Do Implantable Cardioverter-Defibrillators Lower the Risk of Sudden Death and Total Mortality in Patients with End-Stage Renal Disease?

  • Sana M. Al-KhatibEmail author
  • Daniel J. Friedman
  • Paul L. Hess
  • Patrick H. Pun
  • Gillian D. Sanders
Arrhythmias (J. Bunch, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Arrythmias


Purpose of Review

Although the risk of sudden cardiac death is high in patients with end-stage renal disease (ESRD), it is not clear if such patients benefit from the implantable cardioverter defibrillator (ICD). This paper reviews data on the risk of sudden cardiac death in ESRD patients and examines data on outcomes of ICDs in such patients.

Recent Findings

Data from observational studies suggest that primary prevention ICDs may lower the risk of mortality in patients with mild to moderate chronic kidney disease but not in patients with ESRD. Data on secondary prevention ICDs in the setting of ESRD suggest survival benefit in select patients. The subcutaneous ICD is a promising therapy in patients with ESRD, but more data are needed on its short- and long-term outcomes in these patients.


Future studies should examine the outcomes of transvenous and subcutaneous ICDs in patients with ESRD.


Sudden cardiac death Implantable cardioverter defibrillator End-stage renal disease 


Compliance with Ethical Standards

Conflict of Interest

Drs Al-Khatib, Friedman, Hess, Pun, and Sanders declare no conflicts of interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter automatic defibrillator implantation trial investigators. N Engl J Med. 1996;335(26):1933–40. doi: 10.1056/NEJM199612263352601.CrossRefPubMedGoogle Scholar
  2. 2.
    A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. N Engl J Med. 1997;337(22):1576–1583. doi: 10.1056/NEJM199711273372202.
  3. 3.
    Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G. A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter unsustained tachycardia trial investigators. N Engl J Med. 1999;341(25):1882–90. doi: 10.1056/NEJM199912163412503.CrossRefPubMedGoogle Scholar
  4. 4.
    Connolly SJ, Hallstrom AP, Cappato R, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs implantable defibrillator study. Cardiac arrest study Hamburg. Canadian implantable defibrillator study. Eur Heart J. 2000;21(24):2071–8. doi: 10.1053/euhj.2000.2476.CrossRefPubMedGoogle Scholar
  5. 5.
    Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346(12):877–83. doi: 10.1056/NEJMoa013474.CrossRefPubMedGoogle Scholar
  6. 6.
    Kadish A, Dyer A, Daubert JP, et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med. 2004;350(21):2151–8. doi: 10.1056/NEJMoa033088.CrossRefPubMedGoogle Scholar
  7. 7.
    Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352(3):225–37. doi: 10.1056/NEJMoa043399.CrossRefPubMedGoogle Scholar
  8. 8.
    Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society Circulation. 2013;127:e283–352. doi: 10.1016/j.jacc.2012.11.007.Google Scholar
  9. 9.
    Ramesh S, Zalucky A, Hemmelgarn BR, Roberts DJ, Ahmed SB, Wilton SB, et al. Incidence of sudden cardiac death in adults with end-stage renal disease: a systematic review and meta-analysis. BMC Nephrol. 2016;17:78. doi: 10.1186/s12882-016-0293-8.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    National Institute of Diabetes and Digestive and Kidney Diseases: 2006 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, Bethesda, MD, Cardiovascular Special Studies, 2006.Google Scholar
  11. 11.
    Herzog CA, Li S, Weinhandl ED, Strief JW, Collins AJ, Gilbertson DT. Survival of dialysis patients after cardiac arrest and the impact of implantable cardioverter defibrillators. Kidney Int. 2005;68:818–25. doi: 10.1111/j.1523-1755.2005.00462.x.CrossRefPubMedGoogle Scholar
  12. 12.
    Parekh RS, Plantinga LC, Kao WH, Meoni LA, Jaar BG, Fink NE, et al. The association of sudden cardiac death with inflammation and other traditional risk factors. Kidney Int. 2008;74:1335–42. doi: 10.1038/ki.2008.449.CrossRefPubMedGoogle Scholar
  13. 13.
    Wang AY, Lam CW, Chan IH, Wang M, Lui SF, Sanderson JE. Sudden cardiac death in end-stage renal disease patients: a 5-year prospective analysis. Hypertension. 2010;56:210–6. doi: 10.1161/HYPERTENSIONAHA.110.151167.CrossRefPubMedGoogle Scholar
  14. 14.
    Jadoul M, Thumma J, Fuller DS, et al. Modifiable practices associated with sudden death among hemodialysis patients in the dialysis outcomes and practice patterns study. Clinical journal of the American Society of Nephrology: CJASN. 2012;7(5):765–74. doi: 10.2215/CJN.08850811.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Whitman IR, Feldman HI, Deo R. Chronic kidney disease and sudden cardiac death: epidemiology, mechanisms, and therapeutic approaches. J Am Soc Nephrol. 2012;23:1929–39. doi: 10.1681/ASN.2012010037.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Goldenberg I, Moss AJ, McNitt S, Zareba W, Andrews ML, Hall WJ, et al., Multicenter Automatic Defibrillator Implantation Trial-II Investigators. Relations among renal function, risk of sudden cardiac death, and benefit of the implanted cardiac defibrillator in patients with ischemic left ventricular dysfunction. Am J Cardiol. 2006;98:485–90. doi: 10.1016/j.amjcard.2006.03.025.CrossRefPubMedGoogle Scholar
  17. 17.
    Pun PH, Al-Khatib SM, Han JY, Edwards R, Bardy GH, Bigger JT, et al. Implantable cardioverter defibrillators for primary prevention of sudden cardiac death in CKD: a meta-analysis of patient-level data from 3 randomized trials. Am J Kid Dis. 2014;64:32–9. doi: 10.1053/j.ajkd.2013.12.009.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Charytan DM, Patrick AR, Liu J, Setoguchi S, Herzog CA, Brookhart MA, et al. Trends in the use and outcomes of implantable cardioverter-defibrillators in patients undergoing dialysis in the United States. Am J Kidney Dis. 2011;58:409–17. doi: 10.1053/j.ajkd.2011.03.026.CrossRefPubMedGoogle Scholar
  19. 19.
    Herzog CA, Li S, Weinhandl ED, Strief JW, Collins AJ, Gilbertson DT. Survival of dialysis patients after cardiac arrest and the impact of implantable cardioverter defibrillators. Kidney Int. 2005;68:818–25. doi: 10.1111/j.1523-1755.2005.00462.x.CrossRefPubMedGoogle Scholar
  20. 20.
    • Nakhoul GN, Schold JD, Arrigain S, Harb SC, Jolly S, Wilkoff BL, et al. Implantable cardioverter-defibrillators in patients with CKD: a propensity-matched mortality analysis. Clin J Am Soc Nephrol. 2015;10:1119–27. doi: 10.2215/CJN.11121114. This study reported on the outcomes of ICDs in patients with chronic kidney disease; it showed that ICDs are associated with survival benefit in patients with stage 3 chronic kidney disease but not in patients with stage 4 chronic kidney disease CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Aggarwal A, Wang Y, Rumsfeld JS, Curtis JP, Heidenreich PA, National Cardiovascular Data Registry. Clinical characteristics and in-hospital outcome of patients with end-stage renal disease on dialysis referred for implantable cardioverter-defibrillator implantation. Heart Rhythm. 2009;6:1565–71. doi: 10.1016/j.hrthm.2009.08.006.CrossRefPubMedGoogle Scholar
  22. 22.
    • Hess PL, Hellkamp AS, Peterson ED, Sanders GD, Al-Khalidi HR, Curtis LH, et al. Survival after primary prevention implantable cardioverter-defibrillator placement among patients with chronic kidney disease. Circ: Arrhythm Electrophysiol. 2014;7:793–9. doi: 10.1161/CIRCEP.114.001455. This study examined the risk of 1-year death after ICD placement among 21,226 patients with chronic kidney disease and 26,056 patients with no chronic kidney disease. It found that the risk of death after primary prevention ICD placement was proportional to the severity of chronic kidney disease. This study also identified factors associated with increased risk of death that could inform clinical decision making Google Scholar
  23. 23.
    •• Pun PH, Hellkamp AS, Sanders GD, Middleton JP, Hammill SC, Al-Khalidi H, et al. Primary prevention implantable cardioverter defibrillators in end stage kidney disease patients on dialysis: a matched cohort study. Nephrology Dialysis Transplantation. 2015;30:829–35. doi: 10.1093/ndt/gfu274. This is the only published comparative effectiveness analysis of primary prevention ICDs in patients with ESRD. It showed no survival benefit associated with ICDs. Although the sample size of 108 ESRD patients was relatively small, this study highlighted the importance of conducting similar studies in larger groups of ESRD patients CrossRefGoogle Scholar
  24. 24.
    Hickson LJ, Gooden JY, Le KY, Baddour LM, Friedman PA, Hayes DL, et al. Clinical presentation and outcomes of cardiovascular implantable electronic device infections in hemodialysis patients. Am J Kidney Dis. 2014;64(1):104–10. doi: 10.1053/j.ajkd.2013.11.018.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Drew DA, Meyer KB, Weiner DE. Transvenous cardiac device wires and vascular access in hemodialysis patients. Am J Kidney Dis. 2011;58(3):494–6. doi: 10.1053/j.ajkd.2011.05.005.CrossRefPubMedGoogle Scholar
  26. 26.
    Teruya TH, Abou-Zamzam AM Jr, Limm W, Wong L, Wong L. Symptomatic subclavian vein stenosis and occlusion in hemodialysis patients with transvenous pacemakers. Ann Vasc Surg. 2003;17(5):526–9. doi: 10.1007/s10016-003-0048-4.CrossRefPubMedGoogle Scholar
  27. 27.
    El-Chami MF, Levy M, Kelli HM, Casey M, Hoskins MH, Goyal A, et al. Outcome of subcutaneous implantable cardioverter defibrillator implantation in patients with end-stage renal disease on dialysis. J Cardiovasc Electrophysiol. 2015;26:900–4. doi: 10.1111/jce.12705.CrossRefPubMedGoogle Scholar
  28. 28.
    Koman E, Gupta A, Subzposh F, Saltzman H, Kutalek SP. Outcomes of subcutaneous implantable cardioverter-defibrillator implantation in patients on hemodialysis. J Interv Card Electrophysiol. 2016;45:219–23. doi: 10.1007/s10840-015-0093-2.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Sana M. Al-Khatib
    • 1
    • 2
    Email author
  • Daniel J. Friedman
    • 1
    • 2
  • Paul L. Hess
    • 3
  • Patrick H. Pun
    • 4
  • Gillian D. Sanders
    • 5
  1. 1.Division of Cardiology and Duke Clinical Research InstituteDuke University Medical CenterDurhamUSA
  2. 2.Duke Clinical Research InstituteDurhamUSA
  3. 3.Cardiology Section, Veterans Affairs Eastern Colorado Health Care System and Department of MedicineUniversity of Colorado Anschutz Medical CampusAuroraUSA
  4. 4.Division of Nephrology and Duke Clinical Research InstituteDuke University Medical CenterDurhamUSA
  5. 5.Clinical Pharmacology and Duke Clinical Research InstituteDuke University Medical CenterDurhamUSA

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