Long-term Outcomes Associated With Implantable Cardioverter Defibrillator in Adults With 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.

Figure 1.. Cohort Assembly

Exclusions are not mutually exclusive. CKD indicates chronic kidney disease; HDPS, high-density propensity score; and ICD, implantable cardioverter defibrillator. ^aBased on as many as 3 matches per ICD recipient. ^bIndex date is the date when ICD placement occurred. ^cIndex date is the date when ICD placement occurred for their matched counterparts.

Figure 2.. Probability of Survival Among Adults With Reduced Left Ventricular Ejection Fraction Heart Failure and Chronic Kidney Disease

Data are stratified by implantable cardioverter defibrillator (ICD) placement status. Index date indicates date when ICD placement occurred (ICD group) or date when ICD placement occurred for the matched counterparts (non-ICD group).