Clinical impact of renal function deterioration while awaiting heart transplantation in patients bridged with left ventricular assist devices: a multicenter analysis of the UNOS database
R Asleh, S Kushwaha, F Khalil, O Regev, A Briasoulis, H AlnsasraAbstract
Background
Renal dysfunction is a major determinant of outcomes after heart transplantation (HT). While baseline renal impairment and post-HT dialysis are known predictors of mortality, the prognostic impact of sustained pre-HT renal decline in patients bridged with durable left ventricular assist devices (LVADs) remains unclear.
Methods
We conducted a retrospective, multicenter cohort study using the United Network for Organ Sharing (UNOS) registry to identify adult patients who underwent HT following durable LVAD support between 2009 and 2024. Sustained renal decline was defined as a ≥40% reduction in estimated glomerular filtration rate (eGFR) from listing to HT. Multivariable logistic regression identified predictors of renal decline and post-HT dialysis,while Cox proportional hazards models assessed the impact on post-HT mortality.
Results
Among 10,454 eligible patients, 624 (6.0%) experienced sustained renal decline during LVAD bridging. Compared with patients without renal decline, affected patients had longer waitlist durations (median 297 vs. 197 days; p<0.001), lower eGFR at HT (42.0 vs. 70.6 mL/min/1.73 m²; p<0.001), and higher rates of post-HT dialysis (23.7% vs. 12.8%; p<0.001). Independent predictors of sustained renal decline included longer waitlist time, perioperative blood transfusions, while the use of HeartMate 3 LVAD was protective. Sustained renal decline was independently associated with increased risk of post-HT dialysis (adjusted odds ratio [aOR] 2.64) and all-cause mortality (adjusted hazard ratio [aHR] 1.16),with post-HT dialysis strongly predicting mortality (aHR 3.48).
Conclusions
Sustained renal deterioration while awaiting HT is a significant predictor of post-HT dialysis and mortality in LVAD-bridged patients. Incorporating renal trajectory into risk stratification may enhance candidate selection and promote perioperative renal protection strategies.