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ARTICLE CONTRIBUTORS

Dr Paul R Roberts
Consultant cardiologist and electrophysiologist
Southampton University Hospital
UK

Case Reports

Sudden Cardiac Death in Advanced CKD

Haemodialysis patients are at increased risk of sudden death for many reasons. This important topic was reviewed by Dr Paul R Roberts, Consultant cardiologist and electrophysiologist, Southampton University Hospital, at a recent meeting of the Cardiorenal Forum. The author briefly reviews the data here also.

United States and UK data suggests a risk of sudden cardiac death (SCD) in the haemodialysis (HD) population of 7% per year. SCD is defined as unexpected death from a cardiac cause within one hour of the onset of symptoms. In the majority of cases this will be a sudden arrhythmic death from a ventricular arrhythmia or asystole. The electrophysiological substrate within the HD population for ventricular arrhythmias is rich. This includes coronary artery disease, autonomic imbalance, left ventricular hypertrophy, fibrosis, electrolyte abnormalities, uraemia and inflammation.

There are scarce data in the literature on ambulatory ECG monitoring in the HD population. The data that are there suggest that ventricular arrhythmias are associated with an older population and reduced left ventricular function. The incidence of arrhythmias is greatest during the 3rd hour of dialysis and persists for 5 hours post dialysis.

There is International and National (NICE) guidance on the use of implantable cardioverter defibrillators (ICDs) for the treatment of ventricular arrhythmias. The extensive evidence base that informs these guidelines has excluded patients on HD. Data from the UK suggests that utilisation of ICD therapy in the HD population is lower than would be expected. In spite of this current guidance would not address the high rate of SCD in this population.

A number of studies looking at the ICD population with impaired renal function have identified a direct correlation of renal function with appropriate utilisation of therapy from ICDs. Patients with impaired renal function have a greater survival with an ICD than those that do not but still have a high mortality. This has been shown to be as high as 50% over 18 months. ICD therapy may not necessarily be the complete solution to SCD in the HD population. This population has challenges for device therapy in terms of vascular access, clotting and risk of infection.

At this point in time little is known of the arrhythmia burden of the HD population and further evaluation of this is required. One tool to address this may be an implantable loop recorder.

References

  • Bleyer A J, Russell G B, Satko S G: Sudden and cardiac death rates in hemodialysis patients. Kidney International, Vol. 55 (1999), pp. 1553-1559.
  • Bleyer A J, Hartman J, Brannon P C et al:  Characteristics of sudden death in hemodialysis patients.  Kidney International. 2006; 69 (12): 2268-73.
  • Genovesi S, Valsecchi M G, Rossi E et al:  Sudden death and associated factors in a historical cohort of chronic haemodialysis patients.  Nephrology Dialysis Transplantation 2009 24(8): 2529-2536.

Further information about the Cardiorenal Forum may be found at www.cardiorenalforum.com

Published on: December 10, 2009

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ENDORSED BY

  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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