title: Comparative Effectiveness of CRT-D Versus Defibrillator Alone in HF Patients With Moderate-to-Severe Chronic Kidney Disease.
abstract: BACKGROUND
  Patients with moderate-to-severe chronic kidney disease (CKD) are poorly represented in clinical trials of cardiac resynchronization therapy (CRT).
  
  
  OBJECTIVE
  This study sought to assess the real-world comparative effectiveness of CRT with defibrillator (CRT-D) versus implantable cardioverter-defibrillator (ICD) alone in CRT-eligible patients with moderate-to-severe CKD.
  
  
  METHODS
  We conducted an inverse probability-weighted analysis of 10,946 CRT-eligible patients (ejection fraction <35%, QRS >120 ms, New York Heart Association functional class III/IV) with stage 3 to 5 CKD in the National Cardiovascular Data Registry (NCDR) ICD Registry, comparing outcomes between patients who received CRT-D (n = 9,525) versus ICD only (n = 1,421). Outcomes were obtained via Medicare claims and censored at 3 years. The primary endpoint of heart failure (HF) hospitalization or death and the secondary endpoint of death were assessed with Cox proportional hazards models. HF hospitalization, device explant, and progression to end-stage renal disease were assessed using Fine-Gray models.
  
  
  RESULTS
  After risk adjustment, CRT-D use was associated with a reduction in HF hospitalization or death (hazard ratio [HR]: 0.84; 95% confidence interval [CI]: 0.78 to 0.91; p < 0.0001), death (HR: 0.85; 95% CI: 0.77 to 0.93; p < 0.0004), and HF hospitalization alone (subdistribution HR: 0.84; 95% CI: 0.76 to 0.93; p < 0.009). Subgroup analyses suggested that CRT was associated with a reduced risk of HF hospitalization and death across CKD classes. The incidence of in-hospital, short-term, and mid-term device-related complications did not vary across CKD stages.
  
  
  CONCLUSIONS
  In a nationally representative population of HF and CRT-eligible patients, use of CRT-D was associated with a significantly lower risk of the composite endpoint of HF hospitalization or death among patients with moderate-to-severe CKD in the setting of acceptable complication rates.
authors.affiliation: Division of Cardiology, Duke University Hospital, Durham, North Carolina.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Friedman
authors.affiliation: Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Jagmeet P
authors.initials: JP
authors.lastname: Singh
authors.affiliation: Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Jeptha P
authors.initials: JP
authors.lastname: Curtis
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: W H Wilson
authors.initials: WHW
authors.lastname: Tang
authors.affiliation: Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Haikun
authors.initials: H
authors.lastname: Bao
authors.affiliation: Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Erica S
authors.initials: ES
authors.lastname: Spatz
authors.affiliation: Division of Cardiology, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Adrian F
authors.initials: AF
authors.lastname: Hernandez
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina; Division of Nephrology, Duke University Hospital, Durham, North Carolina.
authors.forename: Uptal D
authors.initials: UD
authors.lastname: Patel
authors.affiliation: Division of Cardiology, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina. Electronic address: alkha001@mc.duke.edu.
authors.forename: Sana M
authors.initials: SM
authors.lastname: Al-Khatib
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D058406:Cardiac Resynchronization Therapy / Q000379:methods / Q000706:statistics & numerical data; D015897:Comorbidity; D057186:Comparative Effectiveness Research; D017147:Defibrillators, Implantable / Q000706:statistics & numerical data; D004554:Electric Countershock / Q000295:instrumentation / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D005919:Glomerular Filtration Rate; D006333:Heart Failure / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000453:epidemiology; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: biventricular; cardiomyopathy; chronic kidney disease; pacemaker