Outcomes of ventricular assist device placement in pediatric patients with renal dysfunction requiring dialysis: an ACTION registry analysis.

Abstract

Renal dysfunction requiring renal replacement therapy (RRT) is associated with poor outcomes following ventricular assist device (VAD) implantation in adults. However, outcomes in pediatric patients are not well-described. We aim to characterize pediatric patients supported by RRT who undergo VAD implantation and assess their short- and long-term outcomes. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Registry contains pre- and post-operative data on pediatric VAD patients across 57 North American sites (April 2018-June 2025). Patients were stratified by RRT use at surgery, including chronic dialysis and newly initiated RRT. Patient characteristics, pre-operative data, and clinical outcomes including one-year post-VAD survival, likelihood of transplant, and post-transplant survival were assessed using Kaplan-Meier survival, multivariable Cox proportional hazards models, and competing risk analysis. Of 1,607 patients undergoing VAD implantation, 75 (4.7%) were supported by RRT at surgery. These patients had worse clinical status, including a higher incidence of ECMO support, higher INTERMACS classification, and higher total bilirubin. RRT patients were less likely to undergo heart transplant (33/75 [44.0%] vs 941/1,532 [61.4%], p<0.001) and had higher mortality rates post-implant. Kaplan-Meier survival analysis revealed lower one-year survival in RRT patients (58.4% vs. 78.3%, p<0.001). However, in multivariable Cox analysis, RRT was not independently associated with one-year mortality risk (HR 1.31, 95% CI 0.81-2.10, p=0.273). Renal dysfunction requiring RRT is rare in children undergoing VAD placement. While these patients demonstrate worse clinical status and higher mortality, RRT is not independently associated with mortality risk, suggesting the underlying illness severity drives outcomes.