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CASE REPORT
Year : 2023 | Volume
: 24
| Issue : 4 | Page : 217-220
Renal function improvement after aortic valve replacement in a patient with chronic kidney disease – A case report
Sathish Kumar1, Azhar Salimahmed Sayyed2, Kiranmoy Roy3, Gauri Parvathy4
1 Department of Cardiothoracic and Vascular Surgery, Jai Prakash Hospital and Research Centre, Rourkela, Odisha, India
2 Department of Cardiovascular and Thoracic Surgery, NH-Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
3 Department of Dip OTT, Jai Prakash Hospital and Research Centre, Rourkela, Odisha, India
4 Department of Medicine, Tbilisi State Medical University, Saburtalo, Tbilisi, Georgia
Correspondence Address:
Dr. Gauri Parvathy
Tbilisi State Medical University, Saburtalo 0194, Tbilisi
Georgia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/heartviews.heartviews_37_23
Abstract
Inadequate peripheral perfusion due to cardiac diseases can worsen renal function in patients with chronic kidney disease (CKD). Due to the nature of the simultaneous cardiac and renal disease, it is often difficult to determine which is the primary cause, and hence many surgeons hesitate to operate on patients with end-stage kidney disease. However, when the primary cause is cardiac related, renal function can improve after successful cardiac surgery. Here, we describe a 55-year-old female patient with CKD Stage 5 who was on maintenance hemodialysis with severe aortic stenosis (AS) and underwent surgical aortic valve replacement and recovered from dialysis-dependent kidney disease. Drastic improvement in renal function after cardiac surgery can occur even in patients with CKD due to improved renal perfusion, especially in cases of AS. Therefore, diagnosing the primary cause of renal dysfunction is essential.
Keywords: Aortic valve replacement in chronic kidney disease, cardiorenal syndrome, case report, chronic kidney disease, renal perfusion, severe aortic stenosis
Introduction 
Chronic kidney disease (CKD) is defined as a decrease in estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m2 for >3 months or pathological abnormalities of kidney structure or function with preserved GFR. Almost 50% of the end-stage renal disease (ESRD) patients on dialysis have cardiac-related problems. Aortic valve disease is the most common valvular pathology in CKD patients on hemodialysis. This coexistent disease is termed cardiorenal syndrome (CRS).[1],[2] It is often difficult to determine which is the primary and secondary cause; however, the combination of both cardiac and renal disease significantly increases morbidity, and mortality,[3] as inadequate peripheral perfusion, can further damage chronically impaired kidneys.
Case Presentation Our patient is a 55-year-old woman who had severe aortic stenosis (AS) with CKD Stage 5. She is a known diabetic, hypertensive for the past 7 years. She was on medical treatment for her kidney disease for the past 4 years, and hemodialysis was initiated (twice weekly) for the past 6 months before surgery.
Meanwhile, she had become symptomatic for the last 1 month irrespective of dialysis. On admission, she had breathlessness (New York Heart Association 3), and a chest X-ray showed features of pulmonary edema. She was stabilized with antifailure measures. eGFR was 22 ml/min/1.73 m2. Ultrasonography kidney, ureter, and bladder was done to assess the renal function which showed Grade 2 parenchymal changes. The laboratory tests revealed anemia, deranged liver enzymes, and renal parameters. Echocardiography [Figure 1] showed calcific AS and mild aortic regurgitation and left ventricular dysfunction with an ejection fraction = 40% [Figure 2] and [Figure 3]. Coronary angiography showed normal coronaries.
She underwent surgical AVR with a 21 size St. Jude mechanical prosthetic valve. Her renal parameters initially worsened in the immediate postoperative period which was mainly due to the inflammatory effects of cardiopulmonary bypass. She was given three cycles of sustained low-efficiency dialysis in the postoperative period. On the 8th postoperative day, her renal parameters started improving. On the 11th day, she recovered completely with renal parameters in the range of medical therapy. eGFR improved to 55 ml/min/1.73 m2.
She was discharged on the 13th day after surgery. Now, she is on regular follow-ups for the past 10 months with no requirement for dialysis, and the patient is doing well.
Discussion This is one of the few case reports where renal function following cardiac surgery has improved from dialysis-dependent levels to medical therapy levels.
In 2018, Kim and Lee reported a case of an 82-year-old patient whose renal function improved after a transcatheter aortic valve replacement (AVR).[4]
In 2000, Masmoudi et al. reported a case of renal dysfunction caused by aortic valve infective endocarditis which improved after successful surgical AVR.[5]
Echocardiography plays a major role in the diagnosis of cardiac-related problems in CKD/ESRD patients.[6] The updated 2017 Kidney Disease: Improving Global Outcomes CKD – mineral bone disorder recommends that a transthoracic echocardiogram must be performed to rule out cardiac problems in patients with CKD Stage 3–5[7].
In our case, only after the cardiac surgery, it became clear that AS was the primary cause of worsening renal dysfunction. Improvement in renal function after surgery to such an extent was unexpected. Therefore, our observation suggests the need for cardiac function assessment in patients with compensated kidney function on hemodialysis. Surgical AVR is a safe and effective procedure even in chronic hemodialysis-dependent patients. The salient points we would like to contribute are:
Our patient had improvement in renal function after nearly 6 months of hemodialysis, so there is always a possibility of reversing or improving renal function in CKD patients by valve replacement as AS once corrected can improve renal perfusionThe need for complete cardiac workup in CKD patients, at least transthoracic echocardiography should be done mandatorily as a part of the initial workup.However, we had a limitation that to what extent renal function could be exactly reversed after surgery is never predictable and in a few cases might not improve as well, especially when the primary cause is of renal origin.
Conclusion This case emphasizes the necessity of a thorough cardiac evaluation in patients with CKD and the possibility of improved renal function following heart surgery in patients with coexisting CRS. Our patient's renal function improved significantly after surgical AVR, which was surprising and not frequently documented in the literature. As a result, prompt cardiac intervention may prevent further renal damage and improve outcomes in CKD patients.
It should be noted, however, that the level of renal function improvement after surgery cannot be predicted and may vary depending on the underlying etiology of renal failure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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