February 05, 2018
By Megan Brooks
NEW YORK (Reuters Health) - New research suggests that implantable cardioverter-defibrillators (ICDs) do not improve overall survival in patients who have chronic kidney disease (CKD) and heart failure with reduced left-ventricular ejection fraction (LVEF) and may lead to more hospitalizations.
“Because placing an ICD can be expensive and can cause other complications, it is critical to better understand how to best use this therapy in high-risk patients, such as those with chronic kidney disease,” Dr. Nisha Bansal, from the Kidney Research Institute, University of Washington in Seattle, told Reuters Health by email. “Based on our results, clinicians should carefully consider the risks and benefits of ICDs when recommending them for this subset of patients.”
Prior research has shown that ICDs reduce the risk of arrhythmia-related death in select patients who have heart failure with reduced LVEF but do not have CKD. Whether ICDs improve long-term outcomes in patients with CKD, however, is less clear.
To investigate, Dr. Bansal and colleagues studied a large contemporary cohort of patients with CKD and heart failure with reduced LVEF (mean age, 73; 69% men) who were potentially eligible for a primary-prevention ICD and were enrolled in Kaiser Permanente healthcare systems. They carefully matched 1,556 patients with an ICD to 4,321 without an ICD.
After further adjustment for other potential confounders, all-cause mortality did not differ significantly between patients with an ICD versus those without one (adjusted hazard ratio, 0.96), the researchers report online February 5 in JAMA Internal Medicine.
However, having an ICD was associated with significantly increased risks for subsequent hospitalizations related to heart failure or to any cause (adjusted relative risks, 1.49 and 1.25, respectively).
“We were surprised by the findings. Many clinical trials, which have been conducted among the general heart failure population, have suggested that ICDs improve survival,” Dr. Bansal told Reuters Health.
But few studies have looked at the effect of CKD on outcomes in ICD-eligible heart failure patients. Those that have largely relied on administrative diagnostic codes to define CKD, which is known to lead to misclassification, or have been limited to patients on dialysis, “who represent a substantially smaller, higher-risk subset of the larger population with CKD,” the authors point out in their article.
“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. 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,” they conclude.
The study had no commercial funding, and the authors have disclosed no conflicts of interest.
JAMA Intern Med 2018.
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