A Systematic Review of the Incidence of Arrhythmias in Hemodialysis Patients Undergoing Long-Term Monitoring With Implantable Loop Recorders

Abstract

Introduction: Establishing the frequency and nature of arrhythmias in hemodialysis (HD) is an important step in improving outcomes of these patients. We undertook this systematic review and meta-analysis to characterize arrhythmia frequency in maintenance HD patients. Methods:We identified studies on arrhythmias in adult patients on maintenance HD detected via implantable loop recorders (ILRs). Studies included were in English and reported ILR-detected arrhythmia incidence in HD patients. Data were extracted by one author using electronic spreadsheets and verified by a second author. Random effects models were used for pooled inferences. The I 2 statistic was used to quantify heterogeneity.Results: Five studies qualified for inclusion (317 patients). The overall estimates for the annualized rate of death and sudden cardiac death (SCD) was 0.14 (95% confidence interval [CI]: 0.11-0.18) and 0.06 (95% CI: 0.03-0.10), respectively. Across all 5 studies, the combined annualized rate of patients experiencing at least 1 bradycardia/asystole event was 0.19 (95% CI: 0.11-0.33) but heterogeneity was high (I 2 ¼ 79.8%). The average annualized rate of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) episodes (0.02, 95% CI: 0.01-0.05) was significantly lower (P < 0.001) than the rate of bradycardia/asystole reported in the same patients. Incidence of atrial fibrillation (AF) varied significantly across the studies (from 0.07 to 0.83 patients per year) reflecting variable definitions (new-onset vs. total number of episodes). Conclusion:The incidence of arrhythmias among chronic HD patients is high, with bradycardia/asystole occurring more frequently than ventricular arrhythmias. Additional studies to refine estimates particularly of AF are needed.

Association of Bradycardia and Asystole Episodes with Dialytic Parameters: An Analysis of the Monitoring in Dialysis (MiD) Study

“…The overall incidence of bradyarrhythmia and asystole was slightly higher in our study than in several other studies using implantable loop recorders in patients on dialysis. 26 The higher incidence rate may have increased our power to detect associations, but suggests that our results should be generalized cautiously, although the sample size of all studies was small with wide confidence interval around the estimates. Our analysis of associations of CSBA with volume status and electrolytes purposely focused on the final 12 hours of prior to each dialysis treatment because we were able to impute the likely value of those parameters during this interval during which the rate of CSBA peaked.…”

“…3,4 Of note, defects in conduction including bradycardia and asystole as opposed to ventricular tachycardia or fibrillation appear to be the predominant arrhythmias underlying hemodialysis-associated sudden cardiac death. [5][6][7][8][9] However, the triggers underlying bradyarrhythmia in the hemodialysis population remain incompletely understood, and analysis of data collected around these events could help in identifying and modifying dialysis practices that may prevent the risk of sudden cardiac death. 2,10 We used data from the Monitoring in Dialysis Study (MiD) 5 to analyze highly granular electrolyte, dialysis, and arrhythmia data from loop recorder monitoring to test for associations of potentially modifiable, pre-dialytic parameters with CSA bradycardic and asystole episodes (CSBA).…”

Cardiac Implantable Electronic Devices in Hemodialysis and Chronic Kidney Disease Patients—An Experience-Based Narrative Review

“…These results could be related to the nature of arrhythmias observed in chronic HD patients. In published data on long-term monitoring of HD patients with implantable loop recorders, the prevalence of bradycar-dia/asystole events as a potential underlying cause of SCD exceeded the frequency of malignant ventricular arrhythmias [20]. Moreover, patients with ESKD receiving ICDs have a significantly increased risk of developing procedure-related complications [21].…”

Types of Arrhythmias and the risk of sudden cardiac death in dialysis patients: A Systematic Review and Meta-analysis

“…[2] Cardiovascular disease is the leading cause of death, and 40% of deaths due to a known cause are attributable to sudden cardiovascular death and arrhythmia. [3] Sudden cardiac death (SCD) is defined as an unexpected death from cardiac causes in a person with a known or undiagnosed cardiac condition that occurs within one hour of the onset of symptoms (witnessed SCD) or within twenty-four hours of the last sign of life (unwitnessed SCD). [4] Sudden cardiac death is the primary cause of death, accounting for up to 15% of all deaths in the general population.…”