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Sudden cardiac death in dialysis patients: different causes and management strategies
Simonetta Genovesi1,2, Giuseppe Boriani3, Adrian Covic4,5
1School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
Insights
Sudden cardiac death (SCD) in end-stage kidney disease (ESKD) is complex, differing from general populations. Management strategies for both intradialysis and extradialysis events are crucial for reducing mortality in these patients.
Area of Science:
- Nephrology
- Cardiology
- Public Health
Background:
- Sudden cardiac death (SCD) is a leading cause of mortality in end-stage kidney disease (ESKD).
- Distinguishing between intradialysis sudden cardiac arrest (SCA) and extradialysis SCD is critical for accurate incidence estimation and management.
- Existing literature often combines these distinct events, complicating analysis.
Purpose of the Study:
- To critically review the literature on causes of extradialysis SCD and intradialysis SCA in ESKD patients.
- To explore potential management strategies for reducing the incidence of these events.
- To differentiate the clinical characteristics and risk factors for intradialysis SCA versus extradialysis SCD.
Main Methods:
- Systematic literature review of studies on SCD and SCA in ESKD patients.
- Critical analysis of identified risk factors and management strategies.
- Comparison of characteristics of SCD in ESKD versus non-ESKD populations.
Main Results:
- Intradialysis SCA has identifiable modifiable risk factors (e.g., dialysate potassium/calcium levels) and benefits from automated external defibrillators.
- Extradialysis SCD in ESKD is complex, with reduced ejection fraction in a minority of cases.
- Fatal arrhythmias in ESKD may stem more from bradyarrhythmias than tachyarrhythmias, potentially explaining limited benefit from implantable cardioverter-defibrillators.
- Electrolyte imbalances and timing of dialysis sessions are linked to SCD, while peritoneal dialysis patients also face high SCD rates, suggesting broader comorbidity and uremia contributions.
Conclusions:
- Intradialysis SCA and extradialysis SCD are distinct clinical entities requiring separate consideration.
- Management of intradialysis SCA can be improved through addressing modifiable factors and utilizing defibrillators.
- Extradialysis SCD in ESKD has unique characteristics, possibly related to bradyarrhythmias and electrolyte disturbances, necessitating further research into effective prevention strategies beyond traditional heart failure management.
- Cardiac comorbidities and uremia itself are significant contributors to sudden mortality in ESKD patients.
Abstract:
Sudden cardiac death (SCD) represents a major cause of death in end-stage kidney disease (ESKD). The precise estimate of its incidence is difficult to establish because studies on the incidence of SCD in ESKD are often combined with those related to sudden cardiac arrest (SCA) occurring during a haemodialysis (HD) session. The aim of the European Dialysis Working Group of ERA-EDTA was to critically review the current literature examining the causes of extradialysis SCD and intradialysis SCA in ESKD patients and potential management strategies to reduce the incidence of such events. Extradialysis SCD and intradialysis SCA represent different clinical situations and should be kept distinct. Regarding the problem, numerically less relevant, of patients affected by intradialysis SCA, some modifiable risk factors have been identified, such as a low concentration of potassium and calcium in the dialysate, and some advantages linked to the presence of automated external defibrillators in dialysis units have been documented. The problem of extra-dialysis SCD is more complex. A reduced left ventricular ejection fraction associated with SCD is present only in a minority of cases occurring in HD patients. This is the proof that SCD occurring in ESKD has different characteristics compared with SCD occurring in patients with ischaemic heart disease and/or heart failure and not affected by ESKD. Recent evidence suggests that the fatal arrhythmia in this population may be due more frequently to bradyarrhythmias than to tachyarrhythmias. This fact may partly explain why several studies could not demonstrate an advantage of implantable cardioverter defibrillators in preventing SCD in ESKD patients. Electrolyte imbalances, frequently present in HD patients, could explain part of the arrhythmic phenomena, as suggested by the relationship between SCD and timing of the HD session. However, the high incidence of SCD in patients on peritoneal dialysis suggests that other risk factors due to cardiac comorbidities and uraemia per se may contribute to sudden mortality in ESKD patients.
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