ICD placement in CKD patients increases hospitalizations without survival benefit

1. Adults with chronic kidney disease (CKD) and heart failure with reduced LVEF who received implantable cardioverter defibrillators (ICDs) did not differ from matched non-ICD patients with relation to all-cause mortality.

2. However, ICD placement in patients with CKD was associated with increased risk of heart failure-related and any-cause hospitalization.

Evidence Rating Level: 2 (Good)

Study Rundown: Cardiovascular disease, most often heart failure, is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD). Placement of implantable cardioverter defibrillators (ICDs) is one of the major interventions know to improve morality in a subset of patients with heart failure with reduced ejection fraction. However, an independent evaluation of the risks and benefits of ICD placement in CKD patients has not been explored. The authors of this study conducted a matched parallel cohort study to compare all-cause mortality, heart failure-related hospitalizations, and any-cause hospitalizations in CKD patients who underwent ICD placement versus matched CKD non-ICD patients.

Results demonstrated no significant difference in survival, but higher rates of heart failure-related hospitalizations, as well as hospitalization for any cause, potentially supporting the contribution of high competing risks of death and post-ICD complications. However, given the noninterventional nature of the study, a causative relationship between ICD placement and hospitalization risk cannot be concluded. Additionally, use of electronic health data limited the depth of data available about arrhythmic events, hospitalizations, etc. Furthermore, the population of CKD patients studied here may not be representative of the general population.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction.

In-Depth [retrospective cohort study]: The study examined a total of 1556 CKD patients from Kaiser Permanente health care delivery systems within the Cardiovascular Research Network, who had ICDs placed, compared to 4321 CKD patients who did not receive an ICD, matched according to demographic characteristics and cormorbidities. The authors ascertained history of ICD placement based on procedure codes from electronic health data, and compared all-cause mortality, heart failure-related hospitalizations, and any-cause hospitalizations between the two groups based on data from administrative databases.

They found through a matched parallel cohort study that there was no significant difference in mortality rate (14.9 per 100 person-years; 95% CI, 13.9-16.1; in the ICD group vs. 13.6 per 100 person-years; 95% CI, 13.0-14.2; in the non-ICD group). However, the rate of heart failure-related hospitalization was significantly higher in the ICD group (16.90 per 100 person-years; 95% CI, 15.64-18.27) compared to the non-ICD group (11.12 per 100 person-years; 95% CI, 10.53-11.74). Additionally, the rate of any-cause hospitalization was also significantly higher in the ICD group (51.65 per 100 person-years; 95% CI, 48.79-54.68) versus the non-ICD group (38.27 per 100 person-years; 95% CI, 36.91-39.69).

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