Abstract
BackgroundHemodialysis patients have high rates of sudden death, but relationships between serum electrolytes, the dialysis prescription, and intra-dialytic shifts in fluid and electrolyte with arrhythmia are uncertain.MethodsWe analyzed sixty-six hemodialysis patients who underwent loop recorder implantation with continuous electrocardiographic monitoring, weekly to bi-weekly testing of pre- and post-dialysis electrolytes, and detailed capture of dialysis prescription and flow sheet data for 6 months. The incidence rate ratio (IRR) of reviewer confirmed arrhythmias (RCA) during dialysis through 8 h after dialysis and associations with serum chemistries and dialytic parameters were assessed using adjusted, negative-binomial regression.ResultsAmong 66 individuals with a mean age of 56 years, 12,480 events were detected in 64 (97%) patients. RCA nadired 12–24 h after dialysis and increased during the final 12 h of the inter-dialytic interval through the first 8 h after dialysis. Higher pre-dialysis serum magnesium concentration was associated with lower incidence rate ratio for arrythmia (IRR per 1 mg/dL increase 0.49, 95% CI; 0.25, 0.94), as was dialysate calcium concentration > 2.5 mEq/L vs. 2.5 mEq/L (IRR 0.52, 95% CI: 0.39, 0.70). Neither intradialytic serum potassium nor weight change were significantly associated with RCA rate. However, there was effect modification such that arrhythmia rate was maximal with concurrently high intradialytic volume and potassium removal (Pinteraction = 0.01).ConclusionsIntra and post-dialytic arrhythmias are common in hemodialysis. Additional studies designed to further elucidate whether modification of the serum magnesium concentration, dialysate calcium concentration, and the extent of intradialytic potassium and fluid removal reduces the risk of per-dialytic arrhythmia are warranted.Trial registrationClinicaltrials.gov NCT01779856. Prospectively registered on January 22, 2013.
Highlights
Hemodialysis patients have high rates of sudden death, but relationships between serum electrolytes, the dialysis prescription, and intra-dialytic shifts in fluid and electrolyte with arrhythmia are uncertain
Dialysate chemistries at baseline were similar across quartiles of observed reviewer confirmed arrhythmia (RCA), but there was a non-significant trend towards increased use of higher dialysate potassium concentrations among those with more RCA (P = 0.05)
Findings were similar when analyzed according to the dichotomous presence or absence of RCA during follow-up. with exception that the dialysate calcium concentration which was significantly higher (2.5 [interquartile range (IQR): 2.5, 2.5] vs. 1.6 [IQR: 1.6, 1.6], P = 0.04) in those with compared to those without RCA (Additional file 1: Table S2)
Summary
Hemodialysis patients have high rates of sudden death, but relationships between serum electrolytes, the dialysis prescription, and intra-dialytic shifts in fluid and electrolyte with arrhythmia are uncertain. Multiple studies demonstrate that cardiovascular disease is the most common cause of death, and approximately two thirds of the cardiac deaths are consistently attributed to arrhythmias [1,2,3,4] This increased incidence of cardiovascular disease, of sudden death, is not fully explained by traditional cardiovascular risk factors [5, 6] and appears to be unique to end stage renal disease. Observational data, have demonstrated associations between serum electrotype concentrations or the dialysate electrolyte concentration and the risk of sudden death [9,10,11,12] These observations suggest current approaches to thrice-weekly dialysis could potentially induce cardiac arrhythmias. The few studies with electrocardiographic data, were constrained by the limits of available technology to short-term capture of arrhythmia data over a maximal observation period of 1–3 dialysis sessions
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