1. Patients with end-stage renal disease (ESRD) have significantly worse survival outcomes following left ventricular assist device (LVAD) implantation compared to recipients without ESRD.
2. The median time to death was substantially shorter in those with ESRD, with many patients dying during the index hospitalization.
Evidence Rating Level: 2 (Good)
Study Rundown: With advancement of technology and growing evidence for improved survival and quality of life, LVAD utilization is increasing both as bridge to transplantation and destination therapy in those not eligible for transplant. Patients with ESRD are not usually considered for transplant and many have comorbid heart failure. The outcomes of LVAD therapy in patients with ESRD is not known but knowledge of the typical clinical course may be important for discussion of risks and benefits of LVAD as destination therapy. The current study used Medicare data to evaluate the outcomes of patients with ESRD who received LVAD compared to those without ESRD. The study found that overall survival is substantially worse amongst LVAD recipients with ESRD. More than half of patients with ESRD died during the index hospitalization. The median time to death was significantly shorter for patients with ESRD.
The study currently highlights the challenges in using LVAD therapy in patients with ESRD. The strength of this study includes its cohort from a national database, and focus on patients with ESRD rather than just transient dialysis at time of device insertion. The main limitations of the study include the administrative level data collection, lack of information on LVAD indication, and other important data regarding clinical context.
In-Depth [retrospective cohort]: This study used data from the United States Renal Data System (USRDS) to identify patients who were on chronic dialysis or having received a renal transplant prior to time of LVAD insertion. Patients were included from 2003 to 2013, and compared to a 5% Medicare representative sample of those without ESRD who underwent LVAD therapy. Patients were excluded if they did not have Medicare coverage for the year before LVAD placement, or in whom LVAD preceded renal failure. The primary outcome was death after LVAD placement.
The study found that of the 155 Medicare beneficiaries with ESRD who received LVAD, 127 patients (81.9%) died during follow up compared to 36.4% of the comparison cohort. During the index hospitalization for LVAD placement, 51.4% of ESRD patients died compared to 4% of non-ESRD recipients. The median time to death was 16 days (IQR 2-447 days) for ESRD patients compared to 2125 days (IQR, 565-3850 days). In multivariate analysis the risk of death after adjustment for covariates was substantially higher in the ESRD cohort (hazard ratio, 36.3; 95%CI, 15.6-84.5).
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