Packed Red Blood Cell Transfusion Associates With Acute Kidney Injury After Transcatheter Aortic Valve Replacement

Akeel M. Merchant; Javier A. Neyra; Abu Minhajuddin; Lauren E. Wehrmann; Richard A. Mills; Sarah K. Gualano; Dharam J. Kumbhani; Lynn C. Huffman; Michael E. Jessen; Amanda A. Fox


BMC Anesthesiol. 2019;19(99) 

In This Article

Abstract and Introduction


Background: Acute kidney injury after cardiac surgery significantly associates with morbidity and mortality. Despite not requiring cardiopulmonary bypass, transcatheter aortic valve replacement patients have an incidence of post-procedural acute kidney injury similar to patients who undergo open surgical aortic valve replacement. Packed red blood cell transfusion has been associated with morbidity and mortality after cardiac surgery. We hypothesized that packed red blood cell transfusion independently associates with acute kidney injury after transcatheter aortic valve replacement, after accounting for other risk factors.

Methods: This is a single-center retrospective cohort study of 116 patients undergoing transcatheter aortic valve replacement. Post-transcatheter aortic valve replacement acute kidney injury was defined by Kidney Disease: Improving Global Outcomes serum creatinine-based criteria. Univariate comparisons between patients with and without post-transcatheter aortic valve replacement acute kidney injury were made for clinical characteristics. Multivariable logistic regression was used to assess independent association of packed red blood cell transfusion with post-transcatheter aortic valve replacement acute kidney injury (adjusting for pre-procedural renal function and other important clinical parameters).

Results: Acute kidney injury occurred in 20 (17.2%) subjects. Total number of packed red blood cells transfused independently associated with post-procedure acute kidney injury (OR = 1.67 per unit, 95% CI 1.13–2.47, P = 0.01) after adjusting for pre-procedure estimated glomerular filtration rate (OR = 0.97 per ml/min/1.73m2, 95% CI 0.94–1.00, P = 0.05), nadir hemoglobin (OR = 0.88 per g/dL increase, CI 0.61–1.27, P = 0.50), and post-procedure maximum number of concurrent inotropes and vasopressors (OR = 2.09 per inotrope or vasopressor, 95% CI 1.19–3.67, P = 0.01).

Conclusion: Packed red blood cell transfusion, along with post-procedure use of inotropes and vasopressors, independently associate with acute kidney injury after transcatheter aortic valve replacement. Further studies are needed to elucidate the pathobiology underlying these associations.


Aortic stenosis is a common form of degenerative valve disease and its prevalence markedly increases as people age.[1,2] Many patients with aortic stenosis have comorbidities that place them at higher risk for morbidity and mortality after surgical aortic valve replacement (SAVR). As a consequence, trans-catheter aortic valve replacement (TAVR) has been increasingly utilized as an alternative to SAVR for aortic valve replacement in patients who are intermediate or high risk SAVR candidates. Despite being less invasive than SAVR and not requiring cardiopulmonary bypass (CPB), the risk of TAVR patients developing post-procedure AKI is similar to the risk observed in SAVR patients (~ 10–30%).[3–6] The occurrence of AKI is associated with increased morbidity and mortality in both SAVR and TAVR patients.[3,7–10] It is therefore important to identify perioperative risk factors that are potentially modifiable for AKI prevention.

Various clinical risk factors have been associated in observational studies with the development of AKI after TAVR.[3,9–14] These have included clinical variables such as chronic kidney disease, trans-apical TAVR approach, diabetes, hypertension, peripheral vascular disease, chronic obstructive pulmonary disease, history of myocardial infarction, leukocytosis, bleeding, and blood transfusion.[3,9–14] Interestingly, a meta-analysis of observational studies reported that contrast media volume is not significantly associated with development of AKI after TAVR.[15]

Transfusion of packed red blood cells (pRBCs) during cardiac surgery or TAVR may be avoided depending upon clinical management of factors such as preoperative anemia, perioperative fluid administration, and utilized transfusion thresholds. In cardiac surgical patients, pRBC transfusion has been associated with development of AKI, with perioperative anemia seeming to present an additional additive risk.[16–18] Observational cohort studies examining the association between pRBC transfusion and the development of AKI after TAVR have reported conflicting results.[11,12,19] To date, the studies that have assessed the association between pRBC transfusion and AKI after TAVR have not included peri-procedure anemia, fluid balance, intra-procedure hypotension, and intra-procedure and post-procedure inotrope/vasopressor use as potential confounders. Since lower nadir hemoglobin (Hgb), hypotension and need for inotropes or vasopressor drugs may occur in conjunction with bleeding and need for blood transfusion, it is important to assess these factors along with pRBC transfusion in order to identify what risk factors might best be targeted to prevent AKI after TAVR.

Given the potential inter-relations between peri-procedure pRBC transfusion, fluid balance, anemia, hypotension and vasoactive drug administration, this study aimed to assess if pRBC transfusion as well as these other potential risk factors associate with the development of AKI after TAVR. The primary hypothesis of this study is that pRBC transfusion associates with AKI after TAVR even after adjusting for other clinical parameters such as peri-procedure anemia and the use of vasoactive drugs.