The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Distinctive kidney function trajectories following left ventricular assist device implantation

Published:September 07, 2022DOI:


      The aim of this study was to assess for distinct kidney function trajectories following left ventricular assist device (LVAD) placement. Cohort studies of LVAD recipients demonstrate that kidney function tends to increase early after LVAD placement, followed by decline and limited sustained improvement. Inter-individual differences in kidney function response may be obscured.


      We identified continuous flow LVAD implantations in US adults (2016-2017) from INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). Primary outcomes were estimated glomerular filtration rate (eGFR) trajectories pre-implantation to ∼12 months. Latent class mixed models were applied to primary and validation samples. Clinical differences among trajectory groups were investigated.


      Among 4,615 LVAD implantations, 5 eGFR trajectory groups were identified. The 2 largest groups (Groups 1 and 2) made up >80% of the cohort, and were similar to group average trajectories previously reported, with early eGFR rise followed by decline and stabilization. Three novel trajectory groups were found: worsening followed by sustained low kidney function (Group 3, 10.1%), sustained improvement (Group 4, 3.3%), and worsening followed by variation (Group 5, 1.7%). These groups differed in baseline characteristics and outcomes. Group 4 was younger and had more cardiogenic shock and pre-implantation dialysis; Group 3 had higher rates of pre-existing chronic kidney disease, along with older age.


      Novel eGFR trajectories were identified in a national cohort, possibly representing distinct cardiorenal processes. Type 1 cardiorenal syndrome may have been predominant in Group 4, and parenchymal kidney disease may have been predominant in Group 3.



      LVAD (left-ventricular assist device), INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support), eGFR (estimated glomerular filtration rate), HF (heart failure), BMI (body mass index), BSA (body surface area), ECMO (extracorporeal membrane oxygenation), IABP (intra-aortic balloon pump), VAD (ventricular assist device), BUN (blood urea nitrogen)
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        • Cook JL
        • Colvin M
        • Francis GS
        • et al.
        Recommendations for the use of mechanical circulatory support: ambulatory and community patient care: a scientific statement from the American Heart Association.
        Circulation. 2017; 135: e1145-e1158
        • Kirklin JK
        • Naftel DC
        • Pagani FD
        • et al.
        Seventh INTERMACS annual report: 15,000 patients and counting.
        J Heart Lung Transplant. 2015; 34: 1495-1504
        • Morgan JA
        • Paone G
        • Nemeh HW
        • et al.
        Impact of continuous-flow left ventricular assist device support on right ventricular function.
        J Heart Lung Transplant. 2013; 32: 398-403
        • Uriel N
        • Sayer G
        • Addetia K
        • et al.
        Hemodynamic ramp tests in patients with left ventricular assist devices.
        JACC: Heart Fail. 2016; 4: 208-217
        • Schefold JC
        • Filippatos G
        • Hasenfuss G
        • Anker SD
        • Von Haehling S.
        Heart failure and kidney dysfunction: epidemiology, mechanisms and management.
        Nat Rev Nephrol. 2016; 12 (Review Article): 610
        • Yalcin YC
        • Muslem R
        • Veen KM
        • et al.
        Impact of continuous flow left ventricular assist device therapy on chronic kidney disease: a longitudinal Multicenter Study.
        J Card Fail. 2020; 26: 333-341
        • Wettersten N
        • Estrella M
        • Brambatti M
        • et al.
        Kidney function following left ventricular assist device implantation: an observational Cohort Study.
        Kidney Med. 2021; 3: 378-385
        • Brisco MA
        • Kimmel SE
        • Coca SG
        • et al.
        Prevalence and prognostic importance of changes in renal function after mechanical circulatory support.
        Circ Heart Fail. 2014; 7: 68-75
        • Miyamoto T
        • Karimov JH
        • Fukamachi K.
        Effects of continuous and pulsatile flows generated by ventricular assist devices on renal function and pathology.
        Expert Rev Med Devices. 2018; 15: 171-182
        • Ross DW
        • Stevens GR
        • Wanchoo R
        • et al.
        Left ventricular assist devices and the kidney.
        Clin J Am Soc Nephrol. 2018; 13: 348-355
        • Walther CP
        • Civitello AB
        • Liao KK
        • Navaneethan SD.
        Nephrology considerations in the management of durable and temporary mechanical circulatory support.
        Kidney. 2022; 360
        • Brisco M
        • Hale A
        • Zile M
        • et al.
        Patients undergoing LVAD placement demonstrate marked sarcopenia leading to overestimation of pre-implant glomerular filtration rate.
        J Heart Lung Transplant. 2015; 34: S165
        • Krishnan A
        • Levin A
        Laboratory assessment of kidney disease: glomerular filtration rate, urinalysis, and proteinuria.
        in: Yu ASL Chertow GM Luyckx VA Marsden PA Skorecki K Taal MW Brenner & Rector’s The Kidney. 11th. Elsevier, Inc., Philadelphia, PA2020: 732-757 (chap 23)
        • Raynaud M
        • Aubert O
        • Reese PP
        • et al.
        Trajectories of glomerular filtration rate and progression to end stage kidney disease after kidney transplantation.
        Kidney Int. 2020; 99: 186-197
        • Allen NB
        • Siddique J
        • Wilkins JT
        • et al.
        Blood pressure trajectories in early adulthood and subclinical atherosclerosis in middle age.
        Jama. 2014; 311: 490-497
        • Gill TM
        • Gahbauer EA
        • Han L
        • Allore HG.
        Trajectories of disability in the last year of life.
        N Engl J Med. 2010; 362: 1173-1180
        • Portegies ML
        • Mirza SS
        • Verlinden VJ
        • et al.
        Mid- to late-life trajectories of blood pressure and the risk of stroke: The Rotterdam Study.
        Hypertension. 2016; 67: 1126-1132
        • Masyn KE.
        Latent class analysis and finite mixture modeling.
        in: Little TD The Oxford Handbook of Quantitative Methods. Oxford University Press, New York City, NY2013: 551-611
        • Proust-Lima C
        • Philipps V
        • Liquet B.
        Estimation of extended mixed models using latent classes and latent processes: the R package lcmm.
        J Stat Softw. 2017; 78: 1-56
        • National Heart Lung and Blood Institute Biologic Specimen and Data Repository Information Coordinating Center
        Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs).
        National Heart, Lung, and Blood Institute, Bethesda, MD2018 (Updated May 21. Available at) (Accessed September 7, 2021)
        • Kirklin JK
        • Pagani FD
        • Kormos RL
        • et al.
        Eighth annual INTERMACS report: Special focus on framing the impact of adverse events.
        J Heart Lung Transplant. 2017; 36: 1080-1086
        • Levey AS
        • Stevens LA
        • Schmid CH
        • et al.
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2009; 150: 604-612
        • Levey AS
        • Coresh J
        • Tighiouart H
        • Greene T
        • Inker LA.
        Measured and estimated glomerular filtration rate: current status and future directions.
        Nat Rev Nephrol. 2020; 16: 51-64
        • Society of Thoracic Surgeons
        STS Intermacs Users Guide. 2018; 28 (Available at:) (Version 5.0. Accessed September 7, 2021): 2018
        • Yalcin YC
        • Muslem R
        • Veen KM
        • et al.
        Impact of continuous flow left ventricular assist device therapy on chronic kidney disease: A longitudinal multicenter study.
        J Cardiac Fail. 2020; 26: 333-341
        • Biernacki C
        • Celeux G
        • Govaert G.
        Choosing starting values for the EM algorithm for getting the highest likelihood in multivariate Gaussian mixture models.
        Comput Stat Data Anal. 2003; 41: 561-575
        • Nylund KL
        • Asparouhov T
        • Muthén BO.
        Deciding on the number of classes in latent class analysis and growth mixture modeling: A Monte Carlo simulation study.
        Struct Equat Model. 2007; 14: 535-569
        • Austin PC.
        Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples.
        Stat Med. 2009; 28: 3083-3107
        • Van Buuren S.
        Classification and Regression Trees.
        Flexible Imputation of Missing Data. CRC press, Boca Raton, FL2018: 84-86
        • Deng H
        • Runger G.
        Gene selection with guided regularized random forest.
        Pattern Recognition. 2013; 46: 3483-3489
        • Hasin T
        • Topilsky Y
        • Schirger JA
        • et al.
        Changes in renal function after implantation of continuous-flow left ventricular assist devices.
        J Am Coll Cardiol. 2012; 59: 26-36
        • Rangaswami EAJ
        • Bhalla IV
        • Blair LJ
        • et al.
        Cardiorenal syndrome: classification, pathophysiology, diagnosis, and treatment strategies: a scientific statement from the American Heart Association.
        Circulation. 2019; 139: e840-e878
        • Neyra JA
        • Chawla LS.
        Acute kidney disease to chronic kidney disease.
        Crit Care Clin. 2021; 37: 453-474
        • Zannad F
        • Rossignol P.
        Cardiorenal syndrome revisited.
        Circulation. 2018; 138: 929-944
        • Cody RJ
        • Ljungman S
        • Covit AB
        • et al.
        Regulation of glomerular filtration rate in chronic congestive heart failure patients.
        Kidney Int. 1988; 34: 361-367
        • Holtkamp FA
        • de Zeeuw D
        • Thomas MC
        • et al.
        An acute fall in estimated glomerular filtration rate during treatment with losartan predicts a slower decrease in long-term renal function.
        Kidney Int. 2011; 80: 282-287
        • Michaels A
        • Cowger J.
        Patient selection for destination LVAD therapy: predicting success in the short and long term.
        Curr Heart Fail Rep. 2019; 16: 140-149
        • Walther CP
        • Winkelmayer WC
        • Deswal A
        • Niu J
        • Navaneethan SD.
        Trends in left ventricular assist device implantation and associated mortality among patients with and without ESRD.
        Am J Kidney Dis. 2018; 72: 620-622
        • Scholz H
        • Boivin FJ
        • Schmidt-Ott KM
        • et al.
        Kidney physiology and susceptibility to acute kidney injury: implications for renoprotection.
        Nat Rev Nephrol. 2021; 17: 335-349
        • Kervella D
        • Lemoine S
        • Sens F
        • et al.
        Cystatin C vs creatinine for GFR estimation in CKD due to heart failure.
        Am J Kidney Dis. 2017; 69: 321-323
        • Kolsrud O
        • Ricksten SE
        • Holmberg E
        • et al.
        Measured and not estimated glomerular filtration rate should be used to assess renal function in heart transplant recipients.
        Nephrol Dial Transplant. 2016; 31: 1182-1189