Advertisement

Selection for Ventricular Assist Device Placement in Patients with Chronic Kidney Disease

  • Nasir Z. Sulemanjee
  • Michael R. Rudnick
  • Mamatha Pinninti
Chapter

Abstract

Use of left ventricular assist devices (LVAD) in the treatment of advanced heart failure has increased significantly in recent years. Renal dysfunction is commonly associated with advanced heart failure and is an indicator of poor outcomes. In this chapter, we review factors that affect the clinical outcomes of LVAD implantation in patients with renal dysfunction, with an eye toward improved patient selection.

Renal dysfunction and the need for hemodialysis prior to LVAD implantation increase mortality after LVAD implantation. Although renal function generally improves during the first 1–3 months after LVAD implantation, it can regress to baseline or stay slightly above pre-implantation value by 1 year. Patients with improved renal function after LVAD implantation had improved survival and transplantation rates. Some factors that predict worsening of renal function and poor outcomes in the immediate post-LVAD period are cardiorenal syndrome type II with ischemic changes and renal fibrosis; long-standing, poorly controlled diabetes or hypertension; and need for hemodialysis or CVVHD after LVAD implantation. Improvement in renal function with optimal medical therapy and intra-aortic balloon pump use prior to LVAD implantation were predictors for post-LVAD renal function improvement.

Renal dysfunction should not be bundled into a single category in patients being evaluated for LVAD implantation because there are reversible causes for renal dysfunction in this population. A thorough work-up of renal failure will help to prevent withdrawal of this life-saving therapy from advanced heart failure patients.

Keywords

Left ventricular assist device Mechanical circulatory assist device Advanced heart failure End-stage heart failure Renal failure Renal dysfunction Chronic kidney disease Patient selection End-stage renal disease Outcomes 

Abbreviations

CF

Continuous-flow

CrCl

Creatinine clearance

CVVHD

Continuous veno-venous hemodialysis

eGFR

Estimated glomerular filtration rate

HF

Heart failure

INTERMACS

Interagency Registry for Mechanical Assisted Circulatory Support

LVAD

Left ventricular assist device

MCS

Mechanical circulatory support

PF

Pulsatile-flow

RAAS

Renin–angiotensin–aldosterone system

Notes

Acknowledgment

The authors gratefully acknowledge Jennifer Pfaff and Susan Nord of Aurora Cardiovascular Services for editorial preparation of the manuscript and Brian Miller and Brian Schurrer from Aurora Research Institute for help in preparing the figures.

References

  1. 1.
    Cleland JG, Carubelli V, Castiello T, Yassin A, Pellicori P, Antony R. Renal dysfunction in acute and chronic heart failure: prevalence, incidence and prognosis. Heart Fail Rev. 2012;17(2):133–49.CrossRefPubMedGoogle Scholar
  2. 2.
    Brisco MA, Kimmel SE, Coca SG, Putt ME, Jessup M, Tang WW, et al. Prevalence and prognostic importance of changes in renal function after mechanical circulatory support. Circ Heart Fail. 2014;7(1):68–75.CrossRefPubMedGoogle Scholar
  3. 3.
    Kirklin JK, Naftel DC, Kormos RL, Pagani FD, Myers SL, Stevenson LW, et al. Quantifying the effect of cardiorenal syndrome on mortality after left ventricular assist device implant. J Heart Lung Transplant. 2013;32(12):1205–13. https://doi.org/10.1016/j.healun.2013.09.001.CrossRefPubMedGoogle Scholar
  4. 4.
    Sandner SE, Zimpfer D, Zrunek P, Rajek A, Schima H, Dunkler D, et al. Renal function and outcome after continuous flow left ventricular assist device implantation. Ann Thorac Surg. 2009;87(4):1072–8. https://doi.org/10.1016/j.athoracsur.2009.01.022.CrossRefPubMedGoogle Scholar
  5. 5.
    Butler J, Geisberg C, Howser R, Portner PM, Rogers JG, Deng MC, et al. Relationship between renal function and left ventricular assist device use. Ann Thorac Surg. 2006;81(5):1745–51.CrossRefPubMedGoogle Scholar
  6. 6.
    Iwashima Y, Yanase M, Horio T, Seguchi O, Murata Y, Fujita T, et al. Effect of pulsatile left ventricular assist system implantation on Doppler measurements of renal hemodynamics in patients with advanced heart failure. Artif Organs. 2012;36(4):353–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Sandner SE, Zimpfer D, Zrunek P, Dunkler D, Schima H, Rajek A, et al. Renal function after implantation of continuous versus pulsatile flow left ventricular assist devices. J Heart Lung Transplant. 2008;27(5):469–73.CrossRefPubMedGoogle Scholar
  8. 8.
    Welp H, Rukosujew A, Tjan TD, Hoffmeier A, Kösek V, Scheld HH, et al. Effect of pulsatile and non-pulsatile left ventricular assist devices on the renin-angiotensin system in patients with end-stage heart failure. Thorac Cardiovasc Surg. 2010;58(Suppl 2):S185–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Hasin T, Topilsky Y, Schirger JA, Li Z, Zhao Y, Boilson BA, et al. Changes in renal function after implantation of continuous-flow left ventricular assist devices. J Am Coll Cardiol. 2012;59(1):26–36.CrossRefPubMedGoogle Scholar
  10. 10.
    Khot UN, Mishra M, Yamani MH, Smedira NG, Paganini E, Yeager M, et al. Severe renal dysfunction complicating cardiogenic shock is not a contraindication to mechanical support as a bridge to cardiac transplantation. J Am Coll Cardiol. 2003;41(3):381–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Demirozu ZT, Etheridge WB, Radovancevic R, Frazier OH. Results of HeartMate II left ventricular assist device implantation on renal function in patients requiring post-implant renal replacement therapy. J Heart Lung Transplant. 2011;30(2):182–7.CrossRefPubMedGoogle Scholar
  12. 12.
    James KB, McCarthy PM, Thomas JD, Vargo R, Hobbs RE, Sapp S, et al. Effect of the implantable left ventricular assist device on neuroendocrine activation in heart failure. Circulation. 1995;92(9 Suppl):II191–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Labban B, Arora N, Restaino S, Markowitz G, Valeri A, Radhakrishnan J. The role of kidney biopsy in heart transplant candidates with kidney disease. Transplantation. 2010;89(7):887–93.CrossRefPubMedGoogle Scholar
  14. 14.
    Kihara S, Litwak KN, Nichols L, Litwak P, Kameneva MV, Wu Z, et al. Smooth muscle cell hypertrophy of renal cortex arteries with chronic continuous flow left ventricular assist. Ann Thorac Surg. 2003;75(1):178–83; discussion 183.CrossRefPubMedGoogle Scholar
  15. 15.
    Naik A, Akhter SA, Fedson S, Jeevanandam V, Rich JD, Koyner JL. Acute kidney injury and mortality following ventricular assist device implantation. Am J Nephrol. 2014;39(3):195–203.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Nasir Z. Sulemanjee
    • 1
    • 2
  • Michael R. Rudnick
    • 3
  • Mamatha Pinninti
    • 4
  1. 1.Aurora Cardiovascular ServicesAurora Sinai/Aurora St. Luke’s Medical CentersMilwaukeeUSA
  2. 2.University of Wisconsin School of Medicine and Public HealthMadisonUSA
  3. 3.Penn Presbyterian Medical CenterPerleman School of Medicine of the University of PennsylvaniaPhiladelphiaUSA
  4. 4.Geisinger Medical CenterDanvilleUSA

Personalised recommendations