Leyva Francisco, Zegard Abbasin, Taylor Robin, Foley Paul W X, Umar Fraz, Patel Kiran, Panting Jonathan, Ferro Charles J, Chalil Shajil, Marshall Howard, Qiu Tian
Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom.
Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom.
Pacing Clin Electrophysiol. 2019 Jun;42(6):595-602. doi: 10.1111/pace.13659. Epub 2019 Apr 3.
Patients with moderate-to-severe chronic kidney disease (CKD) are underrepresented in clinical trials of cardiac resynchronization therapy (CRT)-defibrillation (CRT-D) or CRT-pacing (CRT-P). We sought to determine whether outcomes after CRT-D are better than after CRT-P over a wide spectrum of CKD.
Clinical events were quantified in relation to preimplant estimated glomerular filtration rate (eGFR) after CRT-D (n = 410 [39.2%]) or CRT-P (n = 636 [60.8%]) implantation. Over a follow-up period of 3.7 years (median, interquartile range: 2.1-5.7), the eGFR < 60 group (n = 598) had a higher risk of total mortality (adjusted hazard ratio [aHR]: 1.28; P = 0.017), total mortality or heart failure (HF) hospitalization (aHR: 1.32; P = 0.004), total mortality or hospitalization for major adverse cardiac events (MACEs, aHR: 1.34; P = 0.002), and cardiac mortality (aHR: 1.33; P = 0.036), compared to the eGFR ≥ 60 group (n = 448), after covariate adjustment. In analyses of CRT-D versus CRT-P, CRT-D was associated with a lower risk of total mortality (eGFR ≥ 60 HR: 0.65; P = 0.028; eGFR < 60 HR: 0.64, P = 0.002), total mortality or HF hospitalization (eGFR ≥ 60 aHR: 0.66; P = 0.021; eGFR < 60 aHR: 0.69, P = 0.007), total mortality or hospitalization for MACEs (eGFR ≥ 60 aHR: 0.70; P = 0.039; eGFR < 60 aHR: 0.69, P = 0.005), and cardiac mortality (eGFR ≥ 60 aHR: 0.60; P = 0.026; eGFR < 60 aHR: 0.55; P = 0.003).
In CRT recipients, moderate CKD is associated with a higher mortality and morbidity compared to normal renal function or mild CKD. Despite less favorable absolute outcomes, patients with moderate CKD had better outcomes after CRT-D than after CRT-P.
在心脏再同步化治疗除颤（CRT-D）或心脏再同步化治疗起搏（CRT-P）的临床试验中，中重度慢性肾脏病（CKD）患者的代表性不足。我们试图确定在广泛的CKD范围内，CRT-D后的结局是否优于CRT-P后的结局。
对CRT-D植入后（n = 410 [39.2%]）或CRT-P植入后（n = 636 [60.8%]）的临床事件与植入前估计肾小球滤过率（eGFR）进行量化分析。在3.7年的随访期内（中位数，四分位间距：2.1 - 5.7），与eGFR≥60组（n = 448）相比，eGFR < 60组（n = 598）全因死亡风险更高（校正风险比[aHR]：1.28；P = 0.017）、全因死亡或心力衰竭（HF）住院风险更高（aHR：1.32；P = 0.004）、全因死亡或主要不良心脏事件（MACE）住院风险更高（aHR：1.34；P = 0.002）以及心源性死亡风险更高（aHR：1.33；P = 0.036），经协变量调整后。在CRT-D与CRT-P的分析中，CRT-D与全因死亡风险较低相关（eGFR≥60时HR：0.65；P = 0.028；eGFR < 60时HR：0.64，P = 0.002）、全因死亡或HF住院风险较低相关（eGFR≥60时aHR：0.66；P = 0.021；eGFR < 60时aHR：0.69，P = 0.007）、全因死亡或MACE住院风险较低相关（eGFR≥60时aHR：0.70；P = 0.039；eGFR < 60时aHR：0.69，P = 0.005）以及心源性死亡风险较低相关（eGFR≥60时aHR：0.60；P = 0.026；eGFR < 60时aHR：0.55；P = 0.003）。
在接受CRT治疗的患者中，与正常肾功能或轻度CKD相比，中度CKD与更高的死亡率和发病率相关。尽管绝对结局不太理想，但中度CKD患者接受CRT-D后的结局优于接受CRT-P后的结局。
