Implantable Cardioverter Defibrillator and Resynchronization Therapy in Patients With Overt Chronic Kidney Disease: JACC State-of-the-Art Review (JACC October 2024-1)-Article: Implantable Cardioverter Defibrillator and Resynchronization Therapy in Patients With Overt Chronic Kidney Disease: JACC State-of-the-Art Review

Article: Implantable Cardioverter Defibrillator and Resynchronization Therapy in Patients With Overt Chronic Kidney Disease: JACC State-of-the-Art Review

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This comprehensive review, published in the Journal of the American College of Cardiology, examines the efficacy and safety of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) in patients with chronic kidney disease (CKD) and heart failure (HF). Coexisting CKD and HF can complicate the management and effectiveness of these therapies due to associated cardiovascular and renal pathophysiological changes.<br /><br />Notably, ICDs and CRTs have shown benefits in reducing morbidity and mortality in HF patients but the outcomes are less clear when advanced CKD coexists. ICDs are recommended for HF patients with a left ventricular ejection fraction (LVEF) below 35% to prevent sudden cardiac arrest (SCA), whereas CRTs are advised for those with symptomatic reduced LVEF and prolonged QRS complex. However, randomized controlled trials (RCTs) that form the basis of these guidelines often exclude patients with advanced CKD, making the application of these devices in such populations contentious.<br /><br />The review identifies that patients with CKD may have increased procedural risks and complications from device implantation. For instance, they face a higher likelihood of infection, hemorrhage, and other procedural complications due to compromised immunity and coagulation profiles. Additionally, the altered physiology in CKD can affect device function, such as increased defibrillation thresholds and non-capture of pacing stimuli due to myocardial fibrosis and electrolyte imbalances.<br /><br />Several pathophysiological mechanisms might explain the attenuated benefits of ICD and CRT in advanced CKD patients. These include a higher prevalence of non-shockable arrhythmias, a higher defibrillation threshold, myocardial fibrosis, coexisting atrial fibrillation, and lower adherence to guideline-directed medical therapies due to renal considerations.<br /><br />The paper emphasizes the need for randomized trials specifically focusing on HF patients with advanced CKD to elucidate the efficacy and safety of ICD and CRT in this particular population. Until then, individualized patient care considering the severity and potential reversibility of HF and CKD remains essential.

Keywords

implantable cardioverter-defibrillators

cardiac resynchronization therapy

chronic kidney disease

heart failure

morbidity

mortality

left ventricular ejection fraction

randomized controlled trials

procedural risks

myocardial fibrosis