Adverse Events During Hemodialysis in LVAD Recipients

Abstract

Introduction Over the past decade, implantable left ventricular assist devices (LVAD) have become an acceptable alternative to support patients with advanced heart failure, either as a bridge to transplantation or as destination therapy for patients who are not candidates for heart transplantation. As the number of LVAD implantation increases, greater number of LVAD recipients requiring long term renal replacement therapy (RRT), usually chronic hemodialysis (HD), will be seen. This is due to common simultaneous chronic kidney disease in patients with heart failure, but more frequently due to irreversible acute kidney injury occurring in the peri-implantation period. There though is limited data on HD in LVAD recipients. We sought to assess adverse events that required early termination of HD sessions in HeartWare LVAD recipients while they were hospitalized after LVAD implantation. Methods Between 2015 and 2017 at the University of Maryland Medical Center, 7 patients required HD after LVAD implantation. These 7 patients had a total of 92 HD sessions during their hospitalizations. The average age of the patients was 46 +/- 11.9 years old. Two patients had ESRD and were on HD prior to LVAD implantation. The remaining five patients had CKD but were not on HD. The pre-LVAD creatinine average for all 7 patients was 2.55 +/- 1.8. After LVAD implantation, all of the patients were initially on continuous renal replacement therapy before being transitioned to HD. HD was started anywhere from within 2 to 57 days after LVAD implantation. Results LVAD settings were typically not adjusted during HD sessions. Additionally, during HD all patients were on midodrine, vasopressors, or fludrocortisone to help increase blood pressure. There were seven HD sessions that required early termination due to symptomatic hypotension (3), asymptomatic hypotension (2), sinus tachycardia and cramping and discomfort. The average duration of all HD sessions was 172 minutes and the average duration of HD sessions that were terminated early was 148 minutes. Low flow LVAD alarms did not activate during any of the sessions. Conclusion 7 out of 92 sessions required early termination and the most common reasons (5 out of 7) were related to hypotension. Complications related to blood pressure was also found to be the most common reason for termination of HD in previous study of HD sessions in Heartmate LVAD patients. As a result of continuous-flow technology, in most LVAD recipients, there is an absence of pulse, precluding the standard assessment of blood pressure, making assessment of blood pressure during dialysis difficult. There needs to be more research on how to address this in addition to how to optimize and change LVAD settings during HD sessions.