Introduction:
Tricuspid Regurgitation (TR) with resultant renal venous congestion and reduction in cardiac output adversely affects renal outcomes post kidney transplant. A retrospective observation study by Skalsky, K etal reported lower GFR post transplant in patients with moderate or greater degree of TR. Among many treatment modalities, Transcatheter End to End Repair (TEER) of Tricuspid Valve (TV) has gained attention recently. Sorajja, P reported improved quality of life in patients undergoing TEER VS medical therapy for TR, however the effect of TEER of TV on renal function in patients with cardiorenal syndrome (CRS) in native and transplant kidney remains to be determined. Karam, N reported stabilization of renal function and improvement in hepatic function post TV repair. In the setting of calcineurin inhibitor (CNI) use kidney transplant patients are at higher risk of developing CRS and renal fibrosis. In theory acute CRS should better respond to intervention than chronic CRS given lack of renal fibrosis
Methods:
67 year old male with history of with ESRD secondary to Diabetes Mellitus & Hypertension (HTN), Left sided heart failure with preserved ejection fraction (HFpEF), Mild MR with group 2 Pulmonary HTN, Right Heart Failure and mild to moderate TR presented 4 months after his kidney transplant with AKI and water weight gain (15kg) following recent hospitalization for osteomyelitis & abscess of foot requiring amputation. Creatinine increased to 2.7 mg/dl from his baseline 1.3-1.4 mg/dl. Given lack of renal recovery post treatment of infection and reduction in tacrolimus trough level to 4-6ng/ml a kidney biopsy was performed and revealed no acute abnormal findings in the glomerulus, tubules or interstitium, ruling out parenchymal disease as cause of AKI. ECHO revealed new progression of mild to moderate TR to severe TR, moderately enlarged RV, elevated RV systolic pressure 61 mm Hg and elevated LV filling pressures. Diagnostic right side heart catheterization revealed elevated mean right atrial pressure 23 mmHg, pulmonary artery pressure 31 mmHg, elevated pulmonary capillary wedge pressure 30 mmHg. Given Cardiorenal Syndrome with severe TR and inadequate response to diuretics a TEER of TV was performed with 2 clips. Following TEER, the patient's urine output and response to diuretics improved and his creatinine returned to his baseline 1.4 mg/dl in 2 weeks
Results:
Venous congestion from pulmonary HTN, right side heart failure and TR leads to poor renal allograft function due to hemodynamic reduction in GFR & interstitial edema. TR is an underrecognized yet important cause of venous congestion post transplant. Like with our patient the severity of TR may increase in states of worsening heart failure, pulmonary hypertension and volume overload. Among multiple treatment modalities, studies suggest TEER provides better quality of life and improvement in hepatic function with better safety profile. Its effects on renal outcomes is yet to be definitively determined however studies have suggested stabilization in renal function of native kidneys. Effect on kidney transplant outcomes is unknown however from our patient experience in setting of cardiorenal syndrome TEER improved urine output and response to diuretics and hence AKI
Conclusions:
TEER-TV may improve renal function in kidney transplant recipients with TR. We recommend larger studies to evaluate this hypothesis
I have no potential conflict of interest to disclose.
I used generative AI and AI-assisted technologies in the writing process.
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