Patients with end-stage renal disease (ESRD) have an especially poor prognosis if they decide to get a left ventricular assist device (LVAD) for their advanced heart failure, a small study suggested.
By a median of 762 days since LVAD placement — whether as bridge to heart transplant or destination therapy — 81.9% and 36.4% of ESRD and non-ESRD patients had died, respectively. During the index hospitalization, the odds of death in the two patient groups were 51.6% and 4%, according to Nisha Bansal, MD, MAS, of the University of Washington’s Kidney Research Institute in Seattle, and colleagues.
Even after accounting for factors like demographics and comorbidity, ESRD patients had a markedly higher risk of mortality (adjusted HR 36.3, 95% CI 15.6 to 84.5), with the survival gap widest between groups in the first 60 days (when 72.4% and 6.3% had died), the study published online in JAMA Internal Medicine showed.
“Patients with ESRD at the time of LVAD placement had an extremely poor prognosis, with most surviving for less than 3 weeks,” Bansal and colleagues concluded. “The median survival of 16 days after LVAD placement and high in-hospital mortality for patients with ESRD in this study suggests that these procedures are either being offered at a time when patients are actively dying or that they actually precipitate this process.”
Subjects in the study were Medicare beneficiaries with ESRD (those included in the U.S. Renal Data System registry for having received maintenance dialysis or a kidney transplant; n=155) compared with a 5% sample of peers without the condition (n=261).
Of the entire ESRD group, just 2.9% went on to have a heart transplant and were alive 1 year after LVAD placement.
In an accompanying invited commentary, Sunu Thomas, MD, MSc, of Massachusetts General Hospital in Boston, and colleagues, wrote: “There continues to be a variable practice in mechanical circulatory support utilization among marginal LVAD candidates with end-stage heart failure. We commend the authors for providing further corroborative data in support of current guidelines discouraging LVAD therapy in patients with ESRD.”
Notably, however, according to the commentary, it appeared that more and more patients with ESRD were getting LVADs over time: 0.32 per 10,000 person-years in the 2003-2006 period versus 0.45 per 10,000 in 2010-2013. “The seemingly indiscriminate use of implantable LVADs” may be due to the researchers’ reliance on ICD-9 coding to identify the study cohort — which may have thrown temporary and permanent circulatory support device use into the same mix, Thomas et al wrote.
“The current analysis warrants further elaboration to explain the exceptionally high mortality rate and the appropriateness of LVAD therapy in a recognized marginal mechanical circulatory support candidate population. Paramount among our concerns is the database from which the analysis is derived.”
The commentary also cited the study’s lack of details such as cause of death and concomitant use of acute circulatory support.
Bansal and colleagues acknowledged that their retrospective study was without granular data. In addition, they were not able to perform any subgroup analyses within the ESRD cohort due to the small sample size.
Baseline imbalances between groups were quite common, too: the ESRD group was slightly younger and counted fewer men, and had more black patients with a greater burden of comorbidity as well.
“A strength of our analysis is that we describe outcomes after LVAD placement among nationally representative cohorts,” the team wrote. “Unlike prior studies of outcomes among LVAD recipients with kidney failure, which we suspect have included mainly patients receiving acute dialysis, we studied Medicare beneficiaries with ESRD. Our results may help to inform treatment decisions in patients with ESRD and heart failure who are contemplating LVAD placement. These patients should ideally be informed about the very poor prognosis of most patients with ESRD who receive an LVAD.”
Bansal and colleagues reported no conflicts of interest.
Thomas and co-authors disclosed no conflicts of interest.
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner