Implantable Defibrillators in Patients with Chronic Kidney Disease: Think Twice

Implantable cardioverter-defibrillators (ICDs) can prolong survival in various patient populations, as shown in secondary prevention trials and primary prevention trials in patients with cardiomyopathies. However, most of these trials excluded patients with chronic kidney disease (CKD), and competing mortality and morbidity risks might lessen the benefit of ICDs (NEJM JW Cardiol Oct 2016 and N Engl J Med 2016; 375:1221). To see whether the benefits extend to patients with CKD receiving ICDs as primary prevention, researchers retrospectively identified 18,925 patients eligible for ICDs who had heart failure, left ventricular ejection fraction (LVEF) ≤40%, and CKD (estimated glomerular filtration rate, <60 mL/min/1.73 m²) but without dialysis or kidney transplant; 3380 received ICDs.

The investigators propensity-score–matched 4321 patients without ICDs to 1556 with ICDs (mean age, 73). Despite the careful matching, the ICD group had lower mean LVEF (26.8% vs. 29.4%) and a higher incidence of coronary heart disease (37.1% vs. 30.1%), were more likely to be on a loop diuretic (82.8% vs. 73.5%), and were less likely to be demented (2.8% vs. 3.8%).

Mortality was high: 43% died over a mean follow-up of 3.1 years. ICD implantation did not affect overall mortality but was associated with greater risk for hospitalizations for heart failure (adjusted relative risk, 1.49) and for any cause (ARR, 1.25).