P50: Heart and Kidney Transplant and Recovery after Left Ventricular Assist Device and Intermittent Hemodialysis: Systematic Review and Individual-Participant-Data Meta-analysis

Abstract

Background: Patients with left ventricular assist devices (LVADs) who require chronic intermittent dialysis (iHD) are considered to have poor prognosis despite paucity of supportive evidence, most of which is limited to case reports and very small single-center cohorts. This systematic review and individual-participant-data meta-analysis aims to study the main outcomes of patients receiving iHD during durable LVAD support, including heart, kidney, and heart-kidney transplantation (HT, KT, HKT, respectively) and mortality. Methods: We retrieved citations from ClinicalTrials.gov, Cochrane, Embase, PubMed, and Web of Science through systematic searches. We selected cohort studies (with n ≥5) of patients who were started on iHD at any point during durable LVAD support, excluding patients who exclusively received continuous renal replacement therapy but no actual iHD. We conducted Kaplan-Meier survival estimations and graphs, and compared mortality data between groups using the Gehan-Breslow-Wilcoxon test. P <.05 was considered statistically significant. We did not pursue inputations for missing data. Results: Six studies with a total of 64 patients met selection criteria. Their median age was 57.5 (46-64.5) years, 49 (76.6%) were men, 46 (86.8%) patients had a HeartMate (HM) 2, whereas 5 (9.4%) had a HM3, and 2 (3.8%) had an HVAD. Twenty-eight (66.7%) patients had LVADs as bridge to HT, and 14 (33.3%) as destination therapy. Only 26 (65%) were reported to have a history of CKD. Patients were initiated on iHD at a median of 18 (7-48) days after LVAD implantation, and remained on iHD for 68 (36-185) days. Eleven (17.2%) patients received HT, and at least 1 additional patient achieved myocardial recovery with LVAD explantation. Four (4.3%) patients became recipients of HKT, including one patient who had recovered enough of their renal function as to stop needing iHD prior to transplantation. Twenty-seven (42.2%) experienced renal recovery. Thirty-one (48.4%) patients died at 103 (64-308) days after initiation of iHD. According to Kaplan-Meier survival calculations, median survival was estimated at 153 (SE 217.5; CI 65-835) days (Figure 1). Survival after initiation of iHD was statistically significantly longer for patients who received HT (mortality: 2 [6.4%] vs 16 [11.6%]; p=.0346; median survival: 1972 [SE 98.8; 799-] days vs 93 [SE 10.3; CI 57-404] days), as evidenced in Figure 2. Survival comparisons between groups stratified based on other outcomes (HKT, renal recovery, composite HKT/renal recovery) did not reach statistical significance. Conclusions: The 18.8% of patients who achieved dual heart and kidney recovery and/or transplantation after being supported with LVAD and iHD experienced a significantly longer median survival. Only one patient experienced dual heart-kidney recovery. Larger contemporary multicenter cohort studies are warranted on this topic.Figure 1. Kaplan-Meier Survival Estimate (for the whole sample)Figure 2. Kaplan-Meier Survival Estimate According to Heart Transplant Status