title: Implantable cardioverter-defibrillators for primary prevention of sudden cardiac death in CKD: a meta-analysis of patient-level data from 3 randomized trials.
abstract: BACKGROUND
  The benefit of a primary prevention implantable cardioverter-defibrillator (ICD) among patients with chronic kidney disease is uncertain.
  
  
  METHODS
  Meta-analysis of patient-level data from randomized controlled trials.
  
  
  METHODS
  Patients with symptomatic heart failure and left ventricular ejection fraction<35%.
  
  
  METHODS
  From 7 available randomized controlled studies with patient-level data, we selected studies with available data for important covariates. Studies without patient-level data for baseline estimated glomerular filtration rate (eGFR) were excluded.
  
  
  METHODS
  Primary prevention ICD versus usual care effect modification by eGFR.
  
  
  RESULTS
  Mortality, rehospitalizations, and effect modification by eGFR.
  
  
  RESULTS
  We included data from the Multicenter Automatic Defibrillator Implantation Trial I (MADIT-I), MADIT-II, and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). 2,867 patients were included; 36.3% had eGFR<60 mL/min/1.73m2. Kaplan-Meier estimate of the probability of death during follow-up was 43.3% for 1,334 patients receiving usual care and 35.8% for 1,533 ICD recipients. After adjustment for baseline differences, there was evidence that the survival benefit of ICDs in comparison to usual care depends on eGFR (posterior probability for null interaction P<0.001). The ICD was associated with survival benefit for patients with eGFR≥60 mL/min/1.73 m2 (adjusted HR, 0.49; 95% posterior credible interval, 0.24-0.95), but not for patients with eGFR<60 mL/min/1.73 m2 (adjusted HR, 0.80; 95% posterior credible interval, 0.40-1.53). eGFR did not modify the association between the ICD and rehospitalizations.
  
  
  CONCLUSIONS
  Few patients with eGFR<30 mL/min/1.73 m2 were available. Differences in trial-to-trial measurement techniques may lead to residual confounding.
  
  
  CONCLUSIONS
  Reductions in baseline eGFR decrease the survival benefit associated with the ICD. These findings should be confirmed by additional studies specifically targeting patients with varying eGFRs.
authors: Duke Clinical Research Institute, Durham, NC. Electronic address: patrick.pun@duke.edu.
authors: Patrick H
authors: PH
authors: Pun
authors: Duke Clinical Research Institute, Durham, NC.
authors: Sana M
authors: SM
authors: Al-Khatib
authors: University of Washington, Seattle, WA.
authors: Joo Yoon
authors: JY
authors: Han
authors: Duke Clinical Research Institute, Durham, NC.
authors: Rex
authors: R
authors: Edwards
authors: University of Washington, Seattle, WA.
authors: Gust H
authors: GH
authors: Bardy
authors: Columbia University, New York, NY.
authors: J Thomas
authors: JT
authors: Bigger
authors: Beth Israel Deaconess Medical Center, Boston, MA.
authors: Alfred E
authors: AE
authors: Buxton
authors: University of Rochester, Rochester, NY.
authors: Arthur J
authors: AJ
authors: Moss
authors: Duke Clinical Research Institute, Durham, NC.
authors: Kerry L
authors: KL
authors: Lee
authors: Columbia University, New York, NY.
authors: Richard
authors: R
authors: Steinman
authors: University of Toronto, Toronto, ON, Canada.
authors: Paul
authors: P
authors: Dorian
authors: University of Washington, Seattle, WA.
authors: Al
authors: A
authors: Hallstrom
authors: I.R.C.C.S. Policlinico San Donato, Milan, Italy.
authors: Riccardo
authors: R
authors: Cappato
authors: Northwestern Feinberg School of Medicine, Chicago, IL.
authors: Alan H
authors: AH
authors: Kadish
authors: University of Washington, Seattle, WA.
authors: Peter J
authors: PJ
authors: Kudenchuk
authors: Duke Clinical Research Institute, Durham, NC.
authors: Daniel B
authors: DB
authors: Mark
authors: Duke Clinical Research Institute, Durham, NC.
authors: Paul L
authors: PL
authors: Hess
authors: University of Washington, Seattle, WA.
authors: Lurdes Y T
authors: LY
authors: Inoue
authors: Duke Clinical Research Institute, Durham, NC.
authors: Gillian D
authors: GD
authors: Sanders
mesh_terms: D000368:Aged; D016757:Death, Sudden, Cardiac / Q000517:prevention & control*; D017147:Defibrillators, Implantable; D005260:Female; D005919:Glomerular Filtration Rate / Q000502:physiology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data; D011322:Primary Prevention; D016032:Randomized Controlled Trials as Topic; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000503:physiopathology; D012307:Risk Factors
keywords: Implantable cardioverter-defibrillator (ICD); chronic kidney disease (CKD); heart failure; meta-analysis; reduced ejection fraction; sudden cardiac death