Bogdan Stefan, Nof Eyal, Eisen Alon, Sela Ron, Rosenheck Shimon, Freedberg Nahum, Geist Michael, Ben-Zvi Shlomit, Haim Moti, Glikson Michael, Goldenberg Ilan, Suleiman Mahmoud
Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel.
Am J Nephrol. 2015;42(4):295-304. doi: 10.1159/000440772. Epub 2015 Oct 31.
Renal dysfunction is associated with increased mortality in heart failure (HF) patients. However, there are limited data regarding clinical and arrhythmic outcomes associated with implantable cardioverter defibrillator (ICD) therapy in this population.
We evaluated outcomes associated with the severity of renal dysfunction with or without dialysis among 2,289 patients who were enrolled and prospectively followed up in the Israeli ICD Registry. The primary endpoint of the study was all-cause mortality. Secondary endpoints included cardiac mortality, HF hospitalization, non-cardiac hospitalization, and appropriate and inappropriate ICD therapy.
Severe renal dysfunction patients (estimated glomerular filtration rate<30 ml/min/1.73 m2; n=144 patients; 6%) were older, with higher comorbidities prevalence, and more likely to suffer from advanced HF. Among severe renal dysfunction patients, those on dialysis had a lower prevalence of wide QRS and complete left bundle branch morphology, resulting in lower cardiac resynchronization therapy defibrillator (CRTD) implantation rates. Dialysis was associated with an overall increased risk for all-cause mortality (hazard ratio (HR) 3.22; 95% CI 1.69-6.13; p<0.01) and for noncardiac hospitalizations (HR 2.80; p<0.001) compared to all other study patients. However, within the subgroup of patients with severe renal dysfunction, the presence of dialysis was not an independent risk factor for all-cause mortality (HR 0.99; p=0.97) as compared to non-dialysis. The rate of appropriate ICD therapy for ventricular tachyarrhythmias increased with declining renal function, with the highest rate observed among those undergoing dialysis.
The present findings suggest that dialysis does not significantly modify the adverse outcomes associated with severe renal dysfunction following ICD/CRTD implantation.
肾功能不全与心力衰竭（HF）患者死亡率增加相关。然而，关于该人群中植入式心脏复律除颤器（ICD）治疗相关的临床和心律失常结局的数据有限。
我们评估了以色列ICD注册研究中纳入并前瞻性随访的2289例患者中，伴或不伴透析的肾功能不全严重程度相关的结局。该研究的主要终点是全因死亡率。次要终点包括心脏性死亡、HF住院、非心脏性住院以及恰当和不恰当的ICD治疗。
严重肾功能不全患者（估计肾小球滤过率<30 ml/min/1.73 m2；n = 144例患者；6%）年龄更大，合并症患病率更高，且更易患晚期HF。在严重肾功能不全患者中，接受透析者宽QRS和完全性左束支形态的患病率较低，导致心脏再同步化治疗除颤器（CRTD）植入率较低。与所有其他研究患者相比，透析与全因死亡率（风险比（HR）3.22；95%可信区间1.69 - 6.13；p<0.01）和非心脏性住院（HR 2.80；p<0.001）的总体风险增加相关。然而，在严重肾功能不全患者亚组中，与未透析者相比，透析并非全因死亡率的独立危险因素（HR 0.99；p = 0.97）。室性快速性心律失常的恰当ICD治疗率随肾功能下降而增加，在接受透析者中观察到的发生率最高。
目前的研究结果表明，透析并未显著改变ICD/CRTD植入后与严重肾功能不全相关的不良结局。
