Arrhythmia and Sudden Death in Hemodialysis Patients

Abstract

Background Dialysis patients have high rates of cardiovascular morbidity and mortality, but data on arrhythmia burden, arrhythmia type, arrhythmia triggers, and the identity of terminal arrhythmias have historically been limited by an inability to monitor heart rhythm for prolonged periods.Objectives To investigate arrhythmia and its association with sudden death in dialysis-dependent ESRD, describe the potential for implantable devices to advance study of dialysis physiology, review the ethical implications of using implantable devices in clinical studies, and report on the protocol and baseline results of the Monitoring in Dialysis Study (MiD).Design, setting, participants, & measurements In this multicenter, interventional-observational, prospective cohort study, we placed implantable loop recorders in patients undergoing long-term hemodialysis. The proportion of patients experiencing clinically significant arrhythmias was the primary endpoint. For 6 months, we captured detailed data on the primary endpoint, symptomatic arrhythmias, other electrocardiographic variables, dialysis prescription, electrolytes, dialysis-related variables, and vital signs. We collected additional electrocardiographic data for up to 1 year.Results Overall, 66 patients underwent implantation in sites in the United States and India. Diabetes was present in 63.6% of patients, 12.1% were age $70 years, 69.7% were men, and 53.0% were black. Primary and secondary endpoint data are expected in 2016.Conclusions Cardiac arrhythmia is an important contributor to cardiovascular morbidity and mortality in dialysis patients, but available technology has previously limited the ability to estimate its true burden and triggers and to define terminal rhythms in sudden death. Use of implantable technology in observational studies raises complex issues but may greatly expand understanding of dialysis physiology. The use of implantable loop recorders in MiD is among the first examples of such a trial, and the results are expected to provide novel insights into the nature of arrhythmia in hemodialysis patients.

Electrocardiographic predictors of mortality and sudden cardiac death in patients with end stage renal disease on hemodialysis

“…Further study of the relative contribution of bradyarrhythmias/heart block, ventricular tachyarrhythmias, and non-arrhythmic events to SCD in the hemodialysis population is also critical to improve SCD risk stratification and reduce SCD incidence [48]. Small studies utilizing implantable loop recorders have demonstrated that severe bradyarrhythmias might be the mechanism of SCD in many hemodialysis patients [49], and the proportion of SCD events without any associated arrhythmia is currently unknown.…”

Sudden Cardiac Death Among Hemodialysis Patients

“…45 To help address this knowledge gap, the Monitoring in Dialysis study also used implantable loop recorders to provide information collected over six months on the type and frequency of arrhythmias. 52 The final study reports are pending, but unpublished data on the first 66 patients enrolled in the study have suggested a large number of captured arrhythmic episodes predominantly due to atrial arrhythmias (57.4%) followed by bradycardia (15%), with most events occurring in the post-dialytic period. Ventricular arrhythmias comprised 9.1% of captured events.…”

Prevalence and associated factors of undiagnosed atrial fibrillation among end-stage renal disease patients on maintenance haemodialysis: a cross-sectional study

“…Also, the incidence of AF increases after dialysis due to increase in cardiac dimensions [12][13][14]. Although arrhythmias developed during haemodialysis are mostly brief, asymptomatic, and self-limiting, they have been independently associated with higher mortality and cardiovascular events [15,16]. The incidence of AF in patients with ESRD on dialysis varies between 6.6 to 20% and is 2 to 3 times higher than in the general population [17][18][19][20].…”