Outcomes Of Intermittent Hemodialysis During Support With Ventricular Assist Devices: A Potential Bridge To Heart/kidney Transplantation?

Abstract

Introduction Severe renal dysfunction is a contraindication for receiving ventricular assist devices (VADs). Hence, patients with end-stage heart failure (ESHF) and severe renal dysfunction who are not candidates for heart/kidney transplantation (HT/KT) may only be considered for either intermittent hemodialysis (IHD) or hospice. However, there is little evidence about the outcomes of patients with ESHF who are initiated on IHD after VAD implantation. Methods We reviewed the medical charts of all patients in our center who received IHD after VAD implantation. We considered IHD <6-hour sessions 3-4 times weekly, excluding continuous renal replacement therapy (CRRT). Continuous variables were expressed in means and standard deviations, or medians and p25-p75, according to their distribution. Categorical variables were represented in absolute numbers and percentages. Results Eleven patients (54.1 [±9.9] years of age, 6 [54.6%] women, and 6 [54.6%] African American) underwent VAD implantation as destination therapy (40%) or bridge to transplant (60%) and received IHD. Seven (63.6%) of them received HeartMate II, whereas the other patients were supported with HVAD HeartWare, and HeartMate 3 systems. By the time of VAD implantation, nine (81.8%) patients had history of chronic kidney disease with a median GFR was 60 (45-60) mL/min/1.73 m2 and a mean creatinine was 1.2 (±0.4) mg/dL. The mean outpatient furosemide-dose equivalent prior VAD implantation was 106 (±59.7) mg/day. Ten patients started IHD prior to discharge after VAD placement with a median time from VAD implantation to initiation of IHD was 26 (17-50) days. Another patient was initiated on IHD as outpatient within a year after receiving a VAD. Eight (72.7%) patients died during a follow-up of 886.7 (±762.1) days after initiation of IHD with a median survival time of 838 days. Three patients were bridged to transplantation: 2 HT/KT, and 1 HT (recovered renal function). Details about the timeline of events can be found in Fig 1. Conclusions Intermittent hemodialysis helped to bridge 2 VAD patients to HT/KT, and another to HT and recovery of renal function. Larger studies could provide valuable insight into this potential strategy to widen the options of advanced heart failure therapies for patients with ESHF. Severe renal dysfunction is a contraindication for receiving ventricular assist devices (VADs). Hence, patients with end-stage heart failure (ESHF) and severe renal dysfunction who are not candidates for heart/kidney transplantation (HT/KT) may only be considered for either intermittent hemodialysis (IHD) or hospice. However, there is little evidence about the outcomes of patients with ESHF who are initiated on IHD after VAD implantation. We reviewed the medical charts of all patients in our center who received IHD after VAD implantation. We considered IHD <6-hour sessions 3-4 times weekly, excluding continuous renal replacement therapy (CRRT). Continuous variables were expressed in means and standard deviations, or medians and p25-p75, according to their distribution. Categorical variables were represented in absolute numbers and percentages. Eleven patients (54.1 [±9.9] years of age, 6 [54.6%] women, and 6 [54.6%] African American) underwent VAD implantation as destination therapy (40%) or bridge to transplant (60%) and received IHD. Seven (63.6%) of them received HeartMate II, whereas the other patients were supported with HVAD HeartWare, and HeartMate 3 systems. By the time of VAD implantation, nine (81.8%) patients had history of chronic kidney disease with a median GFR was 60 (45-60) mL/min/1.73 m2 and a mean creatinine was 1.2 (±0.4) mg/dL. The mean outpatient furosemide-dose equivalent prior VAD implantation was 106 (±59.7) mg/day. Ten patients started IHD prior to discharge after VAD placement with a median time from VAD implantation to initiation of IHD was 26 (17-50) days. Another patient was initiated on IHD as outpatient within a year after receiving a VAD. Eight (72.7%) patients died during a follow-up of 886.7 (±762.1) days after initiation of IHD with a median survival time of 838 days. Three patients were bridged to transplantation: 2 HT/KT, and 1 HT (recovered renal function). Details about the timeline of events can be found in Fig 1. Intermittent hemodialysis helped to bridge 2 VAD patients to HT/KT, and another to HT and recovery of renal function. Larger studies could provide valuable insight into this potential strategy to widen the options of advanced heart failure therapies for patients with ESHF.