Summary
There is a paucity of data describing acute kidney injury (AKI) following transcatheter aortic valve implantation and its impact on mortality remains unknown. We therefore evaluate the incidence, predictors and impact of AKI following transcatheter aortic valve implantation. We searched MEDLINE for studies from 2008 to 2013, evaluating AKI after transcatheter aortic valve implantation. All studies were compared according to the incidence, predictors and impact of AKI following transcatheter aortic valve implantation. AKI was diagnosed according to the Valve Academic Research Consortium definition using the RIFLE criteria. Thirteen studies with more than 1900 patients were included. AKI occurred in 8.3–57% of the patients. The following factors were associated with AKI: blood transfusion; transapical access; preoperative creatinine concentration; peripheral vascular disease; hypertension; and procedural bleeding events. The 30-day mortality rate in patients with AKI ranged from 13.3% to 44.4% and was 2–6-fold higher than in patients without AKI. The amount of contrast agent used was not associated with the occurrence of AKI. AKI is a common complication, with an incidence of 8.3–57% following transcatheter aortic valve implantation. Patients with AKI had higher 30-day and late mortality rates. However, AKI was related to the amount of contrast volume used in only one study.
Résumé
Il y a peu de sources qui décrivent l’incidence d’une insuffisance rénale aiguë (IRA) après l’implantation des valves aortiques par voie percutanée et son influence sur la mortalité. Le but de cette étude est d’évaluer l’incidence, les facteurs prédictifs et l’influence d’IRA sur la mortalité. Les études sur ce thème publiées entre 2008 et 2013 étaient choisies lors d’une analyse de base de donnée de Medline. Ces études étaient comparées entre-eux en ce qui concerne l’incidence, prédicteurs et l’influence d’IRA sur la mortalité. Le diagnostic d’IRA était retenu selon les définitions de VARC en utilisant les critères RIFLE. Treize études étaient inclues dans notre analyse. Parmi tous les patients inclus, l’IRA était développé chez 8,3 % à 57 %. Les facteurs suivants étaient liés à l’occurrence de L’IRA : la transfusion sanguine ; l’accés transapical ; la créatinine plasmatique ; l’arthropathie oblitérante periphérique ; la tension artérielle ; et l’hémorrhagie intraopérative. L’insuffisance rénale aiguë est une complication fréquente avec une incidence de 8,3 % à 57 % chez les patients ayant une implantation de valves aortiques par voie percutanée. Les patients présentant une IRA ont une haute mortalité dans les premiers 30 jours après ĺimplantation et à long terme. En revanche, la dose du produit de contraste n’est pas un facteur de risque que dans seulement une étude.
Background
Acute kidney injury (AKI) is a common complication in patients undergoing cardiac surgery, occurring in up to 30% of all patients. Moreover, an estimated 2–15% patients require renal replacement therapy (RRT) after a surgical cardiac procedure, with an in-hospital mortality rate of > 40% .
Transcatheter aortic valve implantation (TAVI) has emerged as an alternative therapy in high-risk patients with severe aortic stenosis. Despite the encouraging results associated with TAVI, post-procedural AKI remains a common complication, with a wide range of reported incidences .
Since the introduction of the Valve Academic Research Consortium (VARC) criteria in January 2011 for standardizing definitions of clinical endpoints for TAVI , a recent pooled analysis confirmed the use of VARC criteria in 16 studies involving 3519 patients . The diagnosis of AKI was recommended to be made using the modified RIFLE criteria. The recently published VARC-2 criteria recommended the use of the Acute Kidney Injury Network (AKIN) classification . In comparison with the original VARC criteria, the timing for the diagnosis of AKI is extended from 72 hours to 7 days, to ensure the association with the procedure. Patients with AKI should be followed for 7 days during the index hospitalization.
TAVI procedures involve the administration of contrast agent; the need for rapid pacing with resulting hypotension that may influence renal function and lead to acute kidney injury. Moreover, atherosclerosis is a co-morbidity in the majority of patients undergoing TAVI, with the risk of embolization during the implantation.
Our aim in this review was to analyse the incidence of AKI among patients undergoing TAVI in the literature. In addition, we intended to show and compare all the predictors of AKI and mortality rates in the appropriate studies. Moreover, we tried to assess whether contrast agent has an influence on AKI after TAVI.
Methods
We performed a web-based search on PubMed to find articles describing AKI after TAVI. The following keywords were used: transcatheter aortic, acute kidney injury and VARC. Only articles that described AKI incidence, prognostic factors and mortality in details were evaluated.
Definition of acute kidney injury
AKI was defined according to the RIFLE criteria or the VARC criteria (using the modified RIFLE criteria) ( Table 1 ) . The decision to undertake RRT during the index hospitalization was made by the intensivist responsible for the patient. Among all the reviewed studies, four used the RIFLE criteria and six used the VARC criteria. Only one study used the AKIN classification .
| Stage | Change in serum creatinine (72 hours) compared with baseline |
|---|---|
| Stage 1 | Increase in serum creatinine to 150–200% (1.5–2.0-fold increase compared with baseline) or increase of > 0.3 mg/dL (> 26.4 mmol/L) |
| Stage 2 | Increase in serum creatinine to 200–300% (2.0–3.0-fold increase compared with baseline) or increase of > 0.3 mg/dL (> 26.4 mmol/L) but < 4.0 mg/dL (< 354 mmol/L) |
| Stage 3 a | Increase in serum creatinine to ≥ 300% (> 3.0-fold increase compared with baseline) or serum creatinine ≥ 4.0 mg/dL (≥ 354 mmol/L), with acute increase of ≥ 0.5 mg/dL (44 mmol/L) |
a Patients receiving renal replacement therapy are considered to meet stage 3 criteria, irrespective of other criteria.
Statistical analysis
Continuous variables are presented as means ± standard deviations or medians with interquartile ranges. Categorical variables are presented as frequencies (percentages).
Results and discussion
Our systematic search found 13 studies with more than 1900 patients (aged 79–84 years) who underwent TAVI for severe aortic stenosis between 2006 and 2012 ( Fig. 1 ). The EuroSCORE ranged from 18% to 34% and the STS score ranged from 6% to 14% ( Table 2 ). All studies were published between 2010 and 2013.
| Study | Patients ( n ) | Access (%) | Age (years) a | Baseline creatinine (μmol/L) a | Baseline GFR a | Contrast medium used (mL) a | EuroSCORE (%) a | STS score (%) a |
|---|---|---|---|---|---|---|---|---|
| Elhmidi et al. | 234 | TF: 65.2; TA: 24; TaA:2.2 | 81.8 ± 6.4 | 124.9 ± 43 | NA | 144 ± 59 | 22.55 ± 14.77 | 7.04 ± 3.6 |
| Barbash et al. | 165 | TF: 50; TA: 50 | 84 ± 5 | NA | 43 ± 18 | 98 ± 46 | NA | 11 ± 4 |
| Sinning et al. | 70 | TF: 100 | 79.9 ± 6.8 | NA | NA | 207 ± 70 | 31.2 ± 17.6 | 9.3 ± 6.1 |
| Saia et al. | 102 | NA | 83.7 ± 5.3 | NA | NA | 111 ± 35 | 22.6 ± 12.4 | 8.2 ± 4.1 |
| Genereux et al. | 218 | TF: 64,2; TA: 35,7 | 84.0 ± 7.4 | 123.2 ± 52.8 | 52.9 ± 19.2 | 122.6 ± 96 | NA | 12.8 ± 4.3 |
| Nuis et al. | 118 | NA | 83 (76–85) | 119 ± 71 | 54 ± 20 | 213 ± 56 | 18.4 (8.7–30.5) | 9.3 (3.9–13.8) |
| Van Linden et al. | 270 | TA: 100 | 82 ± 5.8 | 167 ± 44 | 44.3 ± 15.9 | 110 ± 21 | 31.4 ± 15.6 | 12.1 ± 7.4 |
| Strauch et al. | 28 | TA: 100 | 82.1 (71–88) | NA | NA | NA | 19.01 (5.1–77.4) | 13.6 (3.2–26) |
| Bagur et al. | 213 | TF: 36; TA: 64 | 84 ± 7 | 102.9 ± 44 | 70 (49–80) | 79 ± 55 | 34.3 + 21.8 | NA |
| Aregger et al. | 60 | TF: 79; TA: 21 | 83 ± 6 | 123 ± 72 | 57 ± 33 | 242 ± 101 | 25 ±10 | NA |
| Khawaja et al. | 248 | TF: 32.6; TA: 44.9; TaA: 22.5 | 83.3 ± 6.9 | 134.7 ± 74.5 | 43.2 ± 26.1 | 110.35 ± 47.5 | 25.3 ± 16.1 | NA |
| Alassar et al. | 79 | NA | 84 (78–87) | NA | NA | NA | NA | NA |
| Gebauer et al. | 150 | TF: 64; TA: 36 | 81 ± 7 | 126.4 ± 59.2 | 51 ± 17 | 147 ± 71 | 24 ± 15 | 6.0 ± 3.5 |
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