Evaluation and management of aortic stenosis in chronic kidney disease

The combination of aortic stenosis (AS) and chronic kidney disease (CKD) represents a formidable clinical challenge commonly encountered in practice. Specific guidelines addressing the management of AS in CKD/end-stage kidney disease (ESKD) patients are lacking. This review addresses the unique epidemiological features, caveats relevant to diagnostic modalities and specific management considerations pertinent for AS in patients with CKD/ESKD. Transthoracic echocardiography remains the imaging modality of choice for establishing an accurate diagnosis and assessing severity of AS in this population. However, the presence of anatomical and hemodynamic alterations along with co-prevalent valve disease often necessitates complementary imaging including dobutamine stress echocardiography, cardiac computed tomography and magnetic resonance imaging. Management includes blood pressure control, addressing CKD-related metabolic bone disease, and the selection of optimal dialysis modality. For aortic valve replacement (AVR), the choice between mechanical versus biological prosthesis, as well as between surgical versus transcatheter approaches requires careful consideration of patient-specific factors, including life expectancy, bleeding risk, risk of acute kidney injury; as well as prosthesis specific considerations including durability and need for long-term anticoagulation. Patients with CKD/ESKD encounter higher periprocedural risks as well as worse long-term outcomes; yet AVR is associated with improved survival compared to conservative management. Shared-decision making with the patient is essential regarding choice of prosthesis. A multidisciplinary heart-kidney team is recommended for optimizing perioperative planning, hemodynamic/volume status and preventing acute kidney injury to ensure a balanced and comprehensive patient-centered strategy for managing AS in the context of CKD/ESKD.