The Role of Implantable Cardioverter-Defibrillators in Long-term Dialysis Patients

Cardiovascular implantable electronic devices in hemodialysis patients: prevalence and implications for arteriovenous hemodialysis access interventions

Cardiovascular implantable electronic devices (CIEDs) are frequently utilized in hemodialysis patients. CIED leads are typically implanted via the subclavian vein resulting in stenosis and venous hypertension. We studied 1235 chronic hemodialysis patients under the care of our nephrology practice. For each, we determined the presence of a CIED, indication for implantable cardioverter-defibrillator (ICD), and type of hemodialysis access. Records were reviewed to identify all interventions performed on the access circuit and the central veins specifically. A CIED was present in 129 patients (10.5%), including ICDs in 75 (6.1%) and pacemakers in 54 (4.4%). The access circuit intervention rate was 1.48/access year (AY) and was similar when a CIED was ipsilateral (1.53/AY) or contralateral (1.44/AY) to arteriovenous access (p = 0.477). The rate of central venous interventions was greater in the ipsilateral (0.59/AY) versus contralateral group (0.28/AY), (p < 0.001). Fifty-four of 59 patients with ipsilateral access and CIED required <2 interventions per AY, but six failed angioplasty and required access ligation. None had superior vena cava stenosis requiring intervention. We conclude that there is a high prevalence of CIEDs in our HD patients. Ipsilateral CIED and arteriovenous access results in higher central venous intervention rates compared with contralateral cases; overall access circuit intervention rates are similar.

Mortality in patients on renal replacement therapy and permanent cardiac pacemakers

End stage renal disease is a relatively frequent disease with high mortality due to cardiac causes. Permanent pacemaker (PM) implantation rates are also very common; thus combination of both conditions is not unusual. We hypothesized that patients with chronic kidney disease with a PM would have significantly higher mortality rates compared with end stage renal disease patients without PM. Our objectives were to analyze mortality of patients on renal replacement therapy with PM. 2778 patients were on renal replacement therapy (RRT) and 110 had a PM implanted during the study period. To reduce the confounding effects of covariates, a propensity-matched score was performed. 52 PM patients and 208 non-PM matched patients were compared. 41% of the PM were implanted before entering the RRT program and 59% while on RRT. Mortality was higher in the PM group. Cardiovascular disease and infections were the most frequent causes of death. Propensity analysis showed no differences in long-term mortality between groups. We concluded that in patients on RRT and PM mortality rates are higher. Survival curves did not differ from a RRT propensity-matched group. We concluded that the presence of a PM is not an independent mortality risk factor in RRT patients.