Benefit of primary prevention implantable cardioverter-defibrillators in the setting of chronic kidney disease: a decision model analysis.

Introduction: Primary prevention ICD trials have excluded patients with CKD. Comorbidities and lower life expectancy in patients with CKD make the benefit of primary prevention ICD implantation uncertain.

Methods: A decision analysis model was devised to evaluate the risks and benefits of implantable cardioverter-defibrillators (ICD) implantation in patients with chronic kidney disease (CKD) who meet current criteria for a primary prevention ICD. Published data capturing event rates, infection risks, and overall survival in CKD patients with and without ICDs were utilized. Variables included patient's age, GFR and stage of CKD, probability of sudden cardiac death (SCD), and device implantation mortality.

Results: The benefit of an ICD for primary prevention of SCD in patients with CKD depends primarily on the patient's age and stage of kidney disease. With stages 1 and 2 CKD, ICD implantation reduces mortality. However, in patients with more advanced stages of CKD, the benefit is less significant and age-dependent. This is attributed to patients with advanced CKD having a higher procedural risk and decreased life expectancy. With average procedural mortality, ICD implantation is favored at ages <80 for stage 3, ages <75 for stage 4, and ages <65 for stage 5. As procedural mortality rates increase, age thresholds for ICD implantation decrease.

Conclusions: Our model shows that benefit from primary prevention ICD implantation is determined by the patient's age and stage of kidney disease. While there is limited impact with lower stages of CKD, careful consideration of ICD implantation is suggested for older patients with more advanced stages of kidney disease.