Arrhythmias and Sudden Cardiac Death in End Stage Renal Disease: Epidemiology, Risk Factors, and Management

Patients with end-stage renal disease (ESRD) are predisposed to heart rhythm disorders resulting in significant morbidity and mortality. Bradyarrhythmia appears to be more prevalent than ventricular tachyarrhythmias. There is also a high incidence of sudden cardiac death (SCD) in this group of patients, which cannot be explained only by traditional cardiac risk factors. The reported incidence and prevalence of arrhythmias and SCD is quite variable mainly because of the different study populations and recording techniques. The mechanism of SCD in patients with ESRD is also not clear. Although traditionally the thinking has been that ventricular arrhythmias are the main contributor to SCD, recent studies with implantable loop recorders have highlighted the role of bradyarrhythmias. The pathophysiological processes resulting in arrhythmia and SCD in patients with ESRD are unique. Some of the risk factors, including dialysate composition, timing, and frequency, are modifiable and hence provide an option for interventions to potentially reduce SCD. In addition, there might be a relationship with the timing of dialysis with SCD tending to occur during the long interdialytic period. Patients with ESRD have a higher likelihood of requiring pacemaker implantation; however, they also have a higher risk of device-related complications. The limited data available regarding the role of the implantable cardioverter defibrillator to prevent SCD in patients with ESRD have shown conflicting results. Future research is needed to develop appropriate risk stratification tools to identify patients who will benefit from such interventions and to assess their safety and efficacy.