Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death in CKD: A Meta-analysis of Patient-Level Data From 3 Randomized Trials

Pun, Patrick H.; Al‐Khatib, Sana M.; Han, Joo Yoon; Edwards, Rex; Bardy, Gust H.; Bigger, J. Thomas; Buxton, Alfred E.; Moss, Arthur J.; Lee, Kerry L.; Steinman, Richard C.; Dorian, Paul; Hallstrom, Al; Cappato, Riccardo; Kadish, Alan H.; Kudenchuk, Peter J.; Mark, Daniel B.; Hess, Paul L.; Inoue, Lurdes Y.T.; Sanders, Gillian D

doi:10.1053/j.ajkd.2013.12.009

Cited by 99 publications

(89 citation statements)

References 23 publications

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“…This is consistent with prior conclusions from Pun et al (16) A higher comorbidity burden in the CKD population and hence a greater, competing risk for death from nonsudden causes may explain this attenuation of ICD benefit. In other words, ICD benefit may be limited in advanced CKD if arrhythmic death accounts for a lower proportion of overall mortality among individuals with CKD despite the higher overall mortality rate and higher incidence of both sudden and nonsudden cardiovascular death and death from noncardiovascular causes (19).…”

supporting

confidence: 92%

“…Alternatively, the benefits of ICD implantation in advanced CKD, particularly in patients on dialysis, compared with those with preserved renal function may be limited by a differential defibrillation threshold in the setting of advanced myocardial fibrosis and capillary rarefaction (20), frequent electrolyte shifts (5), and occurrence of noncardiovertable rhythms such as bradycardia (21) and asystole. Finally, advanced CKD may increase the likelihood of short-and long-term complications from ICDs as a result of an increased risk of bleeding and infection (16,22), with mortality risks further increased when ICD replacement is required (23). Each of these factors may limit utility of ICDs in CKD and are important considerations for clinicians when assessing the value of invasive or costly therapies in this population.…”

mentioning

confidence: 99%

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Khattak

Charytan

2015

Clinical Journal of the American Society of Nephrology

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supporting

confidence: 92%

mentioning

confidence: 99%

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Khattak

Charytan

2015

Clinical Journal of the American Society of Nephrology

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“…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.…”

Section: Resultsmentioning

confidence: 99%

“…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.…”

Section: Discussionmentioning

confidence: 99%

“…9) However, another metaanalysis including patient-level data from 3 RCTs of primary prevention ICD implantation has shown no significant survival benefit of ICD implantation compared with controls in 1,040 patients with an estimated glomerular filtration rate (eGFR) < 60 mL/minute/1.73 m 2 not on dialysis (aHR = 0.92, 95%CI, 0.74 to 0.92). 10) These meta-analyses have predominantly included patients recruited many years ago. Moreover, these meta-analyses did not conduct a subgroup analysis in patients with severe renal dysfunction, especially in dialysis patients.…”

Section: Editorial P303mentioning

confidence: 99%

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

Zhou

Zhu

et al. 2017

Int. Heart J.

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SummaryThe benefits of implantable cardioverter defibrillator (ICD) implantation in chronic kidney disease (CKD) patients with high sudden cardiac death (SCD) risk are uncertain. To clarify the effects of receiving an ICD in CKD patients, we conducted this meta-analysis to identify the effects of ICDs on patients with CKD, including those on dialysis. We searched the Cochrane library, EMBASE, PubMed, and clinical trials for studies published before July 2016. Eleven studies including 20,196 CKD patients were considered for inclusion. The pooled analysis suggested that patients with an estimated glomerular filtration rate (eGFR) < 60 mL/minute/1.73 m 2 would benefit from receiving treatments with ICDs compared with patients without an ICD device (aHR = 0.77; 95% confidence interval [CI], 0.63 to 0.95). This is the first report of a subgroup analysis on the survival rate of ICD implantation in CKD patients according to an eGFR group. The subgroup analysis indicated a similar protective association of ICDs in stage 3 CKD patients (aHR = 0.71; 95%CI, 0.61 to 0.82) compared with the control group. However, there was no significant improvement in all-cause mortality in stage 4 CKD patients (aHR = 1.02; 95%CI, 0.75 to 1.37) or stage 5 CKD patients (aHR = 0.80; 95%CI, 0.60 to 1.31). This is the first meta-analysis reporting that ICD implantation reduces all-cause mortality in stage 3 CKD patients. However, the data do not indicate there is any benefit to ICD implantation in stage 4 or 5 CKD patients. (Int Heart J 2017; 58: 371-377)

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Long-term Outcomes Associated With Implantable Cardioverter Defibrillator in Adults With Chronic Kidney Disease

Bansal¹,

Szpiro

Reynolds

et al. 2018

JAMA Intern Med

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IMPORTANCE Chronic kidney disease (CKD) is common in adults with heart failure and is associated with an increased risk of sudden cardiac death. Randomized trials of participants without CKD have demonstrated that implantable cardioverter defibrillators (ICDs) decrease the risk of arrhythmic death in selected patients with reduced left ventricular ejection fraction (LVEF) heart failure. However, whether ICDs improve clinical outcomes in patients with CKD is not well elucidated. OBJECTIVE To examine the association of primary prevention ICDs with risk of death and hospitalization in a community-based population of potentially ICD-eligible patients who had heart failure with reduced LVEF and CKD. DESIGN, SETTINGS, AND PARTICIPANTS This noninterventional cohort study included adults with heart failure and an LVEF of 40% or less and measures of serum creatinine levels available from January 1, 2005, through December 31, 2012, who were enrolled in 4 Kaiser Permanente health care delivery systems. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 mL/min/1.73 m 2. Patients who received and did not receive an ICD were matched (1:3) on CKD status, age, and high-dimensional propensity score to receive an ICD. Follow-up was completed on December 31, 2013. Data were analyzed from 2015 to 2017. EXPOSURES Placement of an ICD. MAIN OUTCOMES AND MEASURES All-cause death, hospitalizations due to heart failure, and any-cause hospitalizations. RESULTS A total of 5877 matched eligible adults with CKD (1556 with an ICD and 4321 without an ICD) were identified (4049 men [68.9%] and 1828 women [31.1%]; mean [SD] age, 72.9 [8.2] years). In models adjusted for demographics, comorbidity, and cardiovascular medication use, no difference was found in all-cause mortality between patients with CKD in the ICD vs non-ICD groups (adjusted hazard ratio, 0.96; 95% CI, 0.87-1.06). However, ICD placement was associated with increased risk of subsequent hospitalization due to heart failure (adjusted relative risk, 1.49; 95% CI, 1.33-1.60) and any-cause hospitalization (adjusted relative risk, 1.25; 95% CI, 1.20-1.30) among patients with CKD. CONCLUSIONS AND RELEVANCE In a large, contemporary, noninterventional study of community-based patients with heart failure and CKD, ICD placement was not significantly associated with improved survival but was associated with increased risk for subsequent hospitalization due to heart failure and all-cause hospitalization. The potential risks and benefits of ICDs should be carefully considered in patients with heart failure and CKD.

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Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death in CKD: A Meta-analysis of Patient-Level Data From 3 Randomized Trials

Abstract: Background-The benefit of a primary prevention implantable cardioverter defibrillator (ICD) among patients with chronic kidney disease (CKD) is uncertain.

Cited by 99 publications

References 23 publications

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

Long-term Outcomes Associated With Implantable Cardioverter Defibrillator in Adults With Chronic Kidney Disease

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