Research has shown that implantable cardioverter defibrillators (ICDs) decrease the number of deaths among patients with heart failure and reduced left ventricular ejection fraction (LVEF). But previous studies often failed to include a subset of patients with co-existing chronic kidney disease (CKD), who represent roughly a third of the population. Now new study findings published online ahead of print in JAMA Internal Medicine suggest that the risks associated with ICD placement in patients with moderate CKD might outweigh the benefits.
Nisha Bansal, MD, MAS, of the University of Washington in Seattle, and colleagues studied 5877 matched adults with CKD (estimated glomerular filtration rate below 60 mL/min/1.72m2) and heart failure and an LVEF of 40% or less. Patients with end-stage renal disease excluded from the study. The group included 1156 patients with an ICD and 4321 without an ICD.
The all-cause mortality rate among the ICD and non-ICD groups were 14.9 and 13.6 deaths per 100 person-years, respectively. In a fully adjusted model, the investigators found no significant difference in all-cause mortality. ICD recipients, however, had a significant 49% and 25% greater risk for hospitalizations due to heart failure and for any cause, respectively, compared with the non-ICD group.
“The findings of this noninterventional study may have important therapeutic implications, particularly given the paucity of clinical trial data related to ICD placement in patients with CKD,” the authors wrote. “These data call for a more comprehensive view of the net risks and benefits of ICD placement in eligible patients with reduced LVEF heart failure and CKD and for future trials to help directly address these questions.”
Hospitalizations affect quality of life and represent an economic burden, the authors noted. ICDs have complications, such as device infections, that may contribute to these hospitalizations.
Roughly a third of patients had coronary heart disease, so the findings might not broadly apply to all patients with LVEF heart failure.
Bansal N, Szpiro A, Reynolds K, et al. Long-term Outcomes Associated With Implantable Cardioverter Defibrillator in Adults With Chronic Kidney Disease. JAMA Intern Med. doi:10.1001/jamainternmed.2017.8462 [Published online February 5, 2018]