Background: Most defibrillator (ICD) trials have excluded patients on hemodialysis (HD). It is therefore not
known whether the ICD, when indicated, confers the same mortality benefit to HD and non-HD patients.
Method: HD patients implanted with an ICD from July 2001 to June 2004 were matched by age, gender,
left ventricular ejection fraction (LVEF), and class of heart failure to non-HD ICD recipients.
Results: Forty-six (16 on HD) patients (age = 65 15 yrs, LVEF = 30 14%, 44% in class III-IV HF) were
followed for a mean of 30 16 months (range, 461 months) after ICD implantation. During this period,
12/16 HD versus 9/30 non-HD patients died (P = 0.006). The two-year mortality rates were 54% and 29%
in the HD and non-HD groups, respectively (P = 0.01). After correcting for age, gender, race, LVEF, class
of HF, and ICD indication (primary vs. secondary prevention) in a Cox regression model, HD remained a
significant predictor of the time to death (HR = 2.9, adjusted P = 0.023).
Conclusion: Despite having an ICD, HD patients have approximately a three-fold increase in total mortality and may therefore not extract the same survival benefits from the ICD as their non-HD counterparts.
If duplicated in larger randomized trials, these results may demonstrate the futility of implanting defibrillators in HD patients. (PACE 2007; 30:10911095)
renal failure, dialysis, defibrillators, mortality
Introduction
End-stage renal disease constitutes a major
burden on the health-care system in the United
States with more than 300,000 patients nationwide
being treated with renal replacement therapy.1 Although mortality rates among such patients have
been declining over the past two decades, they remain in excess of 20% during the first year of dialysis, with more than half of the deaths being related
to cardiovascular events.1 Based on the United
States Renal Data System database, cardiac arrests
account for about 60% of deaths in patients with
end-stage renal disease2 with the annual mortality
rates among survivors of cardiac arrests reaching
up to 87%.2
Previous studies3,4 have shown that patients
with renal insufficiency or end-stage renal disease
are at a higher risk for ventricular tachyarrhythmia
and appropriate implantable cardioverter defibrillator (ICD) therapies. Other studies have suggested
a potential survival benefit of the ICD in patients on
hemodialysis therapy for renal failure.5 However,
most secondary68 and primary912 ICD trials have
excluded patients with advanced renal failure and
sources of available information on the benefits of
Address for reprints: Samir Saba, M.D., Chief, Electrophysiology Section, 200 Lothrop Street, UPMC Presbyterian, Suite
B-535, Pittsburgh, PA 15213-2582. Fax: 412-647-7979; e-mail:
sabas@upmc.edu
Received April 10, 2007; revised May 15, 2007; accepted June
8, 2007.
C 2007, The Authors. Journal compilation
C 2007, Blackwell Publishing, Inc.
PACE, Vol. 30
September 2007
1091
HREYBE, ET AL.
Table I.
Clinical Characteristics of Hemodialysis and Control Patients
Variable
Age (years)
Gender (% male)
Race (% white)
LVEF (%)
NYHA Class
I
II
III
IV
Diabetes mellitus
Hyperlipidemia
Class I antiarrhythmic drugs
-Blockers
Class III antiarrhythmic drugs
Calcium channel blockers
Smoking
Smoker
Non-smoker
Ex-smoker
1092
Patients on Hemodialysis
(n = 16)
P-value
64.3 14.6
62.5%
75%
31.9 14.9
64.6 14.7
80%
66.7%
29.4 14.0
NS
NS
NS
NS
25%
25%
37.5%
12.5%
56.3%
81.3%
0%
81.3%
37.5%
12.5%
26.7%
33.3%
30%
10%
26.7%
53.3%
0%
70.0%
26.7%
3.3%
NS
18.8%
25%
56.3%
13.3
43.3
43.3
September 2007
0.06
NS
NS
NS
NS
NS
NS
PACE, Vol. 30
Discussion
As shown previously,3,4 patients with renal
insufficiency and in particular patients with endstage renal disease on HD are at a high risk for
recurrent ventricular tachyarrhythmia, which is
reflected in a higher incidence of ICD therapies
and a shorter time to first appropriate ICD shock
compared to patients with normal kidney function. The survival benefit of the ICD in HD patients
has been suggested by Herzog et al.,5 but not established, as these patients were excluded from all
major ICD trials.612 Also, the study by Herzog et
al. focused on the value of the ICD for secondary
prevention of death in HD patients, which is in
contrast to the primary prevention population included in our current study.
The implications of implanting HD patients
with defibrillators without proof of benefit are numerous. In HD patients who are prone to vascular
access problems, poor platelet function, and high
risk of infection, the invasive and expensive practice of implanting an ICD may negatively impact
patient outcome, thus the great need for clinical
Table II.
Cause of Death in Hemodialysis and Control Patients
Variable
PACE, Vol. 30
Death
Patients with known
cause of death
Heart failure
Sepsis
During kidney
transplantation
Lethal arrhythmia
September 2007
12
0.006
4
1
2
5
4
1
NS
1
0
0
0
1093
HREYBE, ET AL.
References
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National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases, April 2000.
2. http://www.usrds.org
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