Long- and Short-Term Changes in Serum Creatinine Prior to LVAD Surgery are Associated with Postoperative Outcomes

Abstract

Purpose Declining renal function portends poor prognosis in advanced HF. Hemodynamic optimization with diuretics, inotropes, and temporary mechanical circulatory support is frequently performed for optimization of end-organ function before LVAD surgery. We aimed to study the relationship between long- and short-term changes in serum creatinine (sCr) that occur prior to implant and postoperative outcome in LVAD pts. Methods We retrospectively identified 146 LVAD pts with sCr at 3 time points: 1-year (1y), day of index admission, and 1-day (1d) prior to LVAD. Pts were classified based on the changes in sCr that occurred between 1y and 1d prior to LVAD as: Improved = sCr reduction >10% (n=42); Stable = sCr change ≤10% (n=50); Worsened = sCr increase >10% (n=54). Pts were also classified as Optimized using the following exploratory cutoffs: sCr reduction of ≥10, 15, and 20% during the index admission. The primary endpoint was survival free from renal replacement therapy (RRT) after LVAD. Multivariable Cox models were developed to adjust for age, sex, race and sCr 1d pre-LVAD. Results On average, sCr increased from 1 y to the time of index admission, while subsequently declined prior to LVAD (Fig A). Among 147 pts, 47 (31%) met the primary endpoint. In univariable model, Stable 1y-1d sCr was associated with a reduced risk for the primary endpoint (Fig B). After adjustment, there was only a trend towards significance in Stable vs. Improved (p=0.06). Optimization of sCr during index admission was not associated with improved outcomes. Furthermore, in an adjusted model, a decrease in sCr≥15% was significantly associated with increased risk for the primary endpoint (Fig B). Conclusion In the year preceding LVAD implant, a stable renal function is associated with a trend towards improved post-LVAD survival free from RRT. Moreover, a decrease in sCr≥15% during index admission was associated with worse outcome. The effect of sarcopenia on sCr levels in advanced HF may explain these paradoxical findings.