Leadless vs. Transvenous Pacemakers in Patients with End-Stage Renal Disease: A Systematic Review and Meta-Analysis

Background: Patients with end-stage renal disease (ESRD) are at elevated risk for device-related complications following pacemaker implantation. Leadless pacemakers (LPMs) offer theoretical advantages over transvenous pacemakers (TVPs), but their safety and efficacy in this high-risk population remain unclear. Our aim was to compare clinical outcomes and complication profiles between leadless and transvenous pacemakers in patients with ESRD. Methods: We conducted a systematic review and meta-analysis according to PRISMA guidelines, including three retrospective studies comparing LPMs and TVPs in ESRD patients. The primary endpoint was overall complications post-implantation. Secondary outcomes included early mortality (within 30 days), access site complications, device-related events, thrombotic events, and respiratory complications. A random-effects model was used to pool odds ratios (ORs) and 95% confidence intervals (CIs). Results: Three studies comprising 10.075 ESRD patients were included. No significant difference was found in overall complications (OR 1.35, 95% CI 0.78-2.33, p = 0.14) or early mortality (OR 1.01, 95% CI 0.42-2.43, p = 0.97) between LPM and TVP groups. However, LPMs were associated with increased access site complications (OR 2.51, 95% CI 1.06-5.90, p = 0.04), thrombotic events (OR 1.42, 95% CI 1.14-1.78, p = 0.03), and respiratory complications (OR 1.43, 95% CI 1.01-2.03, p = 0.05). Device-related complication rates were similar (OR, 1.09; 95% CI, 0.63-1.88; p = 0.30). Heterogeneity was low across most outcomes. Conclusions: Among patients with ESRD, leadless pacemakers did not reduce overall complications or short-term mortality compared to transvenous systems and were associated with increased risk of certain procedural complications. These findings could support a personalized approach to device selection in ESRD and highlight the need for further prospective studies to guide clinical decision-making in this population.