Implantable cardioverter defibrillators confer survival benefit in patients with renal insufficiency but not in dialysis-dependent patients

Do Implantable Cardioverter-Defibrillators Prevent Sudden Cardiac Death in End-Stage Renal Disease Patients on Dialysis?

Chronic kidney disease patients appear to be predisposed to heart rhythm disorders, including atrial fibrillation/atrial flutter, ventricular arrhythmias, and supraventricular tachycardias, which increase the risk of sudden cardiac death. The pathophysiological factors underlying arrhythmia and sudden cardiac death in patients with end-stage renal disease are unique and include timing and frequency of dialysis and dialysate composition, vulnerable myocardium, and acute proarrhythmic factors triggering asystole. The high incidence of sudden cardiac deaths suggests that this population could benefit from implantable cardioverter-defibrillator therapy. The introduction of implantable cardioverter-defibrillators significantly decreased the rate of all-cause mortality; however, the benefits of this therapy among patients with chronic kidney disease remain controversial since the studies provide conflicting results. Electrolyte imbalances in haemodialysis patients may result in ineffective shock therapy or the appearance of non-shockable underlying arrhythmic sudden cardiac death. Moreover, the implantation of such devices is associated with a risk of infections and central venous stenosis. Therefore, in the population of patients with heart failure and severe renal impairment, periprocedural risk and life expectancy must be considered when deciding on potential device implantation. Harmonised management of rhythm disorders and renal disease can potentially minimise risks and improve patients' outcomes and prognosis.

Temporal Trends and Outcomes of Implantable Cardioverter Defibrillators in Heart Failure and Chronic Kidney Disease in the United States

Chronic kidney disease (CKD) and hemodialysis increase the risk of sudden cardiac death (SCD) in heart failure (HF); however, national trends in utilization and outcomes of implantable cardioverter-defibrillator (ICD) in this population remain unknown. We sought to evaluate the utilization and outcomes of ICD therapy in HF patients with CKD and end-stage renal disease (ESRD) using the National Inpatient Sample from 2009 to 2018. Hospitalizations with a discharge diagnosis of systolic HF and ICD implantation were identified and stratified by stages of kidney disease. A total of 281,219 systolic HF hospitalizations who underwent ICD implantation were included. A significant decrease in inpatient ICD implantation was observed over the past decade (3.7% in 2009 to 1.1% in 2018) regardless of renal impairment. In-hospital mortality was highest in ESRD, followed by CKD compared with patients with no CKD. Length of hospital stay and hospitalization costs were also significantly higher in patients with CKD and ESRD. The overall utilization of inpatient ICD implantation has decreased in systolic HF patients and inpatient ICD placement in CKD is associated with an increased risk of mortality and adverse clinical outcomes. This indicates that patients with renal impairment and HF represent a sicker cohort than the general HF population.

Effect of Implanted Defibrillator on Mortality in Patients With Chronic Kidney Disease

The beneficial role of implantable cardioverter defibrillators (ICDs) in patients with chronic kidney disease (CKD) is controversial. This meta-analysis aimed to evaluate the effect of ICD on mortality in patients with CKD. A literature search was conducted for studies reporting the effect of ICD on all-cause mortality in patients with CKD (estimated glomerular filtration rate <60 ml/min/1.73 m²). The search was not restricted to time or publication status. The search included the following databases: Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL. The primary end point was all-cause mortality. The minimum duration of follow-up required for inclusion was 1 year. The literature search identified 834 studies, of which 14 studies with 70,661 patients were included. Mean follow-up was 39 months (12 to 81 months). For all patients with CKD, ICD was associated with lower all-cause mortality (log hazard ratio [HR] -0.247, standard error [SE] 0.101, p = 0.015). Heterogeneity: degree of freedom = 13 (p <0.01), I² = 97.057; test for overall effect: Z = -2.431 (p = 0.015). When further stratified based on dialysis, patients with CKD without the need for dialysis had significantly lower mortality (log HR -0.211, SE 0.095, p = 0.026), with a similar trend in patients who underwent dialysis (log HR -0.262, SE 0.134, p = 0.051). ICD implantation is associated with a significant mortality benefit in patients with CKD.

Cardiovascular implantable electronic devices in hemodialysis patients: an updated review

Cardiovascular diseases are the leading life-threatening complications in hemodialysis patients. In this scenario, both tachy-arrhythmias and brady-arrhythmias are involved with related hemodialysis and nonhemodialysis-dependent mechanisms; moreover, those arrhythmias usually occur in different time intervals before sudden cardiac death (SCD). Furthermore, current evidence shows that the presence of advanced chronic kidney disease (CKD) reduces the benefits of implantable cardioverter--defibrillators (ICDs), which increases the risk of both arrhythmic and nonarrhythmic death, especially in patients with advanced stages of heart failure. Notably, patients with advanced CKD show a more severe degree of heart failure compared with mild CKD patients. However, the benefits of the ICD implantation in the primary prevention of hemodialysis patients is still controversial, and by now, no significant benefits have emerged compared with nonhemodialysis-dependent CKD patients. In secondary prevention, hemodialysis patients with ICD implantation have higher mortality rates compared with nonhemodialysis-dependent CKD patients with ICD. On the other hand, most articles include hemodialysis patients with reduced left ventricular ejection fraction, neglecting those with preserved systolic function. This review focuses on the epidemiology of SCD in the setting of hemodialysis and the current evidence on ICD implantation in patients on hemodialysis therapy analyzing novel strategies, which might reduce the risk of ICD placing.

Implantable cardioverter-defibrillators with end stage renal disease: Nationwide inpatient sample database results

BACKGROUND

When compared to patients with normal renal function, patients with chronic kidney disease develop higher in-hospital complications post implantable cardioverter-defibrillator (ICD) therapy. However, real world data on in-hospital complications post ICD therapy in patients with end stage renal disease (ESRD) is limited. In this study, we aim to explore the procedure-related complications of ICD therapy in patients with ESRD.

METHODS

Using the nationwide inpatient sample (NIS) database, we conducted a retrospective analysis on ESRD patients who underwent inpatient ICD placement from 2010 to 2016. Using 1:2 propensity score matching, we compared ESRD patients to those with normal renal function. Outcomes of interest were postoperative hemorrhage and hematoma formation, blood transfusion, pericardial complications, mechanical complications requiring lead revision, vascular injury, in-hospital mortality, and length of stay.

RESULTS

Our sample included 40,075 cases with subsequent propensity score matching between ESRD and normal renal function. Comparatively, patients with ESRD had higher odds of postoperative hemorrhage (Odds ratio [OR] = 1.67, 95% confidence interval [CI] 1.4-1.99, p = < .0001), blood transfusion (OR, 3.88; CI 3.29-4.56; p = < .0001), mechanical complications requiring lead revision (OR, 1.24; CI 1.01-1.51; p = .035), vascular injury (OR, 2.02; CI 1.27-3.24; p = .0027), in-hospital mortality (OR, 4.56; CI 3.08-6.76; p = < .0001), and longer hospitalization (11 vs. 7 days, p = < .0001), but without significant difference in pericardial complications (OR, 1.9; CI 0.92-1.54; p = < .18).

CONCLUSION

In this large contemporary cohort, patients with ESRD undergoing inpatient ICD therapy are at higher risk of developing postprocedural complications including hemorrhage and hematoma, blood transfusion, mechanical complications requiring lead revision, and in hospital mortality, without increased risk of pericardial complications.

Sudden cardiac death in dialysis patients: different causes and management strategies

Sudden cardiac death (SCD) represents a major cause of death in end-stage kidney disease (ESKD). The precise estimate of its incidence is difficult to establish because studies on the incidence of SCD in ESKD are often combined with those related to sudden cardiac arrest (SCA) occurring during a haemodialysis (HD) session. The aim of the European Dialysis Working Group of ERA-EDTA was to critically review the current literature examining the causes of extradialysis SCD and intradialysis SCA in ESKD patients and potential management strategies to reduce the incidence of such events. Extradialysis SCD and intradialysis SCA represent different clinical situations and should be kept distinct. Regarding the problem, numerically less relevant, of patients affected by intradialysis SCA, some modifiable risk factors have been identified, such as a low concentration of potassium and calcium in the dialysate, and some advantages linked to the presence of automated external defibrillators in dialysis units have been documented. The problem of extra-dialysis SCD is more complex. A reduced left ventricular ejection fraction associated with SCD is present only in a minority of cases occurring in HD patients. This is the proof that SCD occurring in ESKD has different characteristics compared with SCD occurring in patients with ischaemic heart disease and/or heart failure and not affected by ESKD. Recent evidence suggests that the fatal arrhythmia in this population may be due more frequently to bradyarrhythmias than to tachyarrhythmias. This fact may partly explain why several studies could not demonstrate an advantage of implantable cardioverter defibrillators in preventing SCD in ESKD patients. Electrolyte imbalances, frequently present in HD patients, could explain part of the arrhythmic phenomena, as suggested by the relationship between SCD and timing of the HD session. However, the high incidence of SCD in patients on peritoneal dialysis suggests that other risk factors due to cardiac comorbidities and uraemia per se may contribute to sudden mortality in ESKD patients.

Association between CRT(D)/ICD and renal insufficiency: A systematic review and meta-analysis

Cardiac resynchronization therapy with or without a defibrillator (CRT(D)) and implantable cardioverter defibrillator (ICD) may reduce the risk of arrhythmia or heart failure-specific mortality and improves the prognosis of patients with chronic kidney disease (CKD) or dialysis. The aim of this study was to perform a meta-analysis investigating the relationship between CRT(D)/ICD and renal insufficiency. Cochrane Library, Web of Science, Embase, and Pubmed were systematically searched from inception to 29 October 2019. We included studies that report all-cause mortality of patients with renal insufficiency who received CRT(D)/ICD therapy. Twenty-six studies (n = 119,263) were included, exploring the relationship between CRT(D)/ICD and renal insufficiency from two aspects: (1) Compared with ICD-only, CRT(D) was associated with lower risk of all-cause mortality in CKD patients (odds ratios (OR) = 0.67; 95% confidence interval (CI), 0.60 to 0.75). For non-primary prevention (secondary prevention or both), the analysis revealed a lower risk of all-cause mortality in the ICD group than in the no-ICD group (OR = 0.47; 95% CI, 0.40 to 0.55). (2) CKD increased all-cause mortality in comparison with control group (OR = 2.12; 95% CI, 1.85 to 2.44), and so did dialysis (OR = 2.53; 95% CI, 2.34 to 2.73). Furthermore, compared with CKD3 (eGFR: 30-59 ml/min/1.73 m² ), CKD4/5 (eGFR <30 ml/min/1.73 m² ) was observed to have a significantly higher risk of all-cause mortality (OR = 2.70; 95% CI, 1.93 to 3.80). This review shows a clear association between CRT(D)/ICD and renal insufficiency in the aspect of all-cause mortality, and may provide a reference for the clinical application of CRT(D)/ICD.

β-Blocker Use and Risk of Mortality in Heart Failure Patients Initiating Maintenance Dialysis

RATIONAL & OBJECTIVE

Beta-blockers are recommended for patients with heart failure (HF) but their benefit in the dialysis population is uncertain. Beta-blockers are heterogeneous, including with respect to their removal by hemodialysis. We sought to evaluate whether β-blocker use and their dialyzability characteristics were associated with early mortality among patients with chronic kidney disease with HF who transitioned to dialysis.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Adults patients with chronic kidney disease (aged≥18 years) and HF who initiated either hemodialysis or peritoneal dialysis during January 1, 2007, to June 30, 2016, within an integrated health system were included.

EXPOSURES

Patients were considered treated with β-blockers if they had a quantity of drug dispensed covering the dialysis transition date.

OUTCOMES

All-cause mortality within 6 months and 1 year or hospitalization within 6 months after transition to maintenance dialysis.

ANALYTICAL APPROACH

Inverse probability of treatment weights using propensity scores was used to balance covariates between treatment groups. Cox proportional hazard analysis and logistic regression were used to investigate the association between β-blocker use and study outcomes.

RESULTS

3,503 patients were included in the study. There were 2,115 (60.4%) patients using β-blockers at transition. Compared with nonusers, the HR for all-cause mortality within 6 months was 0.79 (95% CI, 0.65-0.94) among users of any β-blocker and 0.68 (95% CI, 0.53-0.88) among users of metoprolol at transition. There were no observed differences in all-cause or cardiovascular-related hospitalization.

LIMITATIONS

The observational nature of our study could not fully account for residual confounding.

CONCLUSIONS

Beta-blockers were associated with a lower rate of mortality among incident hemodialysis patients with HF. Similar associations were not observed for hospitalizations within the first 6 months following transition to dialysis.

Efficacy of Implantable Cardioverter-defibrillators for Secondary Prevention of Sudden Cardiac Death in Patients with End-stage Renal Disease

End-stage renal disease (ESRD) constitutes a major burden on the health-care system in the United States, with more than 300,000 patients nationwide being treated with renal replacement therapy. Very few studies to date have evaluated the benefit of implantable cardioverter-defibrillator (ICD) implantation for secondary prevention in patients with ESRD. In this study, we evaluated the efficacy of secondary-prevention ICDs in reducing all-cause mortality in patients on dialysis using the United States Renal Data System (USRDS) database. We queried the USRDS for relevant data between 2004 and 2010. Patients with diagnoses of ventricular fibrillation (VF), ventricular tachycardia (VT), or sudden cardiac arrest (SCA) were included in the study. Patients were excluded from the analysis if they were younger than 18 years; had missing age, sex, or race/ethnicity information; had experienced myocardial infarction; or had an ICD in situ at the time of VF, VT, or SCA diagnosis. The primary endpoint of this study was to determine the efficacy of secondary-prevention ICDs in reducing all-cause mortality in patients on dialysis. A total of 1,442 patients (3.4%) with ESRD had ICD insertion. Patients who received an ICD were predominantly younger, white males with lower Charlson Comorbidity Index and with fewer cardiovascular events. Survival at two years was 53% among those with an ICD relative to 27% among those without an ICD. In this study, we observed a substantial decrease in mortality in patients receiving an ICD for secondary prevention when compared with a cohort of similar patients with a history of VF, VT, or SCA.

Implantable Cardioverter Defibrillators and Chronic Kidney Disease

Use of implantable cardioverter defibrillators (ICDs) is the treatment of choice for heart failure patients with ejection fraction <35% to prevent sudden cardiac death. Whether this benefit remains among patients with chronic kidney disease (CKD) or end stage renal disease (ESRD) is yet to be elucidated. We conducted a systematic review of studies in PubMed that have investigated the use of ICDs among patients with CKD or ESRD. From the 470 studies identified, we selected 42 for the current review. Patients with CKD/ESRD were more likely to get antitachycardia pacing or shocks and had higher cardiac and/or all-cause mortality compared to patients without CKD/ESRD. These associations had an inverse dose-response effect with worse outcomes with decreasing kidney function. In conclusion, use of ICDs in CKD/ESRD is associated with increased antitachycardia pacing/shocks and mortality suggesting that their routine use in this patient population may be associated with more adverse outcomes than benefits.

Do Implantable Cardioverter Defibrillators Reduce Mortality in Patients With Chronic Kidney Disease at All Stages?

The benefits of implantable cardioverter defibrillator (ICD) implantation in chronic kidney disease (CKD) patients with high sudden cardiac death (SCD) risk are uncertain. To clarify the effects of receiving an ICD in CKD patients, we conducted this meta-analysis to identify the effects of ICDs on patients with CKD, including those on dialysis. We searched the Cochrane library, EMBASE, PubMed, and clinical trials for studies published before July 2016. Eleven studies including 20,196 CKD patients were considered for inclusion. The pooled analysis suggested that patients with an estimated glomerular filtration rate (eGFR) < 60 mL/minute/1.73 m2 would benefit from receiving treatments with ICDs compared with patients without an ICD device (aHR = 0.74; 95% confidence interval [CI], 0.63 to 0.86). [corrected]. This is the first report of a subgroup analysis on the survival rate of ICD implantation in CKD patients according to an eGFR group. The subgroup analysis indicated a similar protective association of ICDs in stage 3 (aHR = 0.71; 95% CI, 0.61 to 0.82) and 5 (aHR = 0.71; 95% CI, 0.54 to 0.92) CKD patients [corrected] compared with the control group. However, there was no significant improvement in all-cause mortality in stage 4 CKD patients (aHR = 1.02; 95%CI, 0.75 to 1.37) [corrected]. This is the first meta-analysis reporting that ICD implantation reduces all-cause mortality in stage 3 and 5 [corrected] CKD patients. However, the data do not indicate there is any benefit to ICD implantation in stage 4 [corrected] CKD patients.

Sudden cardiac death and chronic kidney disease: From pathophysiology to treatment strategies

Chronic kidney disease (CKD) patients demonstrate higher rates of cardiovascular mortality and morbidity; and increased incidence of sudden cardiac death (SCD) with declining kidney failure. Coronary artery disease (CAD) associated risk factors are the major determinants of SCD in the general population. However, current evidence suggests that in CKD patients, traditional cardiovascular risk factors may play a lesser role. Complex relationships between CKD-specific risk factors, structural heart disease, and ventricular arrhythmias (VA) contribute to the high risk of SCD. In dialysis patients, the occurrence of VA and SCD could be exacerbated by electrolyte shifts, divalent ion abnormalities, sympathetic overactivity, inflammation and iron toxicity. As outcomes in CKD patients after cardiac arrest are poor, primary and secondary prevention of SCD and cardiac arrest could reduce cardiovascular mortality in patients with CKD.

A novel method to predict the proportional risk of sudden cardiac death in heart failure: Derivation of the Seattle Proportional Risk Model

BACKGROUND

Patients with heart failure are at increased risk of both sudden death and pump failure death. Strategies to better identify those who have greatest net benefit from implantable cardioverter-defibrillator (ICD) implantation could reduce morbidity and maximize cost-effectiveness of ICDs.

OBJECTIVE

We aimed to identify baseline variables in patients with cardiomyopathy that are independently associated with a disproportionate fraction of mortality risk attributable to sudden death vs nonsudden death.

METHODS

We used data from 9885 patients with heart failure without ICDs, of whom 2552 died during an average follow-up of 2.3 years. Using commonly available baseline clinical and demographic variables, we developed a multivariate regression model to identify variables associated with a disproportionate risk of sudden death.

RESULTS

We confirmed that lower ejection fraction and better functional class were associated with a greater proportion of mortality due to sudden death. Younger age, male sex, and higher body mass index were independently associated with a greater proportional risk of sudden death, while diabetes mellitus, hyper/hypotension, higher creatinine level, and hyponatremia were associated with a disproportionately lower risk of sudden death. The use of several heart failure medications, left ventricular end-diastolic dimension, or NT-pro brain natriuretic peptide concentrations were not associated with a disproportionate risk of sudden death.

CONCLUSION

Several easily obtained baseline demographic and clinical variables, beyond ejection fraction and New York Heart Association functional class, are independently associated with a disproportionately increased risk of sudden death. Further investigation is needed to assess whether this novel predictive method can be used to target the use of lifesaving therapies to populations who will derive greatest mortality benefit .

A meta-analysis of mortality in end-stage renal disease patients receiving implantable cardioverter defibrillators (ICDs)

Data on the effectiveness of implantable implantable cardioverter defibrillators (ICDs) with respect to reducing mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are lacking. The purpose of this meta-analysis was to compare the mortality of patients with ESRD who have received and not received an ICD. A search was conducted on January 31, 2013 of Medline, Cochrane, EMBASE, and Google Scholar. Studies were selected for inclusion based on the following criteria. 1) Randomized controlled trial. 2) ESRD patients with heart failure. 3) Device therapy (ICD, CRT-defibrillator [CRT-D]) used to treat heart failure. 4) Primary outcome is survival analysis. 5) Retrospective study if survival analysis was performed. The primary outcome was overall survival (OS), and the secondary outcome was 2-year survival. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated, and a χ2-based test of homogeneity was performed. Three studies were included in the analysis. The combined OR for OS was 2.245 (95% CI 1.871 to 2.685, P<0.001), indicating that patients with an ICD had a significantly higher OS than those without an ICD. The combined OR for 2-year survival was 2.312 (95% CI 1.921 to 2.784, P<0.001), indicating that patients with an ICD had a significantly higher 2-year survival rate than those without an ICD. The use of ICD in patients with ESRD is associated with an increase in the OS and the 2-year survival rate.

Implications of Kidney Disease in the Cardiac Patient

Traditional cardiovascular risk factors, particularly hypertension and diabetes, are common in the disease processes of both renal and cardiac pathology. Unfortunately the coexistence of renal impairment is not an innocent bystander in cardiovascular disease; it disorder not only increases the prevalence and severity of cardiovascular disease, but also negatively affects prognostic outcomes and the safety and efficacy of cardiac interventions. This article discusses the role and impact of kidney disease in the cardiac patient in 3 key common cardiovascular processes: coronary artery disease, arrhythmia, and heart failure.

Do implantable cardioverter defibrillators improve survival in patients with chronic kidney disease at high risk of sudden cardiac death? A meta-analysis of observational studies

AIMS

Prospective randomized clinical trials show that implantable cardioverter defibrillators (ICDs) can reduce the risk of total mortality in select populations. However, data regarding patients with chronic kidney disease (CKD) are inconclusive. The aim of this study was to evaluate if ICDs affect total mortality in CKD patients at high risk of sudden cardiac death.

METHODS AND RESULTS

Two separate meta-analyses were performed to (i) assess the effect of ICD on all-cause mortality in CKD patients at high risk of sudden cardiac death and (ii) assess the effect of CKD on all-cause mortality in patients who already had an ICD for primary or secondary prevention purposes. Medline and EMBASE were searched from 1966 to 2013. A manual search by cross-referencing was performed. Five observational studies with 17 460 CKD patients considered at high risk of sudden cardiac death were included to evaluate the effect of ICDs on patients with severe CKD. Patients with ICD implants had a reduction in all-cause mortality (adjusted hazard ratio (HR) = 0.65, 95% confidence interval (CI) = 0.47-0.91, P < 0.05) compared with a matched control group. Based on 15 observational studies with 5233 patients as part of our second comparison that evaluated the effect of CKD on patients who received an ICD, CKD was associated with higher mortality risk (HR = 2.86, 95% CI = 1.91-4.27, P < 0.05) despite an ICD.

CONCLUSION

The meta-analysis indicates that for patients undergoing ICD implant, CKD is associated with greater risk of dying. However, ICD placement reduces mortality in CKD patients at high risk of sudden cardiac death.

Sudden cardiac death in patients with chronic kidney disease: prevention is the sine qua non

Despite developments in the technology of dialysis procedures and improvements in the understanding of systemic derangements related to chronic kidney disease (CKD), cardiovascular disease is the major cause of death. Unfortunately, the leading subset of cardiovascular disease death is sudden cardiac death (SCD). To date much effort has been exerted to figure out the clues pointing to the risk of future development of SCD in patients with CKD. However, none of these factors satisfactorily detects a truly vulnerable dialysis patient. Thus, recently, it has been advocated that a combination of noninvasive risk assessment methods, carefully chosen to reflect the different aspects of the underlying pathology and changes in the myocardial substrate in CKD, could help to identify patients at high risk of SCD within the CKD. In this review, we aimed to summarize what is known about risk stratification of patients with CKD and appropriate prevention strategies with a special emphasis on recent developments and the use of complimentary tests perhaps as a risk prediction rule.

Effect of renal function on survival after implantable cardioverter defibrillator placement

Implantable cardioverter defibrillators (ICDs) are effective at reducing arrhythmic death in patients with left ventricular dysfunction, but few studies have investigated the outcomes after ICD implantation in patients with chronic kidney disease (CKD). We conducted a 2-center retrospective study of 958 patients who had undergone ICD placement for primary prevention from the 2000 to 2006. The patients were stratified into 5 groups according to the CKD stage (stage 1, glomerular filtration [GFR] 90 to 120 ml/min; stage 2, GFR 60 to 89 ml/min; stage 3, GFR 30 to 59 ml/min; stage 4, GFR 15 to 29 ml/min; and stage 5, GFR 0 to 14 ml/min). The primary end point was death at 1 year. Of the 958 patients included in our analysis, 73 (7.6%) had died at 1 year. The mortality rate at 1 year increased with worsening CKD (1.8%, 5.3%, 9.0%, 22%, and 38% for stage 1 to 5, respectively, p <0.0001 for group). CKD was an independent predictor of mortality; hazard ratio 1.0, 1.075 (95% confidence interval 0.578 to 2.0), 1.372 (95% confidence interval 0.736 to 2.556), 3.092 (95% confidence interval 1.52 to 6.29), and 10.15 (95% confidence interval 4.25 to 24.23) for stage 1 to 5, respectively (p <0.0001 for group). Patients with CKD and left ventricular dysfunction have a poor prognosis despite ICD placement. The 1-year mortality increased as the renal function decreased. In conclusion, physicians should be cognizant of the prognosis when considering whether an ICD should be implanted in patients with CKD.