Implantable cardioverter defibrillators confer survival benefit in patients with renal insufficiency but not in dialysis-dependent patients

Abstract

Randomized clinical trials have demonstrated that the implantable cardioverter defibrillator (ICD) reduces mortality in heart failure patients with reduced systolic function but have excluded patients with advanced chronic kidney disease (CKD). We investigated the impact of ICDs on survival in patients with moderate-to-severe CKD, including those requiring dialysis therapy (DT). Patients followed at our institution between 1998 and 2008 with left ventricular ejection fraction (LVEF)< or =35% and CKD, defined as glomerular filtration rate (GFR) <60 mL/min, or who were on DT were identified from the medical record. The primary endpoint of all-cause death was analyzed by ICD status. A total of 78 patients (age=66+/-12 years, 73% men, EF=0.24+/-0.07, GFR 39+/-12 mL/min in those not on DT) of whom 32 had an ICD were followed for 2.7+/-2.3 years. In the DT (n=45) cohort, the presence of an ICD did not impact survival. In the CKD with no DT cohort (n=33), survival was significantly better in patients with an ICD (2-year survival 80% vs. 54%, p=0.027), and this benefit persisted after adjusting for gender, race, GFR, digoxin use, and presence of coronary disease, heart failure, or hypertension in a multivariate Cox regression model (odd ratio=0.23, adjusted p=0.028). Defibrillators improve survival in CKD patients with LVEF< or =35%, whereas patients requiring DT do not appear to extract such benefit. Further studies with larger number of patients are required to confirm these findings.

Do Implantable Cardioverter Defibrillators Reduce Mortality in Patients With Chronic Kidney Disease at All Stages?

“…Three studies were obtained from a previously published patient-level meta-analysis. 10) Finally, 11 eligible studies 7,8,[11][12][13][18][19][20][21][22][23] from 9 articles [10][11][12][13][18][19][20][21][22] were included. The search steps are illustrated in Figure 1.…”

“…The search steps are illustrated in Figure 1. Characteristics of included studies: Eleven studies 7,8,[11][12][13][18][19][20][21][22][23] enrolled 20,196 CKD patients (4,178 patients receiving ICD therapy and 16,018 patients in the control groups), and the duration of the studies ranged from 12 months to 96 months. There were 5 studies 11,18,19,21,22) involving 18,149 patients on dialysis.…”

“…The mean age was 66.3 years old. Patients were implanted with an ICD for primary prevention in 7 studies [11][12][13]18,[20][21][22]24) and secondary prevention in 4 studies. 19,21,22) Among these studies, most were conducted in the United States.…”

“…25,26) Two previous meta-analyses 9,10) have produced opposite conclusions and did not perform a subgroup analysis in patients with an eGFR < 60 mL/ minute/1.73 m 2 . This updated meta-analysis on the survival rate of ICD implantation in CKD patients is the largest study of its kind to date, accumulating information for over 20,196 patients and 11 studies. No previous article has described the differences in cardiac death between an ICD group and a control group, but all articles described the difference in all-cause mortality between these 2 groups.…”

Role of Implantable Cardioverter Defibrillators for Dialysis Patients

“…To date, no randomized clinical trials have been performed in this area. Khan et al reported the impact of ICDs on survival in 78 patients with advanced CKD of whom 45 patients were on dialysis (Khan et al, 2010). In the dialysis cohort, ICD therapy did not impact survival whereas in CKD patients not on dialysis, survival was significantly better in patients with an ICD (2-year survival 80% versus 54%; p=0.027).…”