Severe aortic stenosis and chronic kidney disease: Outcomes and impact of aortic valve replacement

Abstract

To analyze the relationship between chronic kidney disease(CKD) stages and all-cause and cardiovascular mortality and evaluate the effect of aortic-valve replacement(AVR) versus conservative management according to kidney function in patients with severe aortic stenosis(AS). This analysis included 4119 patients with severe AS. The population was divided into four groups according to the baseline estimated glomerular filtration rate: no CKD, mild CKD, moderate CKD, and severe CKD. The five-year survival rate was 71 ± 1% for patients without CKD, 62 ± 2% for those with mild CKD, 54 ± 3% for those with moderate CKD, and 34 ± 4% for those with severe CKD ( P < 0.001). By multivariable analysis, patients with moderate or severe CKD had a significantly higher risk of all-cause (HR[95%CI] = 1.36[1.08–1.71]; P = 0.009 and HR[95%CI] = 2.16[1.67–2.79]; P < 0.001, respectively) and cardiovascular mortality (HR[95%CI] = 1.39[1.03–1.88]; P = 0.031 and HR[95%CI] = 1.69[1.18–2.41]; P = 0.004, respectively) than patients without CKD. Despite more symptoms, AVR was less frequent in moderate ( P = 0.002) and severe CKD ( P < 0.001). AVR was associated with a marked reduction in all-cause and cardiovascular mortality versus conservative management for each CKD group (all P < 0.001). The joint-test showed no interaction between AVR and CKD stages ( P = 0.676) indicating a non-differential effect of AVR across stages of CKD. After propensity matching, AVR was still associated with substantially better survival for each CKD stage relative to conservative management (all P < 0.0017) ( Fig. 1 ). In severe AS, moderate and severe CKD are associated with increased mortality and decreased referral to AVR. AVR markedly reduces all-cause and cardiovascular mortality, regardless of the CKD stage. Therefore, CKD should not discourage physicians from considering AVR.