerular filtration rate (eGFR)<60ml/min/1.73m2 according to the Modification of Diet in Renal Disea (MDRD) equation20 and dialysis were excluded.
  • Definition criteria of baseline risk factors Baseline variables were defined according to the EuroSCORE II criteria.19 Stratification of the severity of CKD was performed eGFR using the MDRD equation.

Patient selection

  • The registry includes data on 6463 patients who underwent TAVR or SAVR.
  • Pertinent to the present analysis, patients with CKD (n=1907) and those with missing values of serum creatinine (n=1) were excluded.
  • In 4555 patients (TAVR:n=1215; SAVR:n=3340) without CKD, a propensity-score (PS) matching between TAVR and SAVR groups was developed for comparative outcome analysis .

Outcome measures

  • The primary outcome of this study was to elucidate the incidence of post-operative AKI.
  • In the unmatched cohort, the incidence and predictors of AKI, and 5-year all-cause mortality in patients with or without AKI was evaluated.
  • In the matched cohort, the incidence of AKI was evaluated for the purpose of sensitivity analysis and 5-year all-cause mortality between TAVR and SAVR was analyzed.
  • 7 AKI was defined according to the KDIGO criteria,22 because it considers a time frame for creatinine changes of seven days, which usually is the average length of hospital day in patients undergoing SAVR (Supplementary Table S2).
  • Definitio criteria of the other outcomes are summarized in Supplementary Table S3.23,24.

Statistical analysis

  • Categorical variables were presented as counts and/or percentages and were compared using the chi-square test.
  • Continuous variables were present d as the mean ± standard deviation or median and interquartile range (25th-75th IQR) and were compared using the Student’s t-test or the Wilcoxon rank sum test based on their distributions.
  • One-to-one PS matching was performed employing the nearest neighbour method and a caliper width of 0.2 of the standard deviation of the logit of the estimated propensity core.
  • These tts were used to evaluate any difference in the adverse events of matched pairs.
  • Trends for the incide e of AKI over time was analyzed using the 8 Mantel-Haenszel linear-by-linear association chi-square test for trend.

Results

  • Patient characteristics and early outcomes A total of 4555 patients without pre-procedural CKD were the subjects of this analysis .
  • In the unmatched cohort, TAVR patients in comparison to SAVR patients were older and more often female, and had a higher predicted risk of operative mortality (Table 1).
  • During the study period, the proportion of SAVR decreased, whereas that of TAVR increased (Ptrend <0.001) .
  • The procedural characteristics and early outcomes are summarized in Table 3.

Incidence and predictors of AKI

  • In the unmatched series, the proportion of AKI in patients who underwent TAVR significantly decreased during the study period (Ptrend <0.001), but not in those who underwent SAVR (Ptrend =0.23) .
  • The results of multivariable analysis performed to identify predictors of AKI are shown in Table 4 and Supplementary Table S5.
  • The incidence of AKI was significantly increasing according to the severity of bleeding based on VARC-2 and E-CABG grade and increased units of RBC transfusion both in TAVR and SAVR cohort (P <0.001, respectively).

The effect of AKI on 5-years outcomes

  • Cumulative 5-year mortalities following TAVR or SAVR are displayed in Supplementary Figure S4.
  • On the other hand, among patients with intermediat to low surgical risk and lower prevalence of CKD, the incidence of AKI after TAVR decreased to less than 5%.
  • 10,13,14,27,28 5,31 Similarly, the cardiopulmonary bypass time and sever bleeding requiring blood transfusion affected worsening kidney function after SAVR in patients without CKD of the present study.
  • Secondly, even though PS matching resulted in sufficient balance of baseline characteristics, bias due to unknown or unmeasured confounders cannot be excluded.

Figure legends

  • (B) The right y-axis refers to the histogram of thenumber of patients with estimated glomerular filtration rate (eGFR) per 5 ml/min/1.732 increments.
  • Abbreviations as in Table 1 and Figure 1. (A) Cumulative event curves for all-cause death and l mark analysis from 3 month in total cohort.
  • Values are expressed as counts and percentages (in pare theses), mean±standard deviation.

RBC transfusion units

  • Values are expressed as counts and percentages (in pare theses).
  • All abbreviations as in Table 1-4. 45 Covariates included into these models are shown in Supplementary Table S6.

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Citations
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Journal ArticleDOI
TL;DR: In this article, the differences in incidence of acute kidney injury (AKI) and acute kidney recovery (AKR) among patients undergoing transcatheter aortic valve implantation (TAVI), according to the degree of extravalvular cardiac damage (EVCD), were determined.

5 citations

Journal ArticleDOI
TL;DR: In this paper , the authors disentangle, applying mediation analysis, the association between acute kidney injury (AKI) and clinical outcome, considering CKD and bleeding complications in transcatheter aortic valve replacement (TAVR) patients.
Abstract: Background Acute kidney injury (AKI) after transcatheter aortic valve replacement (TAVR) is associated with increased mortality. However, it is controversial whether AKI affects prognosis per se, being linked to baseline chronic kidney disease (CKD) and bleeding complications. The aim of this study was to disentangle, applying mediation analysis, the association between AKI and clinical outcome, considering CKD and bleedings. Methods and Results Consecutive patients undergoing TAVR were prospectively enrolled at 5 high-volume centers in Italy. AKI was defined according to Valve Academic Research Consortium-3 consensus, whereas bleeding with Bleeding Academic Research Consortium. Primary outcome was all-cause mortality after 1-year follow-up. Among 2621 patients undergoing TAVR, AKI occurrence was associated with 1-year mortality. This association of AKI with the primary end points remained significant after adjusting for baseline risk estimators, either Society of Thoracic Surgeons score (hazard ratio [HR], 2.78 [95% CI, 1.95-3.80], P<0.001) or EuroSCORE-II (HR, 1.85 [95% CI, 1.35-2.56], P<0.001). Both AKI and CKD significantly and independently affected primary outcome (HR, 3.06 [95% CI, 2.01-4.64], P<0.001 and HR, 1.82 [95% CI 1.27-2.65], P<0.01, respectively). The estimated proportion of the total effect of CKD mediated via AKI was, on average, 15%, 95% CI, 4%-29%, P<0.001. The significant effect of Bleeding Academic Research Consortium 2-5 bleedings on the primary outcome was not mediated by AKI. Conclusions AKI occurs in 1 out of 6 patients and significantly mediates one fifth of the effect of baseline CKD on all-cause mortality after TAVR. Our analysis supports a systematic effort to prevent AKI during TAVR, which may potentially translate into improved patients' 1-year survival.

4 citations

Journal ArticleDOI
TL;DR: The analysis supports a systematic effort to prevent AKI during TAVR, which may potentially translate into improved patients' 1-year survival, and significantly mediates one fifth of the effect of baseline CKD on all-cause mortality after T AVR.
Abstract: Background Acute kidney injury (AKI) after transcatheter aortic valve replacement (TAVR) is associated with increased mortality. However, it is controversial whether AKI affects prognosis per se, being linked to baseline chronic kidney disease (CKD) and bleeding complications. The aim of this study was to disentangle, applying mediation analysis, the association between AKI and clinical outcome, considering CKD and bleedings. Methods and Results Consecutive patients undergoing TAVR were prospectively enrolled at 5 high‐volume centers in Italy. AKI was defined according to Valve Academic Research Consortium‐3 consensus, whereas bleeding with Bleeding Academic Research Consortium. Primary outcome was all‐cause mortality after 1‐year follow‐up. Among 2621 patients undergoing TAVR, AKI occurrence was associated with 1‐year mortality. This association of AKI with the primary end points remained significant after adjusting for baseline risk estimators, either Society of Thoracic Surgeons score (hazard ratio [HR], 2.78 [95% CI, 1.95–3.80], P<0.001) or EuroSCORE‐II (HR, 1.85 [95% CI, 1.35–2.56], P<0.001). Both AKI and CKD significantly and independently affected primary outcome (HR, 3.06 [95% CI, 2.01–4.64], P<0.001 and HR, 1.82 [95% CI 1.27–2.65], P<0.01, respectively). The estimated proportion of the total effect of CKD mediated via AKI was, on average, 15%, 95% CI, 4%–29%, P<0.001. The significant effect of Bleeding Academic Research Consortium 2–5 bleedings on the primary outcome was not mediated by AKI. Conclusions AKI occurs in 1 out of 6 patients and significantly mediates one fifth of the effect of baseline CKD on all‐cause mortality after TAVR. Our analysis supports a systematic effort to prevent AKI during TAVR, which may potentially translate into improved patients' 1‐year survival.

2 citations

Journal ArticleDOI
TL;DR: In this article , percutaneous management of aortic stenosis and coronary artery bypass grafting with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention.
Abstract: Concomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD. Using discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission. Matching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P < .001) as was periprocedural stroke (0.9% vs 2.2%; P = .004), acute kidney injury (4.3% vs 16.0%, P < .001), blood transfusion (9.6% vs 21.1%, P < .001), and hospital-acquired pneumonia (0.1% vs 1.7%, P = .001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P < .001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P < .001) and SAVR/CABG (8.3 vs 6.8%, P < .001). Thirty-day cardiovascular readmission did not differ between groups. In this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation. La enfermedad coronaria (EC) es frecuente en pacientes con estenosis aórtica; sin embargo, la estrategia terapéutica óptima sigue siendo objeto de debate. Investigamos los resultados periprocedimiento en pacientes sometidos a implante percutáneo de válvula aórtica con intervención coronaria percutánea (TAVI/ICP) frente al recambio valvular aórtico con injerto de derivación de arteria coronaria (RVAo/CABG) en pacientes con estenosis aórtica con EC. Con los datos de alta del Sistema Nacional de Salud Español, se identificaron 6.194 pacientes (5.217 RVAo/CABG y 977 TAVI/ICP) entre 2016 y 2019. Se realizó un análisis emparejado por puntuación de propensión ajustado por características basales. El objetivo primario fue la mortalidad hospitalaria, Los objetivos secundarios fueron las complicaciones hospitalarias y rehospitalización cardiovascular a 30 días. Tras el emparejamiento, se seleccionaron 774 parejas de pacientes. La mortalidad total hospitalaria fue más frecuente en el grupo quirúrgico (3,4 frente a 9,4%, p < 0,001), al igual que el ictus periprocedimiento (0,9 frente a 2,2%, p = 0,004), fallo renal agudo (4,3 frente a 16,0%, p < 0,002), transfusión (9,6 frente a 21,1%, p < 0,001) y neumonía intrahospitalaria (0,1 frente a 1,7%, p = 0,001). La implantación de marcapasos permanente fue más frecuente en el tratamiento percutáneo (12,0 frente a 5,7%, p < 0,001). Los centros de menor volumen (< 130 procedimientos por año) tuvieron mayor mortalidad hospitalaria para ambos procedimientos: TAVI/ICP (3,6 frente a 2,9%, p < 0,001) y RVAo/CABG (9,3 frente a 6,8%, p < 0,001). La rehospitalización cardiovascular a 30 días no difirió entre los grupos. En este estudio nacional contemporáneo, el tratamiento percutáneo de estenosis aórtica y EC tuvo menor mortalidad y morbilidad intrahospitalaria que la intervención quirúrgica. Los centros de mayor volumen presentaron menor mortalidad hospitalaria en ambos grupos, justificándose investigaciones futuras en centros nacionales de alto volumen.

1 citations

Journal ArticleDOI
TL;DR: The present study on low-risk octogenarians, transfemoral TAVI and minimally invasive AVR showed comparable short-term and mid-term results, and both procedures are deemed safe and effective.
References
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Journal ArticleDOI
TL;DR: Impaired renal function at baseline and the occurrence of periprocedural AKI, independent whether renal function returns to baseline or not, are strong predictors of 30-day and 1-year mortality after TAVI.
Abstract: Objectives The aim of this study was to determine the influence of baseline renal function and periprocedural acute kidney injury (AKI) on prognosis after transcatheter aortic valve implantation (TAVI). Background Evidence is growing that renal function is a major predictor of mortality in patients after TAVI. Methods TAVI was performed with the 18-F CoreValve prosthesis via transfemoral access. All-cause mortality was determined 30 days and 1 year after TAVI in 77 patients with a mean Society of Thoracic Surgeons mortality score of 9.3 ± 6.1% and a mean logistic European System for Cardiac Operative Risk Evaluation of 31.2 ± 17.6%. Results Overall procedural success rate was 98% with 1 periprocedural death. The 30-day mortality was 10%, and 1-year mortality was 26%. The mortality risk increased stepwise across quartiles of baseline serum creatinine. An AKI occurred in 20 of 77 patients: 12 patients (60%) with AKI died during follow-up. The incidence of AKI was related to peripheral arterial disease (65% vs. 39%; p = 0.04), the occurrence of a systemic inflammatory response syndrome (60% vs. 21%, p = 0.002), and post-procedural peri-prosthetic regurgitation ≥2+ (35% vs. 9%, p = 0.02). Impaired renal function at baseline reflected by serum creatinine ≥1.58 mg/dl (hazard ratio: 3.9, 95% confidence interval: 1.6 to 9.5; p = 0.002) and the occurrence of AKI (hazard ratio: 5.9, 95% confidence interval: 2.4 to 14.5, p Conclusions Impaired renal function at baseline and the occurrence of periprocedural AKI, independent whether renal function returns to baseline or not, are strong predictors of 30-day and 1-year mortality after TAVI.

258 citations

Journal ArticleDOI
TL;DR: The NOTION trial (Nordic Aortic Valve Intervention) was designed to compare transcatheter aortic valve replacement (TAVR) with surgical aorta replacement (SAVR) in patients ≥70 years old.
Abstract: Background: The NOTION trial (Nordic Aortic Valve Intervention) was designed to compare transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients ≥70 y...

211 citations

Journal ArticleDOI
TL;DR: Although GFR improved in more than half of the patients, this benefit was associated with a risk of postinterventional AKI, and future investigations should define preventive measures of peri-procedural kidney injury.
Abstract: BACKGROUND: Transcatheter aortic valve implantation (TAVI) for high-risk and inoperable patients with severe aortic stenosis is an emerging procedure in cardiovascular medicine. Little is known of the impact of TAVI on renal function. METHODS: We analysed retrospectively renal baseline characteristics and outcome in 58 patients including 2 patients on chronic haemodialysis undergoing TAVI at our institution. Acute kidney injury (AKI) was defined according to the RIFLE classification. RESULTS: Fifty-eight patients with severe symptomatic aortic stenosis not considered suitable for conventional surgical valve replacement with a mean age of 83 +/- 5 years underwent TAVI. Two patients died during transfemoral valve implantation and two patients in the first month after TAVI resulting in a 30-day mortality of 6.9%. Vascular access was transfemoral in 46 patients and transapical in 12. Estimated glomerular filtration rate (eGFR) increased in 30 patients (56%). Fifteen patients (28%) developed AKI, of which four patients had to be dialyzed temporarily and one remained on chronic renal replacement therapy. Risk factors for AKI comprised, among others, transapical access, number of blood transfusions, postinterventional thrombocytopaenia and severe inflammatory response syndrome (SIRS). CONCLUSIONS: TAVI is feasible in patients with a high burden of comorbidities and in patients with pre-existing end-stage renal disease who would be otherwise not considered as candidates for conventional aortic valve replacement. Although GFR improved in more than half of the patients, this benefit was associated with a risk of postinterventional AKI. Future investigations should define preventive measures of peri-procedural kidney injury.

190 citations

Journal ArticleDOI
TL;DR: In this paper, the authors examined the incidence, predictors, and prognostic implications of acute kidney injury after transcatheter aortic valve implantation (TAVI) and found that one fifth of patients developed AKI after TAVI and that AKI was associated with increased in-hospital mortality.

141 citations

Journal ArticleDOI
TL;DR: Advanced CKD was associated with a higher rate of early and late mortality and bleeding events following TAVI, with AF and dialysis therapy determining a higher risk in these patients.
Abstract: Aim The aim of this study was to determine the effects of advanced chronic kidney disease (CKD) on early and late outcomes after transcatheter aortic valve implantation (TAVI), and to evaluate the predictive factors of poorer outcomes in such patients. Methods and results This was a multicentre study including a total of 2075 consecutive patients who had undergone TAVI. Patients were grouped according the estimated glomerular filtration rate as follows: CKD stage 1-2 (≥60 mL/min/1.73 m2; n = 950), stage 3 (30–59 mL/min/1.73 m2; n = 924), stage 4 (15–29 mL/min/1.73 m2; n = 134) and stage 5 (<15 mL/min/1.73 m² or dialysis; n = 67). Clinical outcomes were evaluated at 30-days and at follow-up (median of 15 [6–29] months) and defined according to the VARC criteria. Advanced CKD (stage 4–5) was an independent predictor of 30-day major/life-threatening bleeding ( P = 0.001) and mortality ( P = 0.027), and late overall, cardiovascular and non-cardiovascular mortality ( P < 0.01 for all). Pre-existing atrial fibrillation (HR: 2.29, 95% CI: 1.47–3.58, P = 0.001) and dialysis therapy (HR: 1.86, 95% CI: 1.17–2.97, P = 0.009) were the predictors of mortality in advanced CKD patients, with a mortality rate as high as 71% at 1-year follow-up in those patients with these 2 factors. Advanced CKD patients who had survived at 1-year follow-up exhibited both a significant improvement in NYHA class ( P < 0.001) and no deterioration in valve hemodynamics ( P = NS for changes in mean gradient and valve area over time). Conclusions Advanced CKD was associated with a higher rate of early and late mortality and bleeding events following TAVI, with AF and dialysis therapy determining a higher risk in these patients. The mortality rate of patients with both factors was unacceptably high and this should be taken into account in the clinical decision-making process in this challenging group of patients.

118 citations

Frequently Asked Questions (6)
Q1. What are the contributions mentioned in the paper "Acute kidney injury following aortic valve replacement in patients without chronic kidney disease moriyama, noriaki" ?

Moriyama et al. this paper investigated the incidence and predictors of acute kidney injury following aortic valve replacement in patients without chronic kidney disease. 

Ourfindings demonstrated that patients who underwent TAVR had a significantly lower incidence of AKIin comparison to those who underwent SAVR, and TAVR was associated with decreasing incidence ofAKI during study periods. 

AKI significantly increased the risk of 5-year mortality aftereither TAVR or SAVR and increasing severity of AKI was incrementally associated with 5-yearmortality. 

Patients withAKI had significantly increased 5-year mortality compared to those without AKI (unmatched 36.0%vs 19.1%, log-rank P<0.001; matched 36.3% vs 24.0%, log-rank P<0.001). 

Clinical Trial Registration: ClinicalTrials.gov, Identifier: NCT03385915.(URL https://clinicaltrials.gov/ct2/show/NCT03385915)4From the nationwide registry, 4555 consecutive patients with pre-procedural normal kidneyfunction who underwent TAVR and SAVR (TAVR, n=1215 and SAVR, n=3340) were evaluated. 

The adjusted hazard ratiosfor 5-year mortality were 1.58 (95%CI 1.20-2.08) for AKI grade 1, 3.27 (95%CI 2.09-5.06) for grade 2and 4.82 (95%CI 2.93-8.04) for grade 3.3Conclusions: TAVR in patients without CKD was associated with significantly less frequentincidence of AKI compared with SAVR. 

Trending Questions (1)
What is the relationship between transcatheter aortic valve replacement (TAVR) and chronic Kidney disease?

The paper does not provide information about the relationship between transcatheter aortic valve replacement (TAVR) and chronic kidney disease (CKD).