End-stage kidney patients who receive LVADs likely to die before discharge

Patients with end-stage renal disease (ESRD) who receive a left ventricular assist device (LVAD) survive an average of only 16 days after implantation, according to a small study published in JAMA Internal Medicine.

Lead researcher Nisha Bansal, MD, and colleagues compared survival times of 155 Medicare beneficiaries with ESRD to 261 without ESRD, which was defined as having received maintenance dialysis or a kidney transplant.

At 60 days post-operation, 72.4 percent of ESRD patients had died compared to 6.3 percent of patients without ESRD. Even after covariate adjustment, ESRD patients had a 36-fold increased risk of mortality. More than half (51.6 percent) died before leaving the hospital.

“The median survival of 16 days after LVAD placement and high in-hospital mortality for patients with ESRD in this study suggests that these procedures are either being offered at a time when patients are actively dying or that they actually precipitate this process,” Bansal et al. wrote. “A small subset of patients with ESRD did survive for longer periods of time and did go on to receive a heart transplant, suggesting that some patients with ESRD may derive benefit from LVADs.”

The researchers noted they didn’t have a large enough sample size to conduct subgroup analyses within the ESRD cohort. On the whole, though, they said their study could help inform shared decision-making between physicians, patients and their families about whether LVAD implantation is worthwhile.

Previous studies have primarily focused on earlier stages of kidney disease or those receiving temporary dialysis for acute kidney injury. Because heart failure is present in approximately 40 percent of patients with ESRD, findings related to LVAD survival in these patients have broad importance, according to Bansal and colleagues.

“Our results may help to inform treatment decisions in patients with ESRD and heart failure who are contemplating LVAD placement,” the authors wrote. “These patients should ideally be informed about the very poor prognosis of most patients with ESRD who receive an LVAD. In the context of each patients’ goals and values, this information should then factor into shared decision-making around LVAD placement.”

In an invited commentary, three physicians from Massachusetts General Hospital and Harvard Medical School highlighted the limitations with the database used by Bansal and colleagues. Important details were unavailable, including the mechanism of death, the relative hemodynamic acuity at time of LVAD implantation and whether the LVAD was implemented as a bridge to transplant or with the intent of being a destination therapy.

In addition, the editorialists reported surprise that ESRD patients became increasingly more likely to be treated with LVAD therapy as the study progressed. Current guidelines recommend against LVAD implantation as a destination therapy in patients requiring permanent dialysis, they pointed out.

“ESRD is a leading predictor of morbidity and mortality following cardiac surgery, and the same seems to be true for LVAD surgery,” wrote Sunu S. Thomas, MD, MSc; Emily K. Kern, MD; and David A. D’Alessandro, MD. “As this study emphasizes, we must be more responsible with patient selection as even man-made machines are a limited resource. There continues to be a variable practice in (mechanical circulatory support) utilization among marginal LVAD candidates with end-stage heart failure. We commend the authors for providing further corroborative data in support of current guidelines discouraging LVAD therapy in patients with ESRD.”