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Prevention of sudden cardiac death in patients with chronic kidney disease: risk and benefits of the implantable cardioverter defibrillator

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Abstract

Implantation of implantable cardioverter defibrillators (ICDs) for primary prevention has been shown to significantly reduce mortality in several randomized controlled trials. However, many of these trials have excluded patients on hemodialysis as well as patients with advanced chronic kidney disease (CKD). Whether the benefits of ICD therapy extend to patients with CKD is not clear. This review will examine the relationship between advancing stage of CKD and risk/benefit of ICD placement. Furthermore, we will review the recent evidence for the rates of complications as CKD advances. The intent is to assist the clinician who is considering the risks and benefits of ICD implantation in patients who have significant competing comorbidities and have not been specifically studied in randomized controlled trials.

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Authors and Affiliations

  1. The New England Cardiac Arrhythmia Center, The Cardiovascular Center, Department of Medicine, Tufts Medical Center, 750 Washington Street, Boston, MA, 02111, USA

    Jana M. Hoffmeister, N. A. Mark Estes III & Ann C. Garlitski

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  1. Jana M. Hoffmeister
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  2. N. A. Mark Estes III
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  3. Ann C. Garlitski
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Correspondence to Ann C. Garlitski.

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Editorial Commentary

This comprehensive review summarizes the literature regarding the influence of CKD on outcomes in patients with ICDs, and reinforces its impact on morbidity and mortality in this population. Perioperative complication rates are higher, and late infections not insignificant. A unique aspect of the manuscript is that it summarizes the literature from the perspective of grades of dysfunction.

Many unknowns about these patients exist: What are the mechanisms by which CKD degrades ICD benefit? How do other comorbidities interact with CKD to impact survival? It may be that CKD is such a powerful modifier of ICD benefit that it alone may predict lack of ICD benefit. Is it possible that CRT in selected patients can improve renal function? Also, nonarrhythmic causes of sudden death including coronary and other vascular disease, and bradycardia cannot be ignored. Recall also the negative impact of peripheral vascular disease on outcomes, even in the absence of CKD. Given the vascular and infectious risks of transvenous ICD therapy in dialysis patients, might a subcutaneous ICD be preferable?

From an aerial perspective, the consistency of the conclusion begs the question why have we not done a RCT specifically addressing these patients? Patients with significant CKD were not included in the pivotal trials of ICD therapy, and given the fact that as a sole comorbidity it is such a powerful predictor of poor outcome, such a study would be ethically sound. It would be most appropriate for primary prevention since for those surviving a life-threatening ventricular arrhythmia it would be difficult to not advise device therapy. Unfortunately, since current guidelines for primary prevention do not distinguish patients with and without CKD, it may be difficult to ever proceed with such a venture. Nevertheless, I think it should be done. For now, we need to very carefully counsel patients with CKD about the significant debate that exists about attenuated benefit from ICD therapy afforded to their predecessors.

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Hoffmeister, J.M., Estes, N.A.M. & Garlitski, A.C. Prevention of sudden cardiac death in patients with chronic kidney disease: risk and benefits of the implantable cardioverter defibrillator. J Interv Card Electrophysiol 35, 227–234 (2012). https://doi.org/10.1007/s10840-012-9711-4

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  • DOI: https://doi.org/10.1007/s10840-012-9711-4

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