Association of Dialysate Bicarbonate with Arrhythmia in the Monitoring in Dialysis Study

Sudden death accounts for approximately 25% of deaths among maintenance hemodialysis patients, occurring more frequently on hemodialysis days. Higher dialysate bicarbonate (DBIC) may predispose to alkalemia and arrhythmogenesis.

We conducted a 12-month analysis of session-level data from 66 patients with implantable loop recorders. We fit logistic regression and negative binomial mixed-effects regression models to assess the association of DBIC with clinically significant arrhythmia (ventricular tachycardia ≥115 beats per minute [BPM] for at least 30 seconds, bradycardia ≤40 BPM for at least 6 seconds, or asystole for at least 3 seconds) and reviewer confirmed arrhythmia (RCA—implantable loop recorder-identified or patient-marked event for which a manual review of the stored electrocardiogram tracing confirmed the presence of atrial fibrillation, supraventricular tachycardia, sinus tachycardia with rate >130 BPM, ventricular tachycardia, asystole, or bradycardia). Models adjusted for age, sex, race, hemodialysis vintage, vascular access, and prehemodialysis serum bicarbonate and additionally for serum and dialysate potassium levels.

The mean age was 56±12 years, 70% were male, 53% were Black, and 35% were Asian. Fewer RCA episodes were associated with DBIC >35 than 35 mEq/L (incidence rate ratio 0.45 [0.27 to 0.75] and adjusted incident rate ratio 0.54 [0.30 to 0.97]), but the association was not significant when adjusting for serum and dialysate potassium levels (adjusted incident rate ratio, 0.60 [0.32 to 1.11]). Otherwise, no associations between DBIC and arrhythmia were identified.

We observed a lower frequency of RCA with higher DBIC, compared with DBIC of 35 mEql/L, contrary to our original hypothesis, but this association was attenuated in fully adjusted models. Validation of these findings in larger studies is required, with a further need for interventional studies to explore the optimal DBIC concentration.