New AHA Statement on Aortic Stenosis in Chronic Kidney Disease

Megan Brooks

May 13, 2021

The evaluation and management of aortic stenosis (AS) in patients with chronic kidney disease (CKD) is complex and clinically challenging and requires a multidisciplinary heart-kidney team-based approach, the American Heart Association (AHA) says in a new scientific statement.

"There are several facets in which this population differs quite remarkably from the non-CKD population and is therefore deserving of focused expertise and attention to the details outlined," says the writing group, led by Gautam Shroff, MBBS, Hennepin County Medical Center, Minneapolis, Minnesota.

The 28-page statement was published online today in the journal Circulation.

Unique High-Risk Population

The need for a scientific statement on evaluation and management of AS in CKD was identified by the AHA Council on Kidney in Cardiovascular Disease. A writing group with expertise in this subject was commissioned to review the current literature and to develop an expert-based consensus summary.

The writing group notes that patients with a combination of CKD and AS exhibit distinctive epidemiological and pathophysiological characteristics, presenting diagnostic and management challenges.

AS is more common and progresses more quickly and unpredictably in patients with CKD, and the presence of CKD is associated with worse short- and long-term outcomes after aortic valve replacement, they point out.

Patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, forcing clinicians to make complex management decisions based on retrospective and observational evidence, they note.

The statement summarizes the epidemiological and pathophysiological characteristics of AS in the context of CKD; evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques; and highlights the special risks in this population, they write.

It also provides a "critical review" of the available literature related to clinical outcomes of surgical vs transcatheter aortic valve replacement (TAVR) in this high-risk population. This information should help clinicians in making decisions about the choice of aortic valve replacement and specific prosthesis, the writing group adds.

The statement notes that aortic valve replacement (AVR) is associated with improved survival, but the presence of CKD is also an independent predictor of adverse clinical outcomes in patients after surgical AVR (SAVR) and TAVR compared with patients without CKD.

The statement provides a strategy for the perioperative management of these patients, with special attention given to a multidisciplinary heart-kidney collaborative team-based approach.

The writing group also highlights key opportunities for research in the diagnosis and management of AS in the CKD population, which they hope will inspire future studies to enhance the clinical knowledge of this unique population, leading to improved clinical outcomes.

Disclosures for members of the writing group are available with the original article. 

Circulation. Published online May 13, 2021. Abstract

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