COMMENTARY

Implantable Cardioverter Defibrillators in CKD: More Harm Than Good?

Nisha Bansal, MD, MAS

Disclosures

February 21, 2018

Heart failure (HF) is common in patients with chronic kidney disease (CKD).[1,2,3] It is estimated that more than 5.7 million adults in the United States have HF, of which 30% have CKD.[4,5] A major complication of HF is sudden cardiac death (SCD); CKD is one of the strongest risk factors for it.[6]

Source: Wikimedia Commons

Implantable cardioverter defibrillators (ICDs) can reduce the risk for SCD in adults with HF and have reduced left ventricular ejection fraction when compared with medical therapy alone in selected participants enrolled into randomized trials.[7,8,9] The data on the use of ICDs in patients with CKD are sparse; existing studies of primary-prevention ICDs in patients with CKD have been limited by modest sample size,[6,10,11,12] highly selected populations of trial participants[6,13] (who are typically healthier and less representative compared with target HF patients[14]), and lack of a comparison group of similar CKD patients who did not undergo ICD placement.[10,15]

Therefore, in a recent publication, we studied adults with HF with left ventricular ejection fraction ≤ 40% enrolled in four Kaiser Permanente healthcare delivery systems.[16] A total of 5877 matched eligible adults with CKD (1556 with ICD and 4321 without ICD) were identified. In models adjusted for demographics, comorbidity, and cardiovascular medication use, there was no difference in all-cause mortality among CKD patients who did versus did not receive an ICD (adjusted hazard ratio 0.96; 95% confidence interval [CI], 0.87-1.06).

However, ICD implantation was associated with increased risks for subsequent HF hospitalizations (adjusted relative risk [aRR] 1.48; 95% CI, 1.38-1.59) and any-cause hospitalizations (aRR 1.24; 95% CI, 1.19-1.29) among patients with CKD.[16] Thus, in this large, contemporary observational study of community-based HF patients with CKD, ICD implantation was not significantly associated with improved survival but rather with increased risks for subsequent HF and all-cause hospitalizations. The potential risks and benefits of ICD implantation should be carefully considered in HF patients with CKD.

Our findings confirm and extend the lack of survival benefit with ICD implantation that has been noted in previous studies of CKD patients.[12,17] Furthermore, our data may provide new insight on risk for hospitalizations, which is an important outcome to patients as a quality-of-life measure and places substantial economic burden on the healthcare system. Patients with CKD are known to have a disproportionate burden of hospitalizations and recurrent hospitalizations, even without placement of cardiac devices.[18,19] In our analyses, we found that ICD implantation was independently associated with greater risks for HF hospitalizations and any-cause hospitalizations in patients with CKD and HF, which has also been reported in non-CKD populations.[20,21]

The data from our study highlight the need for a more comprehensive view of the net risks and benefits of ICD implantation in eligible HF patients with CKD. Future trials to test the efficacy of ICD implantation in CKD patients are needed to guide clinical care of this high-risk population.

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