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Left ventricular assist device recipients with advanced kidney disease have low survival odds

Patients with end-stage renal disease who received a left ventricular assist device for the treatment of heart failure had an extremely high mortality rate, compared with those without end-stage renal disease, according to findings published in JAMA Internal Medicine.

“Left ventricular assist devices (LVADs) are widely used both as a bridge to heart transplant and as destination therapy in advanced heart failure,” Nisha Bansal, MD, from the Kidney Research Institute at the University of Washington, and colleagues wrote. “Although heart failure is common in patients with end-stage renal disease (ESRD), little is known about outcomes after LVAD implantation in this population.”

Bansal and colleagues compared the utilization of and outcomes after the placement of an LVAD for advanced heart failure in patients with and without ESRD. They used nationally representative data from the United States Renal Data System which was linked to Medicare claims to identify a cohort of beneficiaries with ESRD who received an LVAD between 2003 and 2013 (n = 155; mean age, 58.4 years; 62% men) and a 5% sample of Medicare beneficiaries without ESRD who received an LVAD (n = 261; mean age, 62.2 years; 75.1% male). There was a median of 1,655 days from ESRD onset to LVAD placement in patients with ESRD.

During the follow-up period (mean, 762 days), the researchers found that death occurred in 81.9% of patients with ESRD and 36.4% of those without ESRD. Additionally, during the index hospitalization, 51.6% of patients with and 4% without ESRD died. The median time to death was shorter in patients with ESRD than those without (16 days vs. 2,125 days).

The risk for death, adjusted for demographics, comorbidity and time period, was substantially increased in patients with ESRD (HR = 36.3; 95% CI, 15.6-84.5), particularly in the initial 60 days after LVAD placement.

“[LVAD] recipients with ESRD at the time of placement have a very poor prognosis, with less than half surviving to hospital discharge and most surviving less than 3 weeks,” Bansal and colleagues concluded. “This information may be crucial in supporting shared decision-making around treatments for advanced heart failure for patients with ESRD.”

In an accompanying editorial, Sunu S. Thomas, MD, MSc, from the cardiology division at Massachusetts General Hospital and Harvard Medical School, and colleagues, praised Bansal and colleagues for offering more corroborative data to support current guidelines that discourage LVAD in patients with ESRD, but noted that further research is needed to explain why the mortality rate was remarkably high, as well as the appropriateness of LVAD.

“We must be more responsible with patient selection as even man-made machines are a limited resource,” they wrote. “There continues to be a variable practice in [mechanical circulatory support] utilization among marginal LVAD candidates with end-stage heart failure.” – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.