Acute kidney injury after transcatheter aortic valve replacement in the elderly: outcomes and risk management

Figures & data

Table 1 Definition and staging of acute kidney injury

Stage	Serum creatininea	Urine output
1	1.5–1.99 times baseline or ≥0.3 mg/dL (>+26.4 µmol/L) increase	<0.5 mL/kg/h for 6–12 hours
2	2.0–2.99 times baseline	<0.5 mL/kg/h for ≥12 hours
3	3.0 times baseline or increase in serum creatinine ≥4.0 mg/dL (≥354 µmol/L) with an acute increase of at least 0.5 mg/dL (44 mmol/L)	<0.3 mL/kg/h for ≥24 hours or anuria for ≥12 hours

Notes:

a Serum creatinine change must occur within 48 hours over the period up to 7 days from transcatheter valve replacement. Data from Kappetein et al.⁸

Table 2 Creatinine drawbacks as an AKI marker modified based on Ostermann et al¹⁰

Clinical scenarios	Possible outcomes
Administration of drugs affecting tubular secretion of creatinine (ie, trimethoprim)	Misdiagnosis of AKI (increase of creatinine without alteration in kidney function)
Reduced creatinine production (ie, muscle wasting sepsis, liver disease)	Delayed or missed diagnosis of AKI
Intake of substances that lead to increase in creatinine generation (ie, cooked meat consumption)	Misdiagnosis of AKI
Factors affecting analytical measurement of creatinine (ie, bilirubin, cefoxitin)	Misdiagnosis or delayed diagnosis depending on the substance
Fluid resuscitation and overload	Delayed AKI diagnosis (dilution of serum creatinine concentration)
Extrinsic creatinine administration as a buffer in medications (ie, dexamethasone)	Pseudo-AKI

Note: Adapted from Ostermann M, Joannidis M. Acute kidney injury 2016: diagnosis and diagnostic workup. Crit Care. 2016;20(1):299 (https://creativecommons.org/licenses/ by/4.0/).¹⁰

Abbreviation: AKI, acute kidney injury.

Table 3 Risk factors of acute kidney injury complicating TAVR

Preprocedural	Periprocedural	Postprocedural
Age	Access route	Hemodynamic instability
Chronic kidney disease	At least moderate paravalvular aortic regurgitation	Bleeding complications/blood transfusion
Diabetes mellitus/preprocedural glycemia control	Renal embolization	Anemia
Heart failure	Rapid ventricular pacing	Decreased left ventricular ejection fraction
Atherosclerotic burden	Contrast media
COPD
Hydratation	Bleeding complications/blood transfusion
Nephrotoxic agents (ie, nonsteroidal anti-inflammatory)	Hemodynamic instability/hypotension (need for mechanical circulatory support, inotropic and vasoconstrictive drugs)
Global surgical risk (ie, EuroScore, STS score)	Systemic inflammatory response to the procedure
	Conversion to open surgery

Note: The TAVR-unique are bolded.

Abbreviation: TAVR, transcatheter valve replacement.

KappeteinAPHeadSJGénéreuxPValve Academic Research Consortium-2Updated standardized endpoint definitions for trans-catheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus documentJ Thorac Cardiovasc Surg2013145162323084102

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OstermannMJoannidisMAcute kidney injury 2016: diagnosis and diagnostic workupCrit Care201620129927670788

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