Giuseppe Gargiulo (Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy) and others report in Circulation: Cardiovascular Interventions that patients with moderate-to-severe chronic kidney disease have significantly worse outcomes after transcatheter aortic valve implantation (TAVI) than have patients with mild disease.
According to Gargiulo et al, the “detrimetnal impact” of baseline chronic kidney disease on the prognosis of patients who undergo surgical aortic valve replacement is “well established” but the impact of the disease on patients undergoing TAVI “remains a debated issue”. They explain that the evidence for the effect of chronic kidney disease on TAVI patients is “mixed” and that chronic kidney disease patients are “typically” under-represented in TAVI trials.
The aim of the present meta-analysis was to review the “impact of preoperative chronic kidney disease on the clinical outcomes of patients undergoing TAVI”. The authors therefore searched for studies that had data for patients with chronic kidney disease undergoing TAVI and identified nine such studies (involving 4,992 patients overall). The primary endpoint was the rate of all-cause mortality at one year, with secondary endpoints including early all-cause mortality, cardiovascular mortality, stroke, and acute kidney injury.
The one-year all-cause mortality rate was significantly increased in patients with stage 3–5 chronic kidney disease compared with patients with stage 1–2 disease (p=0.001 for the comparison). Furthermore, in separate analyses, both patients with stage 4–5 (severe) and those with stage 3 disease (moderate) had significantly higher rates of all-cause mortality at one year than those with stage 1–2 disease (mild; p=0.0003 and p=0.002, respectively). Additionally patients with stage 4–5 disease had significantly higher all-cause mortality than those with stage 3 disease (p=0.003).
Stage 3–5 chronic kidney disease was also associated with significantly higher rates of cardiovascular mortality than stage 1–2 disease (p=0.01), but stage 3 disease was not associated with greater cardiovascular mortality than stage 1–2 disease (p=0.08) and stage 4–5 disease was not associated with significantly higher rates than moderate disease (p=0.07).
Regarding other outcomes, patients with stage 3–5 chronic kidney disease had significantly higher rates of stroke, acute kidney injury, acute kidney injury stage 2–3, need for postoperative dialysis, and length of stay compared with those with stage 1–2 disease. Furthermore, major bleeding was significantly increased in patients with stage 4–5 disease compared with those with stage 1–2 disease or stage 3 disease. However, there were no differences in major bleeding rates between stage 3–5 and stage 1–2 patients or between stage 3 and stage 1–2 patients.
Gargiulo et al conclude: “Moderate-to-severe preoperative chronic kidney disease significantly worsens the early and late prognosis of patients undergoing TAVI. The results of the present meta-analysis should be considered hypothesis-generating for future studies on risk evaluation, prevention, management, and postoperative management.”