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Original Investigation
March 2018

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

Author Affiliations
  • 1Kidney Research Institute, Division of Nephrology, University of, Seattle
  • 2Department of Biostatistics, University of Washington, Seattle
  • 3Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
  • 4Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
  • 5Department of Medicine, Kaiser Permanente Colorado, Denver
  • 6Meyers Primary Care Institute, Worcester, Massachusetts
  • 7University of Colorado Hospital, Aurora
  • 8Marshfield Clinic Research Foundation, Marshfield, Wisconsin
  • 9Kaiser Permanente Northern California Division of Research, Oakland
  • 10Department of Epidemiology, University of California, San Francisco
  • 11Department of Biostatistics, University of California, San Francisco
  • 12Department of Medicine, University of California, San Francisco
JAMA Intern Med. 2018;178(3):390-398. doi:10.1001/jamainternmed.2017.8462
Key Points

Question  Does placement of implantable cardioverter defibrillators improve clinical outcomes in patients with chronic kidney disease?

Findings  In this cohort study of 5877 community-based patients with heart failure and chronic kidney disease, use of implantable cardioverter defibrillators was not significantly associated with improved survival but was associated with increased risk for subsequent heart failure and all-cause hospitalization.

Meaning  The potential risks and benefits of implantable cardioverter defibrillators should be carefully considered in patients with heart failure and chronic kidney disease.

Abstract

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 m2. 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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