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Long-term Outcomes Associated With Implantable Cardioverter Defibrillator in Adults With Chronic Kidney Disease
JAMA Internal Medicine ( IF 39.0 ) Pub Date : 2018-03-01 , DOI: 10.1001/jamainternmed.2017.8462
Nisha Bansal 1 , Adam Szpiro 2 , Kristi Reynolds 3 , David H. Smith 4 , David J. Magid 5 , Jerry H. Gurwitz 6 , Frederick Masoudi 7 , Robert T. Greenlee 8 , Grace H. Tabada 9 , Sue Hee Sung 9 , Ashveena Dighe 1 , Alan S. Go 9, 10, 11, 12
Affiliation  

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.

中文翻译:

慢性肾病成人植入式心脏复律除颤器的长期预后

重要性 慢性肾病 (CKD) 在患有心力衰竭的成年人中很常见,并且与心源性猝死的风险增加有关。对未患 CKD 的参与者进行的随机试验表明,植入式心脏复律除颤器 (ICD) 可降低选定的左心室射血分数 (LVEF) 心力衰竭患者的心律失常死亡风险。然而,ICD 是否能改善 CKD 患者的临床结果尚不清楚。目的 旨在检查一级预防 ICD 与 LVEF 和 CKD 降低的心力衰竭患者的基于社区的人群中死亡和住院风险的关联。设计,设置,和参与者 这项非干预性队列研究包括患有心力衰竭且 LVEF 为 40% 或更低的成年人,以及 2005 年 1 月 1 日至 2012 年 12 月 31 日期间可用的血清肌酐水平测量值,他们被纳入 4 个 Kaiser Permanente 医疗保健服务系统。慢性肾病定义为估计的肾小球滤过率低于 60 mL/min/1.73 m2。接受和未接受 ICD 的患者在 CKD 状态、年龄和接受 ICD 的高维倾向评分方面进行了匹配 (1:3)。随访于 2013 年 12 月 31 日完成。分析了 2015 年至 2017 年的数据。暴露放置 ICD。主要结果和措施全因死亡、心力衰竭住院和全因住院。结果 共确定了 5877 名匹配的符合条件的 CKD 成人(1556 名有 ICD,4321 名没有 ICD)(4049 名男性 [68.9%] 和 1828 名女性 [31.1%];平均 [SD] 年龄,72.9 [8.2] 岁) . 在根据人口统计学、合并症和心血管药物使用情况调整的模型中,ICD 组与非 ICD 组的 CKD 患者的全因死亡率没有差异(调整后的风险比,0.96;95% CI,0.87-1.06)。然而,植入 ICD 与因心力衰竭(调整后的相对风险,1.49;95% CI,1.33-1.60)和任何原因住院(调整后的相对风险,1.25;95% CI,1.20-1.30)而导致的后续住院风险增加相关) CKD 患者。结论和相关性 在一项针对社区心力衰竭和 CKD 患者的大型当代非干预性研究中,ICD 放置与改善生存率没有显着相关性,但与随后因心力衰竭和全因住院而住院的风险增加有关。对于心力衰竭和 CKD 患者,应仔细考虑 ICD 的潜在风险和益处。
更新日期:2018-03-01
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