Cardiac Resynchronization Therapy in CKD Stage 4 Patients

Abstract

Background and objectives Cardiac resynchronization therapy (CRT) is a well established heart failure treatment that has shown to improve renal function. However, landmark CRT trials excluded patients with severe renal dysfunction. Therefore, this study evaluated the effect of CRT on renal function and long-term prognosis in patients with stage 4 CKD.Design, setting, participants, & measurements This study evaluated 73 consecutive CRT patients (71610 years) with stage 4 CKD who underwent echocardiographic and renal function evaluation at baseline and 6-month follow-up between 2000 and 2012. As a control group, 18 patients with stage 4 CKD who received an implantable cardioverter defibrillator (ICD) were selected. CRT recipients with $15% reduction in left ventricular end-systolic volume at 6-month follow-up were classified as CRT responders. During long-term follow-up (median, 33 months), appropriate defibrillator therapy, heart failure hospitalizations, and all-cause mortality (combined end point) were recorded.Results At 6-month follow-up, a significant reduction in left ventricular end-systolic volume was observed in CRT patients compared with patients with ICD (from 159678 to 145678 ml in CRT patients and from 126654 to 119649 ml in ICD patients; P=0.05), and CRT response was observed in 22 patients (30%). Compared with ICD patients, eGFR improved among CRT patients (from 2564 to 3069 ml/min per 1.73 m 2 ; interaction time and group, P=0.04) and was more pronounced among CRT responders (2563 to 3469 ml/min per 1.73 m 2 ; P,0.001). The combined end point was observed in 17 ICD and 62 CRT patients. CRT patients showed superior survival compared with ICD patients (log-rank P=0.03). More importantly, CRT response was independently associated with improved survival free from the combined end point (hazard ratio, 0.51; 95% confidence interval, 0.27 to 0.98; P=0.04) after adjustment for clinical and echocardiographic parameters.Conclusions Response to CRT occurs in approximately 30% of patients with stage 4 CKD, which is less than in the average CRT population. CRT was associated with better clinical outcome, and particularly, CRT response was associated with improvement in eGFR and better long-term prognosis.

Prescription of Guideline-Recommended Implantable Cardioverter Defibrillator and Cardiac Resynchronization Therapy Among Patients Hospitalized With Heart Failure and Varying Degrees of Renal Function

“…23 Other observational studies of CKD patients have noted significant improvements in renal function among patients who received a CRT-D versus those who received an ICD alone. 24,25 Taken together, these findings suggest that the underutilization of guideline-recommended CRT among patients with CKD observed in our study may not be justified; thus, our study findings may highlight an important opportunity to improve care and outcomes for CKD patients.…”

Management of Heart Failure in Patients with Chronic Kidney Disease

“…[ 61 ] A specific study looked at CRT-D in 73 patients with stage 4 CKD patients with LV ejection fraction (LVEF) <35% showed improved renal function (25 ± 4 to 30 ± 9 ml/min/1.73 m 2 ; p=0.04) and survival (HR 0.51; 95% CI [0.27–0.98)] compared to ICD. [ 62 ]…”

Cardiac Implantable Electronic Devices in Hemodialysis and Chronic Kidney Disease Patients—An Experience-Based Narrative Review

“…Thankfully, cardiac resynchronization therapy (CRT) outcomes in patients with systolic heart failure and CKD are clearly more positive, despite a more complex implantation procedure [24][25][26]. Effective left ventricle reverse remodeling plays a vital role in preserving renal function, regardless of the degree of baseline renal insufficiency [27].…”