Long-term kidney outcomes in pediatric continuous-flow ventricular assist device patients,Pediatric Nephrology

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Long-term kidney outcomes in pediatric continuous-flow ventricular assist device patients
Pediatric Nephrology ( IF 3 ) Pub Date : 2023-11-16 , DOI: 10.1007/s00467-023-06190-8
Alexandra Idrovo _{1,

2} , Seth A Hollander ₃ , Tara M Neumayr _{4,

5} , Cynthia Bell ₆ , Genevieve Munoz ₄ , Swati Choudhry ₇ , Jack Price ₇ , Iki Adachi ₈ , Poyyapakkam Srivaths ₁ , Scott Sutherland ₉ , Ayse Akcan-Arikan _{1,

10}

Affiliation

Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA.
Renal Section, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.
Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School, St. Louis, MO, USA.
Division of Nephrology, Department of Pediatrics, Washington University School, St. Louis, MO, USA.
McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA.
Pediatrics, Cardiology Section, Baylor College of Medicine/Texas Children's, Houston, TX, USA.
Division of Congenital Heart Surgery, Department of Pediatrics, Baylor College of Medicine/Texas Children's, Houston, TX, USA.
Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.
Department of Pediatrics Critical Care Section, Baylor College of Medicine, Texas Children's, Houston, TX, USA.

Background

Continuous-flow ventricular assist devices (CF-VADs) are used increasingly in pediatric end-stage heart failure (ESHF) patients. Alongside common risk factors like oxidant injury from hemolysis, non-pulsatile flow constitutes a unique circulatory stress on kidneys. Post-implantation recovery after acute kidney injury (AKI) is commonly reported, but long-term kidney outcomes or factors implicated in the evolution of chronic kidney disease (CKD) with prolonged CF-VAD support are unknown.

Methods

We studied ESHF patients supported > 90 days on CF-VAD from 2008 to 2018. The primary outcome was CKD (per Kidney Disease Improving Global Outcomes (KDIGO) criteria). Secondary outcomes included AKI incidence post-implantation and CKD evolution in the 6–12 months of CF-VAD support.

Results

We enrolled 134 patients; 84/134 (63%) were male, median age was 13 [IQR 9.9, 15.9] years, 72/134 (54%) had preexisting CKD at implantation, and 85/134 (63%) had AKI. At 3 months, of the 91/134 (68%) still on a CF-VAD, 34/91 (37%) never had CKD, 13/91 (14%) developed de novo CKD, while CKD persisted or worsened in 49% (44/91). Etiology of heart failure, extracorporeal membrane oxygenation use, duration of CF-VAD, AKI history, and kidney replacement therapy were not associated with different CKD outcomes. Mortality was higher in those with AKI or preexisting CKD.

Conclusions

In the first multicenter study to focus on kidney outcomes for pediatric long-term CF-VAD patients, preimplantation CKD and peri-implantation AKI were common. Both de novo CKD and worsening CKD can happen on prolonged CF-VAD support. Proactive kidney function monitoring and targeted follow-up are important to optimize outcomes.

Graphical abstract

A higher resolution version of the Graphical abstract is available as Supplementary information

中文翻译：

儿童连续流心室辅助装置患者的长期肾脏结局

背景

连续流心室辅助装置 (CF-VAD) 越来越多地用于儿科终末期心力衰竭 (ESHF) 患者。除了溶血造成的氧化损伤等常见危险因素外，非脉动血流对肾脏构成了独特的循环压力。急性肾损伤 (AKI) 后植入后恢复的情况常见，但长期肾脏结局或长期 CF-VAD 支持导致慢性肾病 (CKD) 演变的因素尚不清楚。

方法

我们研究了 2008 年至 2018 年接受 CF-VAD 治疗超过 90 天的 ESHF 患者。主要结局是 CKD（根据改善肾脏疾病全球结局 (KDIGO) 标准）。次要结局包括植入后 AKI 发生率以及 CF-VAD 支持 6-12 个月内 CKD 的演变。

结果

我们招募了 134 名患者；84/134 (63%) 为男性，中位年龄为 13 [IQR 9.9, 15.9] 岁，72/134 (54%) 在着床时患有 CKD，85/134 (63%) 患有 AKI。3 个月时，仍在接受 CF-VAD 的 91/134 人 (68%) 中，34/91 (37%) 从未患过 CKD，13/91 (14%) 发展为新发 CKD，而 49 人中 CKD 持续存在或恶化％（44/91）。心力衰竭的病因、体外膜肺氧合的使用、CF-VAD 的持续时间、AKI 病史和肾脏替代治疗与不同的 CKD 结局无关。患有 AKI 或既往患有 CKD 的患者死亡率较高。