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Review
. 2017 May;69(5):684-695.
doi: 10.1053/j.ajkd.2016.12.006. Epub 2017 Feb 17.

Sudden Cardiac Death Among Hemodialysis Patients

Melissa S Makar  1 , Patrick H Pun  2
Affiliations
Review

Sudden Cardiac Death Among Hemodialysis Patients

Melissa S Makar et al. Am J Kidney Dis. 2017 May.

Abstract

Hemodialysis patients carry a large burden of cardiovascular disease; most onerous is the high risk for sudden cardiac death. Defining sudden cardiac death among hemodialysis patients and understanding its pathogenesis are challenging, but inferences from the existing literature reveal differences between sudden cardiac death among hemodialysis patients and the general population. Vascular calcifications and left ventricular hypertrophy may play a role in the pathophysiology of sudden cardiac death, whereas traditional cardiovascular risk factors seem to have a more muted effect. Arrhythmic triggers also differ in this group as compared to the general population, with some arising uniquely from the hemodialysis procedure. Combined, these factors may alter the types of terminal arrhythmias that lead to sudden cardiac death among hemodialysis patients, having important implications for prevention strategies. This review highlights current knowledge on the epidemiology, pathophysiology, and risk factors for sudden cardiac death among hemodialysis patients. We then examine strategies for prevention, including the use of specific cardiac medications and device-based therapies such as implantable defibrillators. We also discuss dialysis-specific prevention strategies, including minimizing exposure to low potassium and calcium dialysate concentrations, extending dialysis treatment times or adding sessions to avoid rapid ultrafiltration, and lowering dialysate temperature.

Keywords: Sudden cardiac death (SCD); arrhythmia; dialysis; end-stage kidney disease; end-stage renal disease (ESRD); hemodialysis; pathogenesis; pathophysiology; prevention; prevention strategies; review; risk factors; sudden death.

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Conflict of interest statement

Financial Disclosure: The authors declare that they have no relevant financial interests.

Figures

Figure 1
Figure 1
Cause of death among dialysis patients 2011–2013. Adapted from the United States Renal Data System, 2015 Annual Data Report, Figure 9.1b. Other cardiovascular causes include acute myocardial infarction, atherosclerotic heart disease, congestive heart failure, cerebrovascular accident, and other cardiac events.
Figure 2
Figure 2
Rates of SCD in selected populations (left) and absolute numbers of affected individuals (right). CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; CKD, chronic kidney disease; ND, non-dialysis.,
Figure 3
Figure 3
Mortality among hemodialysis patients with and without ICDs (matched cohorts). Log-rank P = 0.71; HR = 0.94 (95% CI: 0.67, 1.31). Abbreviations: CI, confidence interval; HR, hazard ratio; ICD, implantable cardioverter defibrillator. Reprinted from Pun et al with permission of Oxford University Press.
Figure 4
Figure 4
Major hypothesized risk factors for sudden cardiac death including postulated pathophysiology of sudden cardiac death, data source Di Lullo et al
See this image and copyright information in PMC

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