Mini topic Sudden cardiac arrhythmia in dialysis patients

Mini topic Sudden cardiac arrhythmia in dialysis patients 신장내과 R 4 정우진

Introduction Arrhythmia/Sudden cardiac arrest is the leading cause of death in dialysis Patients The risk of SCD in ESRD-HD is 20 x greater than the general population 19, 440 patients who underwent cardiac catheterization Clin J Am Soc Nephrol 11: 721– 734, 2016. doi: 10. 22 Kidney Int. 2009 September ; 76(6): 652– 658

SCD and Arrhythmias occur most frequently on the first hemodialysis day of the week 32000 US HD patients N engl j med 2011 365(12) 1099 -11

Pathophysiological conditions associated CKD Heart 2011; 97: 766 e 773. doi: 10. 1136/hrt. 2010. 208

The impact of HD on arrhythmia Electrolyte l Potassium l l Calcium l l l Conventional dialysis Sudden decrease in serum potassium concentration during the dialysis Transmembrane potential and repolarization of the cardiac cells Rhythm disturbance. Hypercalcemia by calcium infusion or by a high-calcium dialysate LV relaxation impairment Hypocalcemia (HD or low dialysate calcium) Increase of the QTc interval dysrhythmias and torsades de pointes Magnesium l Intracellular Mg ↑ (concurrent changes in other ion, such as calcium, potassium) QTc prolongation J Nephrol 2009; 22(6): 716 -72

The impact of HD on arrhythmia Atrial fibrillation: HD > PD l Progressive cardiac enlargement, drop in their serum potassium Sympathetic overactivity l Protein semaphorin 3 a catecholamine suprasensitivity and prolonged QT Overexpression of angiotensin II J Nephrol 2009; 22(6): 716 -72

What is lethal arrhythmia? Retrospective observational study with 75 HD patients experienced at least 1 SCA event while wearing the WCD Ann Noninvasive Electrocardiol 2014; 19(3): 247–

What is lethal arrhythmia? Prospective study with 50 clinically stable ambulatory CKD patients receiving stable outpatient thrice-weekly hemodialysis l l l All SCD events occurred during the LIDP with severe bradycardia and ensuing asystole in 4 cases No ventricular arrhythmias were recorded either preceding or following the bradycardic event in any of the 4 cases. 1, 488 arrhythmia events occurring in 22 patients (44%): bradycardia in 12 (24%); sinus arrest in 10 (20%); AV block in 2 (4%); and nonsustained VT in 8 (16%). Journal of the American College of Cardiology. 2015 ; 65(12): 126

Prevention of Sudden Cardiac Death in Dialysis patients KDOQI l 7. 1. b Patients with dysrhythmias should be treated in the same manner as the general population with regard to antiarrhythmic agents (including beta-blockers) and pacing devices (including internal defibrillators). (C) ISPD l l 3. 6. 2 We suggest beta blockers be considered for primary prevention of sudden cardiac death in high-risk peritoneal dialysis patients. (2 D) 3. 6. 3 We suggest an implantable cardioverter-defibrillator be considered for secondary prevention of sudden cardiac death in peritoneal dialysis patients who survive an episode of cardiac arrest confirmed as being the result of malignant ventricular arrhythmia (except those occurring within first 48 hours postacute myocardial infarction). (2 D)

Beta-Blockers for Prevention of Sudden Cardiac Death in Patients on Hemodialysis: A Propensity Score Analysis of the HEMO Study 1, 747 patients on dialysis were included in this study 521 patients were on beta-blocker therapy Am J Kidney Dis. 58(6): 939 -94

Carvedilol Increases Two-Year Survival in Dialysis Patients With Dilated Cardiomyopathy A total of 114 dialysis patients with dilated cardiomyopathy were randomized to receive either carvedilol or placebo There were significantly fewer a all-cause mortality (51. 7%), cardiovascular deaths (29. 3%) and hospital admissions (34. 5%) among patients receiving carvedilol than among those receiving a placebo Journal of the American College of Cardiology. 2003; 41(9): 1438

Survival of dialysis patients after cardiac arrest and the impact of implantable cardioverter defibrillators Kidney International, Vol. 68 (2005), pp. 818– 82

Prevention of Sudden Cardiac Death in Dialysis patients Dialysate l Potassium l l Close association between dialysate K+ concentration and QT interval prolongation with consequent risk of complex arrhythmias Calcium l Low dialysate Ca++levels is associated with increased QT dispersion and prolongation of QTc interval, suggesting a predisposition to ventricular arrhythmias Ultrafiltration l Large UF volume l l >5. 7% of post-dialysis weight increased the risk for SCD Patients treated 2. 5 h for six times a week, showed more favorable survival and decreased LVMI compared with those treated 3. 5 h three times a week International Journal of Cardiology 217 (2016) 16–

Role of Dialysate Potassium in SCA Study of 502 witnessed peridialytic SCA vs 1632 matched controls Use of low potassium diaysate (<2 meq/L) was associated with a two-fold increase in risk of SCA Mean Predialysis serum K was in the normal range (4. 9 meq/L) Kidney Int. 2011 Jan; 79(2): 218 -27

Role of Serum potassium in SCA Kidney Int. 2011 Jan; 79(2): 218 -2

QTc dispersion increases during hemodialysis with low-calcium dialysate Kidney International, Vol. 57 (2000), pp. 2117– 21

Prevention of Sudden Cardiac Death in dialysis patients International Journal of Cardiology 217 (2016) 16–