Impact of ventricular assist device placement on longitudinal renal function in children with end-stage heart failure

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• 作者：Lindsay J. May ; MD^a ; ^{lindsay.may@hsc.utah.edu" class="auth_mail" title="E-mail the corresponding author} ; Maria E. Montez-Rath ; PhD^b ; Justin Yeh ; MD^c ; David M. Axelrod ; MD^d ; Sharon Chen ; MD^d ; Katsuhide Maeda ; MD^e ; Christopher S.D. Almond^d ; David N. Rosenthal ; MD^d ; Seth A. Hollander ; MD^d ; Scott M. Sutherland ; MD^f
• 关键词：ventricular assist device ; end-organ dysfunction ; renal function ; children ; end-stage heart failure
• 刊名：Journal of Heart and Lung Transplantation
• 出版年：2016
• 出版时间：April 2016
• 年：2016
• 卷：35
• 期：4
• 页码：449-456
• 全文大小：693 K

文摘

Although ventricular assist devices (VADs) restore hemodynamics in those with heart failure, reversibility of end-organ dysfunction with VAD support is not well characterized. Renal function often improves in adults after VAD placement, but this has not been comprehensively explored in children.

Methods

Sixty-three children on VAD support were studied. Acute kidney injury (AKI) was defined by Kidney Disease: Improving Global Outcomes criteria. Estimated glomerular filtration rate (eGFR) was determined by the Schwartz method. Generalized linear mixed-effects models compared the pre-VAD and post-VAD eGFR for the cohort and sub-groups with and without pre-VAD renal dysfunction (pre-VAD eGFR < 90 ml/min/1.73 m²).

Results

The pre-VAD eGFR across the cohort was 84.0 ml/min/1.73 m² (interquartile range [IQR] 62.3–122.7), and 55.6% (34 of 63) had pre-VAD renal dysfunction. AKI affected 60.3% (38 of 63), with similar rates in those with and without pre-existing renal dysfunction. Within the cohort, the nadir eGFR occurred 1 day post-operatively (62.9 ml/min/1.73 m²; IQR, 51.2–88.9 ml/min/1.73 m²; p < 0.001). By Day 5, however, the eGFR exceeded the baseline (99.0 ml/min/1.73 m²; IQR, 59.3–146.7 ml/min/1.73 m²; p = 0.03) and remained significantly higher through the first post-operative week. After adjusting for age, gender, and AKI, the eGFR continued to increase throughout the entire 180-day study period (β = 0.0025; 95% confidence interval, 0.0015–0.0036; p < 0.001). Patients with pre-VAD renal dysfunction experienced the greatest improvement in the eGFR (β = 0.0051 vs β = 0.0013, p < 0.001).

Conclusions

Renal dysfunction is prevalent in children with heart failure undergoing VAD placement. Although peri-operative AKI is common, renal function improves substantially in the first post-operative week and for months thereafter. This is particularly pronounced in those with pre-VAD renal impairment, suggesting that VADs may facilitate recovery and maintenance of kidney function in children with advanced heart failure.