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Post-TAVR dialysis linked to increased mortality
The proportion of patients requiring dialysis after transcatheter aortic valve replacement has declined, but the need for new post-TAVR dialysis is associated with a significantly increased risk for mortality, according to new data.
To determine the incidence of dialysis requirement after TAVR and its effect on outcomes, the researchers evaluated data from 2007 to 2014 on patients in the UK TAVI Registry. The median follow-up was 625 days.
TAVR and dialysis
Of all patients, 1.8% were on dialysis before TAVR — a proportion that has remained stable over time (P = .704). The incidence of newly required dialysis after TAVR, however, decreased from 6.1% in 2007-2008 to 2.3% in 2013-2014 (P < .001).
Preprocedural factors associated with the risk for new post-TAVR dialysis included lower baseline renal function (OR = 0.95; 95% CI, 0.94-0.96), year of procedure (OR = 0.89; 95% CI, 0.82-0.96), impaired left ventricular function (OR = 1.53; 95% CI, 1.01-2.33) and diabetes (OR = 1.63; 95% CI, 1.19-2.23), whereas procedural factors included a nontransfemoral approach (OR = 2.46; 95% CI, 1.81-3.34), conversion to open surgery (OR = 9.59; 95% CI, 4.39-20.96) and moderate to severe aortic regurgitation after the procedure (OR = 3.012; 95% CI, 1.99-4.57).
Additionally, use of a balloon-expandable valve (Sapien family of products, Edwards Lifesciences), compared with a self-expanding valve (CoreValve family of products, Medtronic), was associated with elevated risk for new dialysis after TAVR, even after adjustment for access route (OR = 1.85; 95% CI, 1.09-3.14), which was a surprising finding, the researchers noted.
“This data point will no doubt be provocative and stir much discussion,” Anand Prasad, MD, and Marlene Garcia, MD, both from the University of Texas Health Science Center in San Antonio, wrote in an accompanying editorial published in JACC: Cardiovascular Interventions. “We can only speculate as to the reason for this difference.”
Compared with patients who did not require dialysis, the need for new dialysis after TAVR was linked to a significantly increased risk for mortality at 30 days (HR = 6.44; 95% CI, 4.87-8.53) and 4 years (HR = 3.54; 95% CI, 2.99-4.19).
Greater urgency
“Given the marked increase in mortality in patients who end up on dialysis post-TAVR, there needs to be a greater urgency and focus on the role of [chronic kidney disease] in these patients. Given the established role of contrast dye as a nephrotoxic agent and the growing evidence that both the route of valve delivery and perhaps the valve type may influence renal outcomes, future registries should be sufficiently granular in their data extraction to capture variables related to these factors,” Prasad and Garcia wrote. “Although the role of embolic protection remains of interest in preventing stroke during TAVR, we should also look further down the aorta to the renal arteries as another vascular bed worthy of protection.” – by Melissa Foster
Disclosures: Ferro reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Prasad reports being a consultant for GE and Osprey Medical; being a speaker for Abiomed, AstraZeneca and Gilead; and receiving research funding from ACIST Medical and Medtronic. Garcia reports no relevant financial disclosures.