Transkateter Aort Kapak Replasmanı Sonrası Gelişen Akut Böbrek Hasarı, Diyabetik Hastalarda Tek Başına Kötü Prognozu Öngörebilir mi?

Öz

Amaç: Transkateter aort kapak replasmanı (TAVR), cerrahi riski yüksek olan semptomatik şiddetli aort darlığı (AD) hastaları için yerleşik bir tedavi alternatifi haline gelmiştir. Altta yatan komorbiditeler nedeniyle, özellikle diyabetik hastalarda TAVR sonrası akut böbrek hasarı (ABH) sık görülen bir komplikasyon olmaya devam etmektedir. Bu çalışmanın amacı, TAVR uygulanan diyabetik hastalarda postoperatif ABH gelişiminin mortalite ve majör kardiyak advers olaylar (MACE) üzerindeki etkisini değerlendirmektir. Yöntemler: Ocak 2017 - Ocak 2020 tarihleri arasında TAVR uygulanan 141 hasta, ABH gelişimi ve MACE varlığına göre gruplara ayrıldı. ABH gelişen ve gelişmeyen hastalar arasında MACE ve 5 yıllık mortalite oranları karşılaştırıldı. Bulgular: Toplam 35 hastada (%24,8) ABH gelişti. Ayrıca, 36 hastada (%25,5) MACE gözlendi. ABH gelişen hastalarda 5 yıllık mortalite oranı (%42,9 vs. %15,1; p=0,002) ve MACE oranı (%54,3 vs. %16; p<0,001) anlamlı derecede daha yüksekti. MACE gelişimi ile ilişkili parametreler değerlendirildiğinde, univaryant ve multivaryant lojistik regresyon analizlerinde ABH gelişiminin diğer faktörlerden bağımsız olarak MACE için önemli bir belirleyici olduğu tespit edildi (OR=3,92, %95 CI: 1,28-12,02; p=0,017). Sonuçlar: Bu çalışmadan elde edilen en önemli sonuç, şiddetli aort darlığı tanısı ile TAVR uygulanan diyabetik hastalarda ABH gelişiminin, diğer parametrelerden bağımsız olarak MACE ve uzun dönem mortalite üzerinde belirleyici bir etkiye sahip olduğudur.

Anahtar Kelimeler

• Akut böbrek hasarı
• diyabetes mellitus
• TAVR
• aort darlığı
• majör kardiyak advers olaylar.

Can Acute Kidney Injury After Transcatheter Aortic Valve Replacement Alone Predict Poor Prognosis in Diabetic Patients?

Öz

Aim: Transcatheter aortic valve implantation (TAVI) has become a well-recognized treatment option for patients with symptomatic severe aortic stenosis (AS) who are deemed to have a higher risk for surgical intervention. Due to underlying comorbidities, acute kidney injury (AKI) continues to be a common complication, especially in patients with diabetes mellitus after TAVR. The aim of this study is to evaluate the effect of postoperative AKI development in diabetic patients undergoing TAVR on the development of mortality and major adverse cardiac events (MACE) in these patients. Material and Method: A total of 141 patients who underwent TAVR between January 2015 and January 2020 were grouped according to whether they developed AKI and whether they had MACE. MACE and 5-year mortality status were compared according to whether the patients developed AKI. Results: A total of 35 patients were observed to develop AKI (24.8%). Additionally, MACE was observed in 36 patients (25.5%). Five-year mortality rates (42.9% vs. 15.1%; p = 0.002) and MACE rates (54.3% vs. 16%; p < 0.001) were significantly higher in the AKI group. Univariate and multivariate logistic regression analyses identified AKI as a significant independent predictor of MACE development, regardless of other associated parameters (OR = 3.92, 95% CI: 1.28–12.02; p = 0.017). Conclusion: The most important result obtained in this study is that AKI development in diabetic patients who underwent TAVR with the diagnosis of advanced aortic stenosis has an effect on the development of MACE and long-term mortality independently of other parameters.

Anahtar Kelimeler

• Acute kidney injury
• diabetes mellitus
• TAVR
• aortic stenosis
• major adverse cardiac events

Kaynakça

1. Natorska J. Diabetes mellitus as a risk factor for aortic stenosis: from new mechanisms to clinical implications. Kardiol Pol. 2021;79(10):1060-1067.
2. Kochman J, Kołtowski Ł, Huczek Z, et al. Complete percutaneous approach versus surgical access in transfemoral transcatheter aortic valve implantation: results from a multicentre registry. Kardiol Pol. 2018;76(1):202-208.
3. Mack MJ, Leon MB, Smith CR, et al. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet. 2015 Jun 20;385(9986):2477-84.
4. Mack MJ, Leon MB, Thourani VH, et al. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med. 2019 May 2;380(18):1695-1705.
5. Vavilis G, Evans M, Jernberg T, et al. Risk factors for worsening renal function and their association with long-term mortality following transcatheter aortic valve implantation: data from the SWEDEHEART registry. Open Heart.2017;4(2):e000554. Published 2017 Jun 12.
6. Saia F, Ciuca C, Taglieri N, et al. Acute kidney injury following transcatheter aortic valve implantation: incidence, predictors and clinical outcome. Int J Cardiol. 2013;168(2):1034-1040.
7. Najjar M, Salna M, George I. Acute kidney injury after aortic valve replacement: incidence, risk factors and outcomes. Expert Rev Cardiovasc Ther. 2015;13(3):301-316.
8. Kumar N, Garg N. Acute kidney injury after aortic valve replacement in a nationally representative cohort in the USA. Nephrol Dial Transplant. 2019;34(2):295-300.

9. Kappetein AP, Head SJ, Généreux P, et al; Valve Academic Research Consortium (VARC)-2. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg. 2012 Nov;42(5):S45-60.
10. Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461–70.
11. Park HJ, Park JY, Jung SM, et al. Fibrosis-4 index at diagnosis is associated with all-cause mortality in patients with microscopic polyangiitis and granulomatosis with polyangiitis. BMC Gastroenterol. 2019 Jun 13;19(1):90.
12. Mehta A, Sale S, Capdeville M. The Deployment of Valve Academic Research Consortium 3 (VARC-3): New Endpoints, Broader Definitions, and Plenty of Unanswered Questions. J Cardiothorac Vasc Anesth. 2021;35(12):3463-3466.
13. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11;70(2):252-289.
14. Sawada N, Kawata T, Daimon M, et al. Detection of Pulmonary Hypertension with Systolic Pressure Estimated by Doppler Echocardiography. Int Heart J. 2019 Jul 27;60(4):836-844.
15. Breglia A, Godi I, Virzì GM, et al. Subclinical Contrast-Induced Acute Kidney Injury in Patients Undergoing Cerebral Computed Tomography. Cardiorenal Med. 2020;10(2):125-136.
16. Bagur R, Webb JG, Nietlispach F, et al. Acute kidney injury following transcatheter aortic valve implantation: predictive factors, prognostic value, and comparison with surgical aortic valve replacement. Eur Heart J. 2010;31(7):865-874.
17. Dangas G, Iakovou I, Nikolsky E, et al. Contrast-induced nephropathy after percutaneous coronary interventions in relation to chronic kidney disease and hemodynamic variables. Am J Cardiol. 2005;95(1):13-19.
18. Yamamoto M, Hayashida K, Mouillet G, et al. Renal function-based contrast dosing predicts acute kidney injury following transcatheter aortic valve implantation. JACC Cardiovasc Interv. 2013;6(5):479-486.
19. Goldenberg I, Matetzky S. Nephropathy induced by contrast media: pathogenesis, risk factors and preventive strategies [published correction appears in CMAJ. 2005 Nov 8;173(10):1210]. CMAJ. 2005;172(11):1461-1471.
20. Thongprayoon C, Cheungpasitporn W, Srivali N, et al. AKI after Transcatheter or Surgical Aortic Valve Replacement. J Am Soc Nephrol. 2016;27(6):1854-1860.
21. Korczak A, Morawiec R, Stegienta M, et al. Acute kidney injury as the most important predictor of poor prognosis after interventional treatment for aortic stenosis. Kardiol Pol. 2022;80(10):1032-1038.
22. Zhou C, Xia Z, Chen B, et al. Gender Differences in Age-Stratified Early Outcomes in Patients With Transcatheter Aortic Valve Implantation. Am J Cardiol. 2023;187:100-109.
23. Thogata H, Garikipati S, Reddy S, et al. Long-Term Prognosis and Predictors of Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement: A Retrospective Analysis. Cureus. 2023;15(8):e44432. Published 2023 Aug 31.
24. Koskinas KC, O'Sullivan CJ, Heg D, et al. Effect of B-type natriuretic peptides on long-term outcomes after transcatheter aortic valve implantation. Am J Cardiol. 2015;116(10):1560-1565.