Division of Cardiology, Duke University Medical Center, Durham, NC 27710, USA.
Europace. 2011 Dec;13(12):1717-22. doi: 10.1093/europace/eur253. Epub 2011 Aug 6.
Chronic kidney disease (CKD) is increasingly prevalent, and is an independent risk factor for cardiovascular mortality. Clinical trials of the implantable cardioverter-defibrillator (ICD) have demonstrated a survival benefit over medical therapy for the prevention of sudden cardiac death, but its benefit in patients with concomitant CKD is unclear.
We studied 199 subjects with CKD, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2), who underwent ICD implantation in the Duke Electrophysiology Genetic and Genomic Studies (EPGEN) biorepository. The mean age of the cohort was 67.8 ± 9.3 years, and the mean eGFR was 41.1 ± 13.2 mL/min/1.73 m(2). There were 63 deaths over a mean follow-up of 31.1 ± 18.8 months, corresponding to an annual mortality rate of 12.2%. Additionally, there was a 7% annual rate of appropriate ICD therapy. Using Cox regression analysis, older age, lower ejection fraction, and lower eGFR were found to be significant predictors of mortality. There was a gradient of risk associated with lower renal function: a 10 mL/min reduction in eGFR conferred a 48% increase in the risk of death (P < 0.001). Further adjustment for appropriate ICD therapy did not modify these associations.
In patients with CKD treated with a defibrillator, more advanced renal dysfunction is associated with reduced survival despite appropriate defibrillator therapy. This may be due to competing mortality risks in this population that attenuate the benefit of the ICD in reducing arrhythmic death. Age, ejection fraction, and kidney disease severity can be used to risk stratify patients before device implantation.
慢性肾脏病（CKD）的发病率日益增高，是心血管死亡率的独立危险因素。植入式心脏复律除颤器（ICD）的临床试验已经证实，与药物治疗相比，ICD 可预防心源性猝死，提高生存率，但对于同时患有 CKD 的患者，其获益尚不清楚。
我们研究了 199 例 CKD 患者，定义为估算肾小球滤过率（eGFR）<60mL/min/1.73m²，这些患者在杜克电生理学遗传和基因组研究（EPGEN）生物标本库中接受了 ICD 植入。队列的平均年龄为 67.8±9.3 岁，平均 eGFR 为 41.1±13.2mL/min/1.73m²。平均随访 31.1±18.8 个月期间，共有 63 例死亡，年死亡率为 12.2%。此外，每年 ICD 治疗的恰当率为 7%。使用 Cox 回归分析，发现年龄较大、射血分数较低和 eGFR 较低是死亡的显著预测因素。肾功能越低，风险越高：eGFR 降低 10mL/min，死亡风险增加 48%（P<0.001）。进一步调整恰当的 ICD 治疗后，这些相关性并未改变。
在接受除颤器治疗的 CKD 患者中，尽管进行了恰当的除颤器治疗，但肾功能进一步恶化与生存率降低相关。这可能是由于该人群存在其他致死风险，从而削弱了 ICD 降低心律失常性死亡的获益。年龄、射血分数和肾脏疾病严重程度可用于在设备植入前对患者进行风险分层。
