Dialysate content and risk of sudden cardiac death

Thornley‐Brown, Denyse; Saha, Manish

doi:10.1097/mnh.0000000000000177

Cited by 10 publications

(19 citation statements)

References 31 publications

(34 reference statements)

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“…6,14–18 The potential hazards of very low (< 2 mEq/L) DK are triggered by a larger removal of potassium during HD causing intradialytic and post-dialysis hypokalemia, and often a rapid rebound of potassium levels post-dialysis, contributing to cardiac instability. 30 In our primary analysis comparing more common DK prescriptions, we found a similar risk of adverse events; any differences were modest and unlikely to be clinically important.…”

Section: Discussionmentioning

confidence: 99%

“…11,12 While no recommendation on DK levels has been provided in the Kidney Disease Outcomes Quality Initiative (KDOQI) cardiovascular disease guidelines, 13 several recent reviews are in agreement that DK < 2 mEq/L should be avoided, particularly in patients with high pre-dialysis potassium, to avoid a rapid decrease in plasma potassium. 6,14–18 Accordingly, anecdotal reports indicate that the use of DK < 2 mEq/L has become increasingly rare. This prompted us to investigate whether DK = 2 mEq/L was still too low, in comparison to a higher DK of 3 mEq/L.…”

Section: Introductionmentioning

confidence: 99%

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Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Karaboyas

Zee

Brunelli

et al. 2017

American Journal of Kidney Diseases

142

158

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Background Sudden death is a leading cause of death in patients on maintenance hemodialysis (HD). During HD sessions, the gradient between serum and dialysate levels results in rapid electrolytes shifts, which may contribute to arrhythmias and sudden death. Controversies exist on the optimal electrolyte concentration in the dialysate; specifically, it is unclear whether patient outcomes differ among those treated with dialysate potassium (DK) concentration of 3 mEq/L compared to 2 mEq/L. Study Design Prospective cohort study Setting & Participants 55,183 patients from 20 countries in the Dialysis Outcomes and Practice Patterns Study phases 1–5 (1996–2015). Predictor DK at study entry. Outcomes Cox regression was used to estimate the association between DK and both all-cause mortality and an arrhythmia composite outcome (arrhythmia-related hospitalization or sudden death), adjusting for potential confounders. Results During a median follow-up of 16.5 months, 24% of patients died and 7% had an arrhythmia composite outcome. No meaningful difference in clinical outcomes were observed for patients treated with DK 3 vs. 2 mEq/L; the adjusted hazard ratio (95% CI) was 0.96 (0.91, 1.01) for mortality and 0.98 (0.88, 1.08) for the arrhythmia composite. Results were similar across pre-dialysis serum potassium (SK) levels. As in prior studies, higher SK was associated with adverse outcomes. However, DK only had minimal impact on SK measured pre-dialysis (+0.09 mEq/L SK per 1 mEq/L DK; 95% CI: 0.05, 0.14). Limitations Data were not available on delivered (vs. prescribed) DK and post-dialysis SK; possible unmeasured confounding. Conclusions In combination, these results suggest that approaches other than altering DK concentration (e.g., education on dietary K sources, prescription of K-binding medications) may merit further attention to reduce risks associated with high SK.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Karaboyas

Zee

Brunelli

et al. 2017

American Journal of Kidney Diseases

142

158

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“…Dialysate composition may play an important role in all-cause mortality and sudden cardiac death as well [18][19][20]. Several studies have shown that a lower D-Ca may increase the chance of sudden cardiac death, whereas a higher D-Ca may cause positive Ca balance leading to vascular calcification.…”

Section: Discussionmentioning

confidence: 99%

Dialysate Calcium Concentration below 3.0 mEq/L Is Not Associated with Improved Outcomes in the Japanese Dialysis Outcomes and Practice Patterns Study

Iseki

Henn

Nomura

et al. 2018

Nephron

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Background: Abnormal chronic kidney disease-mineral and bone disorder (CKD-MBD) markers have been associated with adverse outcomes in hemodialysis (HD) patients. Dialysate calcium concentration (D-Ca) likely influences serum calcium and phosphorus levels. Optimal D-Ca level remains unclear. We hypothesized that higher D-Ca is associated with cardiovascular events and mortality among Japanese HD patients. Methods: Enrollment data of chronic HD patients in the prospective observational study JDOPPS, phases 1–5 (1999–2015), provided exposures and covariates. All-cause mortality, non-arrhythmic cardiovascular events (NonAR-CVE), or their composites were analyzed by D-Ca, and divided into 2.5, 2.75, and 3.0 mEq/L. To minimize confounding by indication, analyses were restricted to facilities in which at least 90% of patients received the same D-Ca prescription. Association of D-Ca level with outcomes was evaluated in Cox models stratified by phase and accounting for facility clustering. Covariates describing patient demographics, comorbidities, laboratory values, CKD-MBD therapy, and facility attributes provided adjustment. Results: Of 9,201 patients included, 25.0% had D-Ca of 2.5 mEq/L; 6.8% D-Ca 2.75; and 68.2% D-Ca 3.0. Median follow-up time was 2.03 years. D-Ca was not associated with all-cause mortality, with hazards ratios for 2.5 vs. 3.0 mEq/L of 0.90 and 95% CI (0.73–1.11), nor with other outcomes. One effect modification occurred, protective for lower D-Ca on NonAR-CVE in the absence of cardiovascular comorbidities (p = 0.032), although corresponding D-Ca effects were not significant after multiple comparisons adjustment (p = 0.261 [D-Ca 2.5] and 0.125 [D-Ca 2.75]). Conclusion: Lowering D-Ca level below 3.0 mEq/L seems not to have a meaningful effect on patient outcomes.

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“…HD treatment aims to correct metabolic acidosis via bicarbonate concentration of the dialysate [ 123 ], ultrafiltration rate [ 124 ], dialyzer membrane surface area and permeability [ 125 ], blood and dialysis flow rate [ 124 ], transmembrane concentration gradient set by the patient’s serum bicarbonate level and bicarbonate availability from the dialysate [ 125 ], and dialysis adequacy [ 122 , 123 ] through maintaining the pre-dialysis serum bicarbonate levels between 24 and 26 mmol/L as recommended by current opinion [ 126 ]. However, metabolic acidosis correction depends on patient-related determinants such as interdialytic weight gain [ 123 ], acid generation from high protein intake [ 122 , 127 ], or gastrointestinal losses of bicarbonate [ 122 , 125 ]. Individual fluctuation in patients’ bicarbonate levels challenges optimum management [ 122 ].…”

Section: Iatrogenic Factors Of Malnutritionmentioning

confidence: 99%

Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review

et al. 2020

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Hemodialysis (HD) majorly represents the global treatment option for patients with chronic kidney disease stage 5, and, despite advances in dialysis technology, these patients face a high risk of morbidity and mortality from malnutrition. We aimed to provide a novel view that malnutrition susceptibility in the global HD community is either or both of iatrogenic and of non-iatrogenic origins. This categorization of malnutrition origin clearly describes the role of each factor in contributing to malnutrition. Low dialysis adequacy resulting in uremia and metabolic acidosis and dialysis membranes and techniques, which incur greater amino-acid losses, are identified modifiable iatrogenic factors of malnutrition. Dietary inadequacy as per suboptimal energy and protein intakes due to poor appetite status, low diet quality, high diet monotony index, and/or psychosocial and financial barriers are modifiable non-iatrogenic factors implicated in malnutrition in these patients. These factors should be included in a comprehensive nutritional assessment for malnutrition risk. Leveraging the point of origin of malnutrition in dialysis patients is crucial for healthcare practitioners to enable personalized patient care, as well as determine country-specific malnutrition treatment strategies.

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Dialysate content and risk of sudden cardiac death

Abstract: Dialysate content plays an important role in the risk of SCD in hemodialysis patients on hemodialysis. There is a need for further studies designed to identify patients at risk and to determine what strategies can be used to lower this risk.

Cited by 10 publications

References 31 publications

Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Dialysate Calcium Concentration below 3.0 mEq/L Is Not Associated with Improved Outcomes in the Japanese Dialysis Outcomes and Practice Patterns Study

Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review

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