Cardiac Resynchronization Therapy in CKD Stage 4 Patients
Ulas Höke1, Mand J H Khidir2, Enno T van der Velde2
1Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands; and Interuniversity Cardiology Institute of The Netherlands, Utrecht, The Netherlands.
Insights
Cardiac resynchronization therapy (CRT) improves renal function and long-term survival in patients with stage 4 chronic kidney disease (CKD). CRT response is linked to better outcomes, including improved estimated glomerular filtration rate (eGFR).
Area of Science:
- Cardiology
- Nephrology
- Medical Devices
Background:
- Cardiac resynchronization therapy (CRT) is established for heart failure but excluded severe renal dysfunction patients in trials.
- Stage 4 chronic kidney disease (CKD) patients have limited data on CRT's renal and prognostic effects.
Purpose of the Study:
- To evaluate CRT's impact on renal function in stage 4 CKD patients.
- To assess CRT's effect on long-term prognosis in this population.
Main Methods:
- Retrospective study of 73 CRT patients and 18 implantable cardioverter-defibrillator (ICD) controls with stage 4 CKD.
- Echocardiographic and renal function assessments at baseline and 6 months.
- Long-term follow-up for defibrillator therapy, heart failure hospitalizations, and mortality.
Main Results:
- CRT patients showed improved estimated glomerular filtration rate (eGFR) compared to ICD controls (P=0.04).
- CRT responders (30%) had significantly greater eGFR improvement (P<0.001).
- CRT was associated with superior survival compared to ICD (P=0.03), with CRT response independently predicting better prognosis.
Conclusions:
- Approximately 30% of stage 4 CKD patients respond to CRT, a lower rate than typically seen.
- CRT improves clinical outcomes and renal function (eGFR) in stage 4 CKD.
- CRT response is a key predictor of improved long-term prognosis in this patient group.
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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