Key result
CRT response linked to ~49% fewer major events versus ICD in stage 4 CKD.
Why the study?
Does CRT improve renal function and long-term prognosis in patients with stage 4 CKD compared to ICD?
Cohort (n=91)
No
Does CRT improve renal function and long-term prognosis in patients with stage 4 CKD compared to ICD?
Absolute Event Rate: 84.9% vs 94.4%
p-value: p=0.03
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.
May support CRT evaluation in stage 4 CKD; leaves open randomized confirmation of benefit over ICD.
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, & MEASUREMENTS: This study evaluated 73 consecutive CRT patients (71±10 years) with stage 4 CKD who underwent echocardiographic and renal function evaluation at baseline and 6-month follow-up between 2000 and 2012. As a control group, 18 patients with stage 4 CKD who received an implantable cardioverter defibrillator (ICD) were selected. CRT recipients with ≥15% reduction in left ventricular end-systolic volume at 6-month follow-up were classified as CRT responders. During long-term follow-up (median, 33 months), appropriate defibrillator therapy, heart failure hospitalizations, and all-cause mortality (combined end point) were recorded. RESULTS: At 6-month follow-up, a significant reduction in left ventricular end-systolic volume was observed in CRT patients compared with patients with ICD (from 159±78 to 145±78 ml in CRT patients and from 126±54 to 119±49 ml in ICD patients; 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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Höke et al. (2015) conducted a cohort in Stage 4 Chronic Kidney Disease and Heart Failure (n=91). Cardiac resynchronization therapy (CRT) vs. Implantable cardioverter defibrillator (ICD) was evaluated on Combined end point of appropriate defibrillator therapy, heart failure hospitalizations, and all-cause mortality (p=0.03). 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).
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