Renal Decline Before Heart Transplantation in Left Ventricular Assist Device-Supported Recipients: United Network for Organ Sharing Analysis

Although baseline renal impairment and post-heart transplantation (HT) dialysis are established clinical predictors, the prognostic impact of pre-HT renal decline in patients bridged with left ventricular assist devices (LVADs) remains unclear. We retrospectively analyzed patients from the United Network for Organ Sharing registry who underwent HT following LVAD support between 2009 and 2024. Renal decline was defined as a greater than or equal to 40% reduction in estimated glomerular filtration rate (eGFR) from listing to HT. Among 10,454 patients, 624 (6.0%) experienced pre-HT renal decline. Patients with renal decline had longer waitlist durations (median 297 vs. 197 days; p < 0.001), lower eGFR at HT (42.0 vs. 70.6 ml/min/1.73 m 2 ; p < 0.001), and higher rates of post-HT dialysis (23.7 vs. 12.8%; p < 0.001). Independent predictors of renal decline included longer waitlist time and perioperative blood transfusions, whereas HeartMate 3 LVAD use was protective. Renal decline was independently associated with an increased risk of post-HT dialysis (adjusted odds ratio [aOR]: 2.64) and all-cause mortality (adjusted hazard ratio [aHR]: 1.16), with post-HT dialysis strongly predicting mortality (aHR: 3.48). Renal deterioration is a significant predictor of post-HT dialysis and mortality in LVAD-bridged patients. Incorporating renal trajectory into risk stratification may enhance candidate selection and promote perioperative renal protection strategies.