Narrative Review
Sudden Cardiac Death in Hemodialysis Patients: An In-Depth Review

https://doi.org/10.1053/j.ajkd.2011.02.376Get rights and content

Sudden cardiac death (SCD) is the leading cause of death in hemodialysis patients, accounting for death in up to one-quarter of this population. Unlike in the general population, coronary artery disease and heart failure often are not the underlying pathologic processes for SCD; accordingly, current risk stratification tools are inadequate when assessing these patients. Factors assuming greater importance in hemodialysis patients may include left ventricular hypertrophy, electrolyte shift, and vascular calcification. Knowledge regarding SCD in hemodialysis patients is insufficient, in part reflecting the lack of an agreed-on definition of SCD in this population, although epidemiologic studies suggest the most common times for SCD to occur are toward the end of the long 72-hour weekend interval between dialysis sessions and in the 12 hours immediately after hemodialysis. Accordingly, it is hypothesized that the dialysis procedure itself may have important implications for SCD. Supporting this is recognition that hemodialysis is associated with both ventricular arrhythmias and dynamic electrocardiographic changes. Importantly, echocardiography and electrocardiography may show changes that are modifiable by alterations to dialysis prescription. The most effective preventative strategy in the general population, implanted cardioverter-defibrillator devices, are less effective in the presence of chronic kidney disease and have not been studied adequately in dialysis patients. Last, many dialysis patients experience SCD despite not fulfilling current criteria for implantation, making appropriate allocation of defibrillators uncertain.

Section snippets

Epidemiology and Definition of SCD in Dialysis Patients

SCD is the unexpected natural death from a cardiac cause within 1 hour of onset of symptoms in a person not known to have a potentially fatal condition.3 In the general population, this occurs at a rate of ∼1 death/1,000 patient-years and accounts for 6%-13% of all deaths.4, 5 US Renal Data System (USRDS) reports include deaths from confirmed arrhythmia and deaths from cardiac arrest of unknown cause, but without specifying time frame or whether the death is of cardiac origin. These SCDs

Comparative Pathologic Processes of SCD in CKD Patients and the General Population

In the general population, up to 80% of SCD cases will have post mortem evidence of abnormal coronary vessels,10, 11 and those at highest risk of SCD are patients with heart failure. However, these pathologic processes do not appear to be as important in SCD events in dialysis patients. This section compares the underlying disease processes in SCD between dialysis patients and the general population.

Dialysis as a Risk Factor for SCD

With the exception of CKD itself, all previously described pathologic factors shown to predict SCD in dialysis patients are associated with SCD in the general population. Hence, it may be that the high SCD risk associated with dialysis reflects the relative prevalence of these factors rather than dialysis-specific SCD. However, there is evidence that the process of dialysis itself incurs an additional major risk, and this is discussed in the following section.

Hemodialysis patients die of

ICD Devices in Dialysis Patients

The most effective therapy for SCD in the general population is the use of ICD devices. This section discusses their use in dialysis patients. The current international guidelines for ICD implantation are listed in Box 2. A meta-analysis of 6 cohort studies65, 66, 67, 68, 69, 70, 71, 72 assessed the outcome of ICD therapy in patients with CKD according to conventional guidelines. This compared mortality between patients with and without ESRD. Dialysis patients had 2.7-fold higher mortality.25

Conclusion

Risk factors for sudden death in the general population also apply to people on dialysis therapy; however, the relative frequencies of these factors differ between the 2 groups. Furthermore, comparisons between dialysis patients and the general population are hindered by differences in definitions of SCD used. Even comparisons of studies of sudden death within nephrology are limited by the lack of a common term when classifying a death as sudden or unexpected.

CAD and heart failure, pre-eminent

Acknowledgements

Support: None.

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

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    Originally published online April 18, 2011.

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