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Implantable cardioverter-defibrillators for primary prevention of sudden cardiac
death in CKD: a meta-analysis of patient-level data from 3 randomized trials
#MMPMID24518128
Pun PH
; Al-Khatib SM
; Han JY
; Edwards R
; Bardy GH
; Bigger JT
; Buxton AE
; Moss AJ
; Lee KL
; Steinman R
; Dorian P
; Hallstrom A
; Cappato R
; Kadish AH
; Kudenchuk PJ
; Mark DB
; Hess PL
; Inoue LY
; Sanders GD
Am J Kidney Dis
2014[Jul]; 64
(1
): 32-9
PMID24518128
show ga
BACKGROUND: The benefit of a primary prevention implantable
cardioverter-defibrillator (ICD) among patients with chronic kidney disease is
uncertain. STUDY DESIGN: Meta-analysis of patient-level data from randomized
controlled trials. SETTING & POPULATION: Patients with symptomatic heart failure
and left ventricular ejection fraction<35%. SELECTION CRITERIA FOR STUDIES: From
7 available randomized controlled studies with patient-level data, we selected
studies with available data for important covariates. Studies without
patient-level data for baseline estimated glomerular filtration rate (eGFR) were
excluded. INTERVENTION: Primary prevention ICD versus usual care effect
modification by eGFR. OUTCOMES: Mortality, rehospitalizations, and effect
modification by eGFR. RESULTS: We included data from the Multicenter Automatic
Defibrillator Implantation Trial I (MADIT-I), MADIT-II, and the Sudden Cardiac
Death in Heart Failure Trial (SCD-HeFT). 2,867 patients were included; 36.3% had
eGFR<60 mL/min/1.73m2. Kaplan-Meier estimate of the probability of death during
follow-up was 43.3% for 1,334 patients receiving usual care and 35.8% for 1,533
ICD recipients. After adjustment for baseline differences, there was evidence
that the survival benefit of ICDs in comparison to usual care depends on eGFR
(posterior probability for null interaction P<0.001). The ICD was associated with
survival benefit for patients with eGFR?60 mL/min/1.73 m2 (adjusted HR, 0.49; 95%
posterior credible interval, 0.24-0.95), but not for patients with eGFR<60
mL/min/1.73 m2 (adjusted HR, 0.80; 95% posterior credible interval, 0.40-1.53).
eGFR did not modify the association between the ICD and rehospitalizations.
LIMITATIONS: Few patients with eGFR<30 mL/min/1.73 m2 were available. Differences
in trial-to-trial measurement techniques may lead to residual confounding.
CONCLUSIONS: Reductions in baseline eGFR decrease the survival benefit associated
with the ICD. These findings should be confirmed by additional studies
specifically targeting patients with varying eGFRs.
|*Defibrillators, Implantable
[MESH]
|*Primary Prevention
[MESH]
|Aged
[MESH]
|Death, Sudden, Cardiac/*prevention & control
[MESH]
|Female
[MESH]
|Glomerular Filtration Rate/physiology
[MESH]
|Humans
[MESH]
|Kaplan-Meier Estimate
[MESH]
|Male
[MESH]
|Middle Aged
[MESH]
|Patient Readmission/statistics & numerical data
[MESH]
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