Device therapy in chronic kidney disease (implantable cardioverter defibrillator, cardiac resynchronization therapy)

Heart failure and chronic kidney disease (CKD) are frequent co-morbid conditions, and represent two challenging and costly diseases for individuals and societies. CKD has a prevalence up to 55% in patients with heart failure, with a significantly higher risk for arrhythmias, sudden cardiac death, hospitalization, and mortality. Cardiac implantable devices such as implantable cardioverter defibrillators and cardiac resynchronization therapy are treatments proven to have a significant benefit on clinical outcomes in selected patients with heart failure. However, due to the high risk of non-cardiac death and substantial other co-morbidities in patients with CKD, the benefit of cardiac implantable devices may be attenuated. Furthermore, device-related complications are far more frequent in patients with CKD and relate to the patient’s clinical status and co-morbidities. Renal dysfunction, particularly severe CKD (glomerular filtration rate <30 mL/min/1.73 m2) and end-stage CKD (with the necessity of dialysis or kidney transplantation), is associated with major complications including bleeding, infection, device/lead dysfunction, and vascular complications. Specific data and guidelines in this population are lacking due to the fact that CKD is a frequent exclusion criterion in most randomized clinical trials. Decisions for implantation and follow-up should be performed on an individual basis, taking into account individual risk/benefit ratios and done by a multidisciplinary team including a nephrologist and cardiologist.