Sudden Cardiac Death in Dialysis Patients

Different Causes and Management Strategies

Simonetta Genovesi; Giuseppe Boriani; Adrian Covic; Robin W.M. Vernooij; Christian Combe; Alexandru Burlacu; Andrew Davenport; Mehmet Kanbay; Dimitrios Kirmizis; Daniel Schneditz; Frank van der Sande; Carlo Basile

Disclosures

Nephrol Dial Transplant. 2021;36(3):396-405. 

In This Article

Abstract and Introduction

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.

Introduction

Sudden cardiac death (SCD) is defined as an unexpected death due to cardiac causes in a person with known or unknown cardiac disease, within 1 h of symptom onset (witnessed SCD) or within 24 h of the last proof of life (unwitnessed SCD). Since cause of death is subject to interobserver variability, there can be misclassification of SCD.[1]

SCD is a leading cause of death among the general population, accounting for up to 15% of all deaths.[2] SCD represents an important cause of death in end-stage kidney disease (ESKD) patients,[3] but 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. However, extradialysis SCD and intradialysis SCA represent different clinical situations and should be kept distinct. In fact, the dialysis session may itself favour the onset of life-threatening arrhythmias, beyond the clinical conditions of the patient. Moreover, hypotension and syncope are quite common during HD sessions and highlight a series of risk factors.[4,5] Their occurrence requires immediate interventions of healthcare professionals for a prompt diagnosis and for differentiating these events from SCA. The aim of the European Dialysis (EUDIAL) Working Group 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.

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