Author + information
- Mani Arsalan1,
- Matthias Renker1,
- Luise Gaede2,
- Maren Weferling1,
- Arnaud Van Linden1,
- Johannes Blumenstein2,
- Helge Möllmann3,
- Mirko Doss1,
- Karl Lackner4,
- Giovanni Filardo5,
- Christian Hamm6,
- Thomas Walther7,
- Won Kim1 and
- Christoph Liebetrau8
- 1Kerckhoff Heart Center, Bad Nauheim, Germany
- 2St. Johannes-Hospital, Dortmund, Germany
- 3St Johannes Hospital, Dortmund, Germany
- 4Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
- 5Department of Epidemiology, Baylor Scott and White Health, Dallas, Texas, United States
- 6Kerckhoff Clinic, Bad Nauheim, Germany
- 7Kerckhoff Klinik Bad Nauheim, Bad Nauheim, Germany
- 8Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
Acute kidney injury (AKI) is a common complication after transcatheter aortic valve replacement (TAVR) and is associated with increased morbidity and mortality. Routinely used biomarkers such as creatinine show a diagnostic gap in the first hours after kidney injury. Thus, new biomarkers for earlier detection of AKI are of great clinical importance. The aim of the present study was to examine the diagnostic value of cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) after TAVR.
This was a prospective study of 483 patients with severe aortic stenosis undergoing elective TAVR. Blood assessment for biomarker measurement (creatinine, cystatin C, NGAL) was performed before and 4, 24, 48, 72h after TAVR. Periinterventional AKI was defined by VARC-2 (Valve academic research consortium) criteria. Patients were followed up for 12 months.
A total of 110/483 (22.8%) patients developed AKI. Patients with AKI were older (82.0±5.8y vs. 84.0±5.2y; P<0.01), had lower pre-procedural estimated GFR (66±27 ml/min/1.73 m2 vs. 58±27 ml/min/1.73 m2; P<0.01) with higher creatinine values (1.2±0.5 mg/dL vs. 1.3±0.7 mg/dL; p=0.04) and higher STS Score (6.4±4.2 vs. 8.1±5.7; P<0.001). For all other parameters no significant differences were observed. Out of 110 AKI patients, 52 (47.3%) developed AKI stage 1, 27 (24.5%) stage 2 and 31 (28.2%) stage 3. AKI-patients showed higher change in creatinine (1.9 ± 0.7 mg/dL vs. 1.1±0.2 mg/dL; P<0.0001), cystatin C (0.6±0.5 mg/L vs. 0.2±0.4 mg/L; P<0.0001) and NGAL (129±122 ng/mL vs. 52±72 ng/mL; P<0.0001). NGAL and cystatin C both initially decreased after the procedure followed by a phase of increasing values, however biomarker levels were always higher in patients with AKI (see table). When comparing maximum biomarker differences of NGAL and Cystatin C within 72 hours post-TAVR, both biomarkers were highly associated with AKI (see figure). Cystatin C is better in distinguishing between AKI stages as it also predicts stage 3 while NGAL does not . Patients with AKI had a 7.1 fold increased risk for 30-day mortality and a 3.3 fold increased risk for 1 year mortality adjusted for STS predicted risk of mortality.
|Marker||Pre-op||4 hours||24 hours||48 hours||72 hours|
|NGAL (mg/dL) Unadjusted No AKI, mean±SD AKI, mean±SD Adjusted* difference (95%CI) p-value||151±74 172±81 14 (-5, 33) 0.15||150±85 188±110 28 (15, 40) .0001||170±95 216±125 41 (21, 60) <.0001||176±95 250±130 64 (41, 86) <.0001||176±85 230±99 68 (51, 86) <.0001|
|cystatin C (mg/L) Unadjusted No AKI, mean±SD AKI, mean±SD Adjusted** difference (95% CI) p-value||1.7±0.6 1.8±0.6 .04 (.03, .05) <.0001||1.6±0.6 1.7±0.6 .07 (.01, .13) 0.03||1.6±0.6 1.8±0.6 .24 (.16, .32) <.0001||1.7±0.6 2.0±0.7 .37 (.27, .46) <.0001||1.7±0.6 2.2±0.7 .58 (.47, .69) <.0001|
AKI increases short and long-term mortality TAVR-patients. Cystatin C distinguishes AKI better than NGAL, making it a valuable parameter for preoperative risk assessment and early detection. Earlier diagnosis and hence treatment, might improve the overall patient outcome after TAVR.
OTHER: Renal Insufficiency and Contrast Nephropathy