Outcomes Associated With Left Ventricular Assist Devices Among Recipients With and Without End-stage Renal Disease

Abstract

Importance: Left ventricular assist devices (LVADs) are widely used both as a bridge to heart transplant and as destination therapy in advanced heart failure. Although heart failure is common in patients with end-stage renal disease (ESRD), little is known about outcomes after LVAD implantation in this population.

Objective: To determine the utilization of and outcomes associated with LVADs in nationally representative cohorts of patients with and without ESRD.

Design, setting and participants: We described LVAD utilization and outcomes among Medicare beneficiaries after ESRD onset (defined as having received maintenance dialysis or a kidney transplant) from 2003 to 2013 based on Medicare claims linked to data from the United States Renal Data System (USRDS), a national registry for ESRD. We compared Medicare beneficiaries with ESRD to a 5% sample of Medicare beneficiaries without ESRD.

Exposures: ESRD (vs no ESRD) among patients who underwent LVAD placement.

Main outcomes and measures: The primary outcome was survival after LVAD placement.

Results: Among the patients with ESRD, the mean age was 58.4 (12.1) years and 62.0% (96) were male. Among those without ESRD, the mean age was 62.2 (12.6) years and 75.1% (196) were male. From 2003 to 2013, 155 Medicare beneficiaries with ESRD (median and interquartile range [IQR] days from ESRD onset to LVAD placement were 1655 days [453-3050 days]) and 261 beneficiaries without ESRD in the Medicare 5% sample received an LVAD. During a median follow-up of 762 days (IQR, 92-3850 days), 127 patients (81.9%) with and 95 (36.4%) without ESRD died. more than half of patients with ESRD (80 [51.6%]) compared with 11 (4%) of those without ESRD died during the index hospitalization. The median time to death was 16 days (IQR 2-447 days) for patients with ESRD compared with 2125 days (IQR, 565-3850 days) for those without ESRD. With adjustment for demographics, comorbidity and time period, patients with ESRD had a markedly increased adjusted risk of death (hazard ratio, 36.3; 95% CI, 15.6-84.5), especially in the first 60 days after LVAD placement.

Conclusions and relevance: Patients with ESRD at the time of LVAD placement had an extremely poor prognosis, with most surviving for less than 3 weeks. This information may be crucial in supporting shared decision-making around treatments for advanced heart failure for patients with ESRD.

Figure 1.. Derivation of Study Cohorts With and Without End-stage Renal Disease (ESRD)

A, Left ventricular assist device (LVAD) recipients with ESRD. B, Left ventricular assist device (LVAD) recipients without ESRD. HMO indicates health maintenance organization; ICD-9, International Classification of Diseases, Ninth Revision (ICD-9); USRD, United States Renal Data System.

Figure 2.. Kaplan-Meier Curves for Survival After LVAD Placement

ESRD indicates end-stage renal disease; LVAD, left ventricular assist device.

Figure 3.. Outcomes Among Left Ventricular Assist Device Recipients With and Without End-stage Renal Disease (ESRD)