Primary outcomes of the Monitoring in Dialysis Study indicate that clinically significant arrhythmias are common in hemodialysis patients and related to dialytic cycle

Abstract

Sudden death is one of the more frequent causes of death for hemodialysis patients, but the underlying mechanisms, contribution of arrhythmia, and associations with serum chemistries or the dialysis procedure are incompletely understood. To study this, implantable loop recorders were utilized for continuous cardiac rhythm monitoring to detect clinically significant arrhythmias including sustained ventricular tachycardia, bradycardia, asystole, or symptomatic arrhythmias in hemodialysis patients over six months. Serum chemistries were tested pre- and post-dialysis at least weekly. Dialysis procedure data were collected at every session. Associations with clinically significant arrhythmias were assessed using negative binomial regression modeling. Sixty-six patients were implanted and 1678 events were recorded in 44 patients. The majority were bradycardias (1461), with 14 episodes of asystole and only one of sustained ventricular tachycardia. Atrial fibrillation, although not defined as clinically significant arrhythmias, was detected in 41% of patients. With thrice-weekly dialysis, the rate was highest during the first dialysis session of the week and was increased during the last 12 hours of each inter-dialytic interval, particularly the long interval. Among serum and dialytic parameters, only higher pre-dialysis serum sodium and dialysate calcium over 2.5 mEq/L were independently associated with clinically significant arrhythmias. Thus, clinically significant arrhythmias are common in hemodialysis patients, and bradycardia and asystole rather than ventricular tachycardia may be key causes of sudden death in hemodialysis patients. Associations with the temporal pattern of dialysis suggest that modification of current dialysis practices could reduce the incidence of sudden death.

Contemporary Trends in Clinical Outcomes among Dialysis Patients with Medicare Coverage

“…This model of HD is optimized to deliver 3 treatments per week, on either Monday-Wednesday-Friday or TuesdayThursday-Saturday, and thus admits an approximately 72-h gap between the last HD treatment in 1 week and the first HD treatment in the next week. That "long gap" is associated with higher risks of death [5][6][7][8], car- diovascular hospitalization [5,8], and significant arrhythmias [9]. By registry data, 1-, 2-, and 5-year survival probabilities among incident dialysis patients in the United States are 81, 69, and 43%, respectively [1], and cardiovascular disease, especially cardiac arrest, is the leading cause of death [10].…”

Hemodialysis‐induced bradycardia, “a plumbing issue”: Resolved with catheter repositioning

“…Underlying mechanisms of SCD and type of fatal arrhythmia remain controversial. Recent studies involving implantable loop recorders in patients on hemodialysis show that bradyarrythmias rather than tachyarrythmias are associated with fatal events . Premature atrial or ventricular contractions (PAC, PVC) and occasionally, serious arrhythmia complications like atrio‐ventricular block, and malignant ventricular arrhythmia may occur during dialysis catheter insertion, requiring emergent interventions.…”

Cycles, Arrows and Turbulence: Time Patterns in Renal Disease, a Path from Epidemiology to Personalized Medicine?

“…Next to this, the intermittent nature of the HD treatment can impose a major circulatory stress on the body, commonly resulting in complications such as intradialytic hypotension [44][45][46]. Further evidence about the relevance of the interdialytic interval has emerged from a study in 66 patients by Roy-Chaudhury et al [47] using implantable loop recorders over a 6-month period. In this study, the risk of arrhythmias, predominantly bradycardias and ventricular tachycardias, was the highest around the first dialysis session of the week and in the last 12 h of the long inter dialytic interval.…”