Modifiable risk factors associated with sudden cardiac arrest within hemodialysis clinics

Abstract

Sudden cardiac arrest is the most common cause of death among patients with end-stage kidney disease (ESKD) maintained on hemodialysis. Here we sought to identify dialysis-related factors associated with this increased risk in a case-control study encompassing 43,200 patients dialyzed in outpatient clinics of a large organization. Within this group, we compared the clinical and dialysis-specific data of 502 patients who experienced a sudden cardiac arrest with 1632 age- and dialysis-vintage-matched controls. There were 4.5 sudden cardiac arrest events per 100,000 dialysis treatments during the 3-year study period. These patients were significantly more likely to have been exposed to low potassium dialysate of less than 2 meq/l. These differences could not be explained by predialysis serum potassium levels. There was no evidence for a beneficial effect of low potassium dialysate even among those with higher predialysis serum potassium levels. Other factors strongly associated with sudden cardiac arrest by multivariable analysis included increased ultrafiltration volumes, exposure to low calcium dialysate, and predialysis serum creatinine levels. These relationships persisted after adjustment for covariates, but traditional risk factors such as history of coronary heart disease and congestive heart failure were not significantly influential. Hence, our study suggests that modifications of the hemodialysis prescription may improve the risk of sudden cardiac arrest in patients with ESKD.

Predictors of Sudden Cardiac Death

“…We used only baseline variables to determine the association with SCD and did not include changes in clinical measures over time. Thus, we were unable to adjust for dialysis-related factors (i.e., dialysate potassium concentration) more proximate to the time of death (41). We acknowledge that because HD patients are a "captive audience" who are seen three times a week, classification of SCD may differ from definitions in the general population.…”

Near-Term Prediction of Sudden Cardiac Death in Older Hemodialysis Patients Using Electronic Health Records

“…Cardiac disease accounts for 43% of all-cause mortality, with approximately 61% of those deaths caused by sudden cardiac arrest (SCA) (1). Significant work has been undertaken to understand the epidemiology of and identify risk factors for SCA (2)(3)(4)(5)(6)(7)(8)(9)(10). Many of the risk factors identified, including lower ultrafilitration volume, low calcium dialysate, and shorter treatment time, are readily captured by electronic health record (EHR) systems.…”

Impact of Abnormal Serum Electrolyte Levels and Acid-Base Disorders on Clinical Outcomes among Maintenance Hemodialysis Patients

“…In a historical cohort of chronic HD patients, Genovesi et al showed pre-dialysis hyperkalemia to be associated with a 2.7 (CI 95% 1.3 -5.8)-fold increase in the risk of sudden death [29]. Also, an increasing risk of sudden cardiac arrest among patients with pre-dialysis serum potassium levels above 5.0 mmol/L was observed but no advantage of using low potassium dialysate (<2 mmol/L) was found at any level of serum potassium in a study by Pun et al [27]. However, hypokalemia is also V. Guttee et al…”

“…Pre-dialysis hyper-and hypokalemia have been found to be associated with a higher risk of electrocardiogram abnormalities and cardiac death [25] [26] [27] [28]. In a large cohort of MHD patients, Kovesdy et al found the association of pre-dialysis hyperkalemia with all-cause and cardiovascular mortality after detailed adjustments for potential confounding variables [16].…”