Background The prognostic significance of chronic kidney disease (CKD) in severe aortic stenosis is poorly understood and no studies have yet evaluated the effect of aortic-valve replacement (AVR) versus conservative management on long-term mortality by stage of CKD. Methods and Results We included 4119 patients with severe aortic stenosis. The population was divided into 4 groups according to the baseline estimated glomerular filtration rate: no CKD, mild CKD, moderate CKD, and severe CKD. The 5-year survival rate was 71±1% for patients without CKD, 62±2% for those with mild CKD, 54±3% for those with moderate CKD, and 34±4% for those with severe CKD (P<0.001). By multivariable analysis, patients with moderate or severe CKD had a significantly higher risk of all-cause (hazard ratio [HR] [95% CI]=1.36 [1.08-1.71]; P=0.009 and HR [95% CI]=2.16 [1.67-2.79]; P<0.001, respectively) and cardiovascular mortality (HR [95% CI]=1.39 [1.03-1.88]; P=0.031 and HR [95% CI]=1.69 [1.18-2.41]; P=0.004, respectively) than patients without CKD. Despite more symptoms, AVR was less frequent in moderate (P=0.002) and severe CKD (P<0.001). AVR was associated with a marked reduction in all-cause and cardiovascular mortality versus conservative management for each CKD group (all P<0.001). The joint-test showed no interaction between AVR and CKD stages (P=0.676) indicating a nondifferentialeffect of AVR across stages of CKD. After propensity matching, AVR was still associated with substantially better survival for each CKD stage relative to conservative management (all P<0.0017). Conclusions In severe aortic stenosis, moderate and severe CKD are associated with increased mortality and decreased referral to AVR. AVR markedly reduces all-cause and cardiovascular mortality, regardless of the CKD stage. Therefore, CKD should not discourage physicians from considering AVR.
Keywords: aortic stenosis; aortic valve replacement; chronic kidney disease; kidney failure; outcome; survival.