What is the clinical evidence from this study?

Study design: Cohort. Population: Stage 4 Chronic Kidney Disease and Heart Failure (n=91). Intervention: Cardiac resynchronization therapy (CRT) vs. Implantable cardioverter defibrillator (ICD). Primary outcome: Combined end point of appropriate defibrillator therapy, heart failure hospitalizations, and all-cause mortality (p=0.03).

September 26, 2015Open Access

Cardiac Resynchronization Therapy in CKD Stage 4 Patients

UHUlas HökeLeiden University MKMand KhidirLeiden University Medical Center EVEnno T. van der VeldeAdult Congenital Heart Disease

Key Result

Cardiac resynchronization therapy was associated with superior survival free from the combined end point compared with ICD in patients with stage 4 CKD, with CRT response independently reducing risk (HR 0.51).

Study Design

Type

Cohort (n=91)

Multicenter

Structured PICO

Does CRT improve renal function and long-term prognosis in patients with stage 4 CKD compared to ICD?

Population

91 patients with stage 4 CKD, including 73 consecutive CRT patients (mean age 71±10 years) and 18 ICD control patients.

Intervention

Cardiac resynchronization therapy (CRT)

Comparator

Implantable cardioverter defibrillator (ICD)

Outcome

Combined end point of appropriate defibrillator therapy, heart failure hospitalizations, and all-cause mortality at median 33 months follow-upcomposite

In patients with stage 4 CKD, CRT response occurs in approximately 30% of patients and is associated with improved eGFR and better long-term prognosis compared to ICD alone.

Main Result

Absolute Event Rate: 84.9% vs 94.4%

p-value: p=0.03

Limitations

Small patient population
Retrospective design
Potential selection bias due to indication for device therapy
eGFR not systematically available after 6 months
Preexistent pathology of renal dysfunction preceding HF could not be evaluated

Abstract

BACKGROUND AND OBJECTIVES: Cardiac resynchronization therapy (CRT) is a well established heart failure treatment that has shown to improve renal function. However, landmark CRT trials excluded patients with severe renal dysfunction. Therefore, this study evaluated the effect of CRT on renal function and long-term prognosis in patients with stage 4 CKD. DESIGN, SETTING, PARTICIPANTS, P=0.05), and CRT response was observed in 22 patients (30%). Compared with ICD patients, eGFR improved among CRT patients (from 25±4 to 30±9 ml/min per 1.73 m(2); interaction time and group, P=0.04) and was more pronounced among CRT responders (25±3 to 34±9 ml/min per 1.73 m(2); P<0.001). The combined end point was observed in 17 ICD and 62 CRT patients. CRT patients showed superior survival compared with ICD patients (log-rank P=0.03). More importantly, CRT response was independently associated with improved survival free from the combined end point (hazard ratio, 0.51; 95% confidence interval, 0.27 to 0.98; P=0.04) after adjustment for clinical and echocardiographic parameters. CONCLUSIONS: Response to CRT occurs in approximately 30% of patients with stage 4 CKD, which is less than in the average CRT population. CRT was associated with better clinical outcome, and particularly, CRT response was associated with improvement in eGFR and better long-term prognosis.

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