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Franczyk B, Rysz J, Olszewski R, Gluba-Sagr A. Do Implantable Cardioverter-Defibrillators Prevent Sudden Cardiac Death in End-Stage Renal Disease Patients on Dialysis? J Clin Med 2024; 13:1176. [PMID: 38398488 PMCID: PMC10889557 DOI: 10.3390/jcm13041176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/23/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Chronic kidney disease patients appear to be predisposed to heart rhythm disorders, including atrial fibrillation/atrial flutter, ventricular arrhythmias, and supraventricular tachycardias, which increase the risk of sudden cardiac death. The pathophysiological factors underlying arrhythmia and sudden cardiac death in patients with end-stage renal disease are unique and include timing and frequency of dialysis and dialysate composition, vulnerable myocardium, and acute proarrhythmic factors triggering asystole. The high incidence of sudden cardiac deaths suggests that this population could benefit from implantable cardioverter-defibrillator therapy. The introduction of implantable cardioverter-defibrillators significantly decreased the rate of all-cause mortality; however, the benefits of this therapy among patients with chronic kidney disease remain controversial since the studies provide conflicting results. Electrolyte imbalances in haemodialysis patients may result in ineffective shock therapy or the appearance of non-shockable underlying arrhythmic sudden cardiac death. Moreover, the implantation of such devices is associated with a risk of infections and central venous stenosis. Therefore, in the population of patients with heart failure and severe renal impairment, periprocedural risk and life expectancy must be considered when deciding on potential device implantation. Harmonised management of rhythm disorders and renal disease can potentially minimise risks and improve patients' outcomes and prognosis.
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Affiliation(s)
- Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Lodz, Poland; (B.F.); (J.R.)
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Lodz, Poland; (B.F.); (J.R.)
| | - Robert Olszewski
- Department of Gerontology, Public Health and Didactics, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Anna Gluba-Sagr
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Lodz, Poland; (B.F.); (J.R.)
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 302] [Impact Index Per Article: 100.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Obremska M, Madziarska K, Zyśko D, Ładny JR, Gałązkowski R, Gąsior M, Nadolny K. Out-of-hospital cardiac arrest in dialysis patients. Int Urol Nephrol 2020; 53:563-569. [PMID: 33337538 PMCID: PMC7907018 DOI: 10.1007/s11255-020-02694-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/27/2020] [Indexed: 11/04/2022]
Abstract
Purpose The aim of the study was to assess whether a history of dialysis is related to cardiopulmonary resuscitation (CPR) attempts and survival to hospital admission in patients with out-of-hospital cardiac arrest (OHCA). Methods The databases of the POL-OHCA registry and of emergency medical calls in the Command Support System of the State of Emergency Medicine (CSS) were searched to identify patients with OHCA and a history of dialysis. A total of 264 dialysis patient with OHCA were found: 126 were dead on arrival of emergency medical services (EMS), and 138 had OHCA with CPR attempts. Data from the POL-OHCA registry for patients with CPR attempts, including age, sex, place of residence, first recorded rhythm, defibrillation during CPR, and priority dispatch codes, were collected and compared between patients with and without dialysis. Results CPR attempts by EMS were undertaken in 138 dialyzed patients (52.3%). The analysis of POL-OHCA data revealed no differences in age, sex, place of residence, first recorded rhythm, and priority dispatch codes between patients with and without dialysis. Defibrillation was less frequent in dialysis patients (P = 0.04). A stepwise logistic regression analysis revealed no association between survival to hospital admission and a history of hemodialysis (odds ratio = 1.12; 95% CI 0.74–1.70, P = 0.60). Conclusions A history of dialysis in patients with OHCA does not affect the rate of CPR attempts by EMS or a short-term outcome in comparison with patients without dialysis. Defibrillation during CPR is less common in patients on dialysis than in those without.
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Affiliation(s)
- Marta Obremska
- Department of Preclinical Research, Wroclaw Medical University, Wroclaw, Poland
| | - Katarzyna Madziarska
- Department and Clinic of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska St. 213, 50-556, Wroclaw, Poland.
| | - Dorota Zyśko
- Department of Emergency Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Jerzy R Ładny
- Department of Emergency Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Robert Gałązkowski
- Department of Emergency Medical Service, Medical University of Warsaw, Warsaw, Poland
| | - Mariusz Gąsior
- Department of Cardiology, Silesian Center for Heart Diseases, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Klaudiusz Nadolny
- Department of Emergency Medicine, Medical University of Bialystok, Bialystok, Poland.,Department of Emergency Medical Service, Higher School of Strategic Planning in Dabrowa Gornicza, Dabrowa Gornicza, Poland.,Faculty of Medicine, Katowice School of Technology, Katowice, Poland
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Ramer SJ, Reid MC, Unruh ML. Patient reactions to witnessed medical events in the dialysis center or to the sudden absence of other patients from the center: A qualitative study. Hemodial Int 2020; 25:220-231. [PMID: 33103350 DOI: 10.1111/hdi.12898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/21/2020] [Accepted: 10/10/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients receiving in-center maintenance hemodialysis (HD) spend a significant amount of time together. To date, little or no research has examined how these patients perceive and process other patients' medical events in and absences from their centers. We therefore undertook this qualitative study using semi-structured interviews to explore these phenomena from the patient perspective. METHODS Patients at a suburban Pittsburgh HD center participated in semi-structured interviews in April to May 2011, reporting on their impressions of their relationships with other patients in the center; their experiences of witnessing clinical decompensations in the center; and their reactions to absences of fellow patients from the center. Trained coders developed a codebook and applied it to interview transcripts. FINDINGS There were 17 participants, 47% women, 29% black, with median age 63 years. Almost every participant had witnessed other patients' medical events during HD. Three main themes emerged in analysis of interviews: (1) incomplete knowledge of many aspects of witnessed events and patient absences in the HD center; (2) a process of "filling in the blanks": Participants used their own past events and absences to help process other patients' events and absences and used other patients' events and absences to help process their own future events and absences; and (3) participants' broad support for HD center staff being able to share with other patients basic information about their whereabouts if they themselves are absent from the center. DISCUSSION Witnessed medical events in and patients' absences from the HD center are not only common but are also important to patients, who struggle to process these events and absences due to limited information about what actually happened. Interventions, such as providing patients with more information, could improve patients' experience of witnessed events and fellow patients' absences and potentially impact other patient-centered outcomes.
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Affiliation(s)
- Sarah J Ramer
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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Bernacki GM, Engelberg RA, Curtis JR, Kurella Tamura M, Brumback LC, Lavallee DC, Vig EK, O’Hare AM. Cardiopulmonary Resuscitation Preferences of People Receiving Dialysis. JAMA Netw Open 2020; 3:e2010398. [PMID: 32833017 PMCID: PMC7445594 DOI: 10.1001/jamanetworkopen.2020.10398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Whether the cardiopulmonary resuscitation (CPR) preferences of patients receiving dialysis align with their values and other aspects of end-of-life care is not known. OBJECTIVE To describe the CPR preferences of patients receiving dialysis and how these preferences are associated with their responses to questions about other aspects of end-of-life care. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey study of a consecutive sample of patients receiving dialysis at 31 nonprofit dialysis facilities in 2 US metropolitan areas (Seattle, Washington, and Nashville, Tennessee) between April 22, 2015, and October 2, 2018. Analyses for this article were conducted between December 2018 and April 2020. EXPOSURES Participants were asked to respond to the question "If you had to decide right now, would you want CPR if your heart were to stop beating?" Those who indicated they would probably or definitely want CPR were categorized as preferring CPR. MAIN OUTCOMES AND MEASURES This study examined the association between preference for CPR and other treatment preferences, engagement in advance care planning, values, desired place of death, expectations about prognosis, symptoms, and palliative care needs. RESULTS Of the 1434 individuals invited to complete the survey, 1009 agreed to participate, and 876 were included in the analytic cohort (61.1%). The final cohort had a mean (SD) age of 62.6 (14.0) years; 492 (56.2%) were men, and 528 (60.3%) were White individuals. Among 738 of 876 participants (84.2%) who indicated that they would definitely or probably want CPR (CPR group), 555 (75.2%) wanted mechanical ventilation vs 13 of 138 (9.4%) of those who did not want CPR (do not resuscitate [DNR] group) (P < .001). A total of 249 of 738 participants (33.7%) in the CPR group vs 84 of 138 (60.9%) in the DNR group had documented treatment preferences (P < .001). In terms of values about future care, 171 participants (23.2%) in the CPR group vs 5 of 138 (3.6%) in the DNR group valued life prolongation (P < .001); 320 in the CPR group (43.4%) vs 109 of 138 in the DNR group (79.0%) valued comfort (P < .001); and 247 participants (33.5%) in the CPR group vs 24 of 138 (17.4%) in the DNR group were unsure about their wishes for future care (P < .001). In the CPR group, 207 (28.0%) had thought about stopping dialysis vs 62 of 138 (44.9%) in the DNR group (P < .001), and 181 (24.5%) vs 58 of 138 (42.0%) had discussed stopping dialysis (P = .001). No statistically significant associations were observed between CPR preference and documentation of a surrogate decision maker, thoughts or discussion of hospice, preferred place of death, expectations about prognosis, reported symptoms, or palliative care needs. CONCLUSIONS AND RELEVANCE The CPR preferences of patients receiving dialysis were associated with some, but not all, other aspects of end-of-life care. How participants responded to questions about these other aspects of end-of-life care were not always aligned with their CPR preference. More work is needed to integrate discussions about code status with bigger picture conversations about patients' values, goals, and preferences for end-of-life care.
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Affiliation(s)
- Gwen M. Bernacki
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A. Engelberg
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - J. Randall Curtis
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Manjula Kurella Tamura
- Department of Medicine, Stanford University Medical Center, Palo Alto, California
- Division of Nephrology, Geriatric Research, Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
| | | | | | - Elizabeth K. Vig
- Department of Medicine, University of Washington, Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Geriatrics, VA Puget Sound Health Care System, Seattle, Washington
| | - Ann M. O’Hare
- Department of Medicine, University of Washington, Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Kidney Research Institute, University of Washington, Seattle
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Imbeault B, Chan CT. Cardiopulmonary Resuscitation in Outpatient Dialysis Clinics: Perception of Futility? J Am Soc Nephrol 2019; 30:369-370. [PMID: 30733236 PMCID: PMC6405143 DOI: 10.1681/asn.2019010046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Benoit Imbeault
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Christopher T Chan
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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Pun PH, Dupre ME, Starks MA, Tyson C, Vellano K, Svetkey LP, Hansen S, Frizzelle BG, McNally B, Jollis JG, Al-Khatib SM, Granger CB. Outcomes for Hemodialysis Patients Given Cardiopulmonary Resuscitation for Cardiac Arrest at Outpatient Dialysis Clinics. J Am Soc Nephrol 2019; 30:461-470. [PMID: 30733235 PMCID: PMC6405155 DOI: 10.1681/asn.2018090911] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 11/28/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest, the leading cause of death among patients on hemodialysis, occurs frequently within outpatient dialysis centers. Practice guidelines recommend resuscitation training for all dialysis clinic staff and on-site defibrillator availability, but the extent of staff involvement in cardiopulmonary resuscitation (CPR) efforts and its association with outcomes is unknown. METHODS We used data from the Cardiac Arrest Registry to Enhance Survival and the Centers for Medicare & Medicaid Services dialysis facility database to identify patients who had cardiac arrest within outpatient dialysis clinics between 2010 and 2016 in the southeastern United States. We compared outcomes of patients who received dialysis staff-initiated CPR with those who did not until the arrival of emergency medical services (EMS). RESULTS Among 398 OHCA events in dialysis clinics, 66% of all patients presented with a nonshockable initial rhythm. Dialysis staff initiated CPR in 81.4% of events and applied defibrillators before EMS arrival in 52.3%. Staff were more likely to initiate CPR among men and witness cardiac arrests, and were more likely to provide CPR within larger dialysis clinics. Staff-initiated CPR was associated with a three-fold increase in the odds of hospital discharge and favorable neurologic status on discharge. There was no overall association between staff-initiated defibrillator use and outcomes, but there was a nonsignificant trend toward improved survival to hospital discharge in the subgroup with shockable initial cardiac arrest rhythms. CONCLUSIONS Dialysis staff-initiated CPR was associated with a large increase in survival but was only performed in 81% of cardiac arrest events. Further investigations should focus on understanding the potential facilitators and barriers to CPR in the dialysis setting.
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Affiliation(s)
- Patrick H. Pun
- Duke Clinical Research Institute,,Division of Nephrology, Department of Medicine, and
| | - Matthew E. Dupre
- Duke Clinical Research Institute,,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | | | - Kimberly Vellano
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | | | - Steen Hansen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark; and
| | - Brian G. Frizzelle
- Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
| | - Bryan McNally
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
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Boyle NG, Do DH. Hemodialysis Patients. JACC Clin Electrophysiol 2018; 4:409-411. [DOI: 10.1016/j.jacep.2017.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/14/2017] [Indexed: 10/18/2022]
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Makar MS, Pun PH. Sudden Cardiac Death Among Hemodialysis Patients. Am J Kidney Dis 2017; 69:684-695. [PMID: 28223004 DOI: 10.1053/j.ajkd.2016.12.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/12/2016] [Indexed: 02/07/2023]
Abstract
Hemodialysis patients carry a large burden of cardiovascular disease; most onerous is the high risk for sudden cardiac death. Defining sudden cardiac death among hemodialysis patients and understanding its pathogenesis are challenging, but inferences from the existing literature reveal differences between sudden cardiac death among hemodialysis patients and the general population. Vascular calcifications and left ventricular hypertrophy may play a role in the pathophysiology of sudden cardiac death, whereas traditional cardiovascular risk factors seem to have a more muted effect. Arrhythmic triggers also differ in this group as compared to the general population, with some arising uniquely from the hemodialysis procedure. Combined, these factors may alter the types of terminal arrhythmias that lead to sudden cardiac death among hemodialysis patients, having important implications for prevention strategies. This review highlights current knowledge on the epidemiology, pathophysiology, and risk factors for sudden cardiac death among hemodialysis patients. We then examine strategies for prevention, including the use of specific cardiac medications and device-based therapies such as implantable defibrillators. We also discuss dialysis-specific prevention strategies, including minimizing exposure to low potassium and calcium dialysate concentrations, extending dialysis treatment times or adding sessions to avoid rapid ultrafiltration, and lowering dialysate temperature.
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Affiliation(s)
- Melissa S Makar
- Duke Clinical Research Institute, Durham, NC; Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC.
| | - Patrick H Pun
- Duke Clinical Research Institute, Durham, NC; Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
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Sánchez Perales C, Vázquez Ruiz de Castroviejo E. Muerte súbita en pacientes con enfermedad renal crónica avanzada. Nefrologia 2017; 37:111-112. [DOI: 10.1016/j.nefro.2016.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022] Open
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Luque Y, Bataille A, Taldir G, Rondeau É, Ridel C. [Cardiac arrest in dialysis patients: Risk factors, preventive measures and management in 2015]. Nephrol Ther 2015; 12:6-17. [PMID: 26547563 DOI: 10.1016/j.nephro.2015.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 02/06/2023]
Abstract
Patients undergoing hemodialysis have a 10 to 20 times higher risk of sudden cardiac arrest (SCA) than the general population. Sudden cardiac death is a rare event (approximately 1 event per 10,000 sessions) but has a very high mortality rate. Epidemiological data comes almost exclusively from North American studies; there is a great lack of European data on the subject. Ventricular arrhythmia is the main mechanism of sudden cardiac deaths in dialysis patients. These patients develop increased sensitivity mainly due to a high prevalence of severe ischemic heart disease and left ventricular hypertrophy and to a frequent trigger event: electrolytic and plasma volume shifts during dialysis sessions. Unfortunately, accurate predictive markers of SCA do not exist, however some primary prevention trials using beta-blockers or angiotensin II receptor blockers are encouraging, while the use of implantable cardioverter defibrillators in the population of chronic dialysis patients remains controversial. Identification of patients at risk, minimizing trigger events such as electrolytic shifts and improving team skills in the diagnosis and initial resuscitation with the latest recommendations from 2010 seem necessary to reduce incidence and improve survival in this high risk population. Organization of European studies would also allow a more accurate view of this reality in our dialysis units.
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Affiliation(s)
- Yosu Luque
- Service des urgences néphrologiques et de transplantation rénale, hôpital Tenon, 4, rue de la Chine, 75571 Paris cedex 20, France; Inserm UMR S 1155, bâtiment recherche, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France.
| | - Aurélien Bataille
- Département d'anesthésie-réanimation, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France; Inserm UMR S 1155, bâtiment recherche, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - Guillaume Taldir
- Service de cardiologie, centre hospitalier de Saint-Brieuc, 22027 Saint-Brieuc cedex 1, France
| | - Éric Rondeau
- Service des urgences néphrologiques et de transplantation rénale, hôpital Tenon, 4, rue de la Chine, 75571 Paris cedex 20, France; Inserm UMR S 1155, bâtiment recherche, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France; Sorbonne universités, UPMC université Paris 06, 4, place Jussieu, 75005 Paris, France
| | - Christophe Ridel
- Service dialyse et aphérèse Aura Paris Plaisance, 185A, rue Raymond-Losserand, 75014 Paris, France
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Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP, Böttiger BW, Georgiou M, Handley AJ, Lindner T, Midwinter MJ, Monsieurs KG, Wetsch WA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148-201. [PMID: 26477412 DOI: 10.1016/j.resuscitation.2015.07.017] [Citation(s) in RCA: 532] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic.
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | | | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hermann Brugger
- EURAC Institute of Mountain Emergency Medicine, Bozen, Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - David J Lockey
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Clinical Sciences, University of Bristol, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany
| | - Peter Paal
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | | | - David A Zideman
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
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Franczyk-Skóra B, Gluba-Brzózka A, Wranicz JK, Banach M, Olszewski R, Rysz J. Sudden cardiac death in CKD patients. Int Urol Nephrol 2015; 47:971-82. [PMID: 25962605 DOI: 10.1007/s11255-015-0994-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 04/20/2015] [Indexed: 02/02/2023]
Abstract
The risk of sudden cardiac death (SCD) is high in chronic kidney disease patients, and it increases with the progression of kidney function deterioration. The most common causes of SDC are the following: ventricular tachycardia, ventricular tachyarrhythmia, tachycardia torsade de pointes, sustained ventricular fibrillation and bradyarrhythmia. Dialysis influences cardiovascular system and results in hemodynamic disturbances as well as electrolyte shifts altering myocardial electrophysiology. Studies suggest that this procedure exerts both detrimental (poor volume control can exacerbate hypertension and left ventricle hypertrophy) and beneficial effects (associated with fluid removal and subsequent decrease in left ventricle stretch). Dialysis-related vulnerability to serious arrhythmias is the result of sudden shifts in fluid status and electrolytes, particularly potassium, which alter the physiological milieu. Also Ca(2+) ions, in which concentration alters during dialysis, are of key importance in the contraction of vascular smooth muscle cells and cardiac myocytes, thus exerting significant effects on hemodynamics. Due to the fact that SCD occurs with similar frequency in peritoneal dialysis and in hemodialysis patients, it seems that end-stage renal disease factors are more important than the specific ones associated with dialysis type. The results of randomized trials suggested that hemodialysis patients may not derive the same benefit of cardiovascular disease therapy including beta-blockers, calcium channel blockers and angiotensin-converting enzyme inhibitors as the general population with normal kidney function. Noninvasive tests used to stratify SCD risk in HD patients have poor positive value, and thus, combining tests including HRV, baroreceptor sensitivity and effectiveness index as well as its function indices and heart rate turbulence should be implemented. There are only few large randomized placebo-controlled trials assessing the influence of cardioprotective medications or implantable cardioverter defibrillator (ICD) implantation in dialysis patients on life quality and survival, and their results are sometimes contradictory. The decision concerning treatment and/or ICD implantation in this group of patients should be made on the basis of careful assessment of individual risk factors. Moreover, due to the high hazard of cardiovascular mortality including SCD in dialysis patients, physicians should concentrate on the early selection of high-risk patients, monitoring them and introduction of preventive measures.
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Affiliation(s)
- Beata Franczyk-Skóra
- Department of Nephrology, Hypertension and Family Medicine, WAM University Hospital, Żeromskiego 113, 90-549, Lodz, Poland
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17
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Associates of cardiopulmonary arrest in the perihemodialytic period. Int J Nephrol 2014; 2014:961978. [PMID: 25530881 PMCID: PMC4235586 DOI: 10.1155/2014/961978] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/24/2014] [Indexed: 11/26/2022] Open
Abstract
Cardiopulmonary arrest during and proximate to hemodialysis is rare but highly fatal. Studies have examined peridialytic sudden cardiac event risk factors, but no study has considered associates of cardiopulmonary arrests (fatal and nonfatal events including cardiac and respiratory causes). This study was designed to elucidate patient and procedural factors associated with peridialytic cardiopulmonary arrest. Data for this case-control study were taken from the hemodialysis population at Fresenius Medical Care, North America. 924 in-center cardiopulmonary events (cases) and 75,538 controls were identified. Cases and controls were 1 : 5 matched on age, sex, race, and diabetes. Predictors of cardiopulmonary arrest were considered for logistic model inclusion. Missed treatments due to hospitalization, lower body mass, coronary artery disease, heart failure, lower albumin and hemoglobin, lower dialysate potassium, higher serum calcium, greater erythropoietin stimulating agent dose, and normalized protein catabolic rate (J-shaped) were associated with peridialytic cardiopulmonary arrest. Of these, lower albumin, hemoglobin, and body mass index; higher erythropoietin stimulating agent dose; and greater missed sessions had the strongest associations with outcome. Patient health markers and procedural factors are associated with peridialytic cardiopulmonary arrest. In addition to optimizing nutritional status, it may be prudent to limit exposure to low dialysate potassium (<2 K bath) and to use the lowest effective erythropoietin stimulating agent dose.
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Pun PH. The interplay between CKD, sudden cardiac death, and ventricular arrhythmias. Adv Chronic Kidney Dis 2014; 21:480-8. [PMID: 25443573 DOI: 10.1053/j.ackd.2014.06.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 06/04/2014] [Accepted: 06/27/2014] [Indexed: 12/23/2022]
Abstract
CKD patients face an increased risk of cardiovascular disease mortality, and the risk of sudden cardiac death (SCD) increases as kidney function declines. Risk factors for SCD are poorly understood and understudied among CKD patients. In the general population, coronary heart disease-associated risk factors are the most important determinants of SCD risk, but among CKD patients, there is evidence that these factors play a much smaller role. Complex relationships between CKD-specific risk factors, structural heart disease, and arrhythmic triggers contribute to the high risk of SCD and ventricular arrhythmias and modulate the effectiveness of available therapies. This review examines recent data on the epidemiology, pathophysiology, and mechanisms of SCD among CKD patients and examines current evidence regarding the use of pharmacologic and device-based therapies for management of SCD risk.
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Poulikakos D, Banerjee D, Malik M. Risk of sudden cardiac death in chronic kidney disease. J Cardiovasc Electrophysiol 2013; 25:222-31. [PMID: 24256575 DOI: 10.1111/jce.12328] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 11/12/2013] [Indexed: 12/14/2022]
Abstract
The review discusses the epidemiology and the possible underlying mechanisms of sudden cardiac death (SCD) in chronic kidney disease (CKD), and highlights the unmet clinical need for noninvasive risk stratification strategies in these patients. Although renal dysfunction shares common risk factors and often coexists with atherosclerotic cardiovascular disease, the presence of renal impairment increases the risk of arrhythmic complications to an extent that cannot be explained by the severity of the atherosclerotic process. Renal impairment is an independent risk factor for SCD from the early stages of CKD; the risk increases as renal function declines and reaches very high levels in patients with end-stage renal disease on dialysis. Autonomic imbalance, uremic cardiomyopathy, and electrolyte disturbances likely play a role in increasing the arrhythmic risk and can be potential targets for treatment. Cardioverter defibrillator treatment could be offered as lifesaving treatment in selected patients, although selection strategies for this treatment mode are presently problematic in dialyzed patients. The review also examines the current experience with risk stratification tools in renal patients and suggests that noninvasive electrophysiological testing during dialysis may be of clinical value as it provides the necessary standardized environment for reproducible measurements for risk stratification purposes.
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Affiliation(s)
- Dimitrios Poulikakos
- Cardiovascular Sciences Research Centre, St. George's University of London, London, UK; Renal and Transplantation Unit, St. George's Hospital NHS Trust, London, UK
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Wan C, Herzog CA, Zareba W, Szymkiewicz SJ. Sudden cardiac arrest in hemodialysis patients with wearable cardioverter defibrillator. Ann Noninvasive Electrocardiol 2013; 19:247-57. [PMID: 24252154 PMCID: PMC4034590 DOI: 10.1111/anec.12119] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background The survival outcome following a sudden cardiac arrest (SCA) in hemodialysis (HD) patients is poor regardless of whether an event takes place in or out of a dialysis center. The characteristics of SCA and post‐SCA survival with HD patients using a wearable cardioverter defibrillator (WCD) are unknown. Methods All HD patients who were prescribed a WCD between 2004 and 2011 and experienced at least one SCA event were included in this study. Demographics, clinical background, characteristics of SCA events were identified from the manufacturer's database. An SCA event was defined as all sustained ventricular tachycardia/fibrillation (VT/VF) or asystole occurring within 24 hours of the index arrhythmia episode. The social security death index was used to determine mortality after WCD use. Results A total of 75 HD patients (mean age = 62.9 ± 11.7 years, female = 37.3%) experienced 84 SCA events (119 arrhythmia episodes) while wearing the WCD. Sixty six (78.6%) SCA events were due to VT/VF and 18 (21.4%) were due to asystole. Most SCA episodes occurred between 09:00 and 10:00 (RR = 2.82, 95% CI [1.05, 7.62], P < 0.0001), followed by the 13:00–14:00 time interval (RR = 2.22, 95% CI [0.79, 6.21], P = 0.006). Acute 24‐hour survival was 70.7% for all SCA events; 30‐day and 1‐year survival were 50.7% and 31.4%, respectively. Women had a better post‐SCA survival than men (HR = 2.41, 95% CI [1.09, 5.36], P = 0.03). Conclusions The use of WCD in HD patients was associated with improved post‐SCA survival when compared to historical data.
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Hirakata H, Nitta K, Inaba M, Shoji T, Fujii H, Kobayashi S, Tabei K, Joki N, Hase H, Nishimura M, Ozaki S, Ikari Y, Kumada Y, Tsuruya K, Fujimoto S, Inoue T, Yokoi H, Hirata S, Shimamoto K, Kugiyama K, Akiba T, Iseki K, Tsubakihara Y, Tomo T, Akizawa T. Japanese Society for Dialysis Therapy Guidelines for Management of Cardiovascular Diseases in Patients on Chronic Hemodialysis. Ther Apher Dial 2012; 16:387-435. [DOI: 10.1111/j.1744-9987.2012.01088.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Alpert MA. Sudden cardiac arrest and sudden cardiac death on dialysis: Epidemiology, evaluation, treatment, and prevention. Hemodial Int 2012; 15 Suppl 1:S22-9. [PMID: 22093597 DOI: 10.1111/j.1542-4758.2011.00598.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Sudden cardiac death is the most common cause of death in dialysis patients and is usually preceded by sudden cardiac arrest due to ventricular tachycardia or ventricular fibrillation. A variety of risk factors have been identified that predispose the sudden cardiac arrest and sudden cardiac death in dialysis patients. Primary prevention of sudden cardiac arrest in dialysis patients may be accomplished by avoiding the use of low potassium dialysate. Pharmacotherapy with beta-blockers angiotensin converting enzyme inhibitors and angiotensin receptor blockers and use of implantable cardioverter defibrillators (ICDs) may also prevent sudden cardiac arrest and sudden cardiac death in high-risk dialysis patients. Secondary prevention of sudden cardiac death may be accomplished by similar pharmacotherapy and by the use of ICDs. Indications for ICD use in dialysis patients are similar to those for nondialysis patients; however, survival rates following ICD implantation in dialysis patients are substantially lower than in non-dialysis patients.
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Affiliation(s)
- Martin A Alpert
- Division of Cardiovascular Medicine, School of Medicine, University of Missouri, Columbia, Missouri, USA.
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O'Shaughnessy MM, Lappin DW, Reddan DN. Sudden cardiac death in dialysis: do current guidelines for implantable cardioverter defibrillator therapy apply to patients with end-stage kidney disease? Semin Dial 2012; 25:272-6. [PMID: 22452711 DOI: 10.1111/j.1525-139x.2012.01067.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Arrhythmic mechanisms account for one in four deaths in end-stage kidney disease. Large-scale randomized controlled trials have demonstrated a mortality benefit from implantable cardioverter defibrillator therapy in carefully selected patient groups at high risk for sudden cardiac death. Unfortunately, patients with end-stage kidney disease were systematically excluded from these trials. Consequently, the applicability of American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) guidelines on implantable cardioverter defibrillator therapy to dialysis patients remains uncertain. Observational data suggest that secondary preventative implantable cardioverter defibrillator therapy following resuscitated cardiac arrest prolongs the lives of dialysis patients. This intervention may also offer a survival advantage as a primary preventative strategy in end-stage kidney disease. However, competing risk from co-morbidity can negate any perceived benefit. Device-related complications also negatively impact outcome. The recommendation that primary preventative device implantation be reserved for patients with severely impaired left ventricular function may be excessively restrictive in this high-risk population. Trials of implantable cardioverter defibrillator therapy that include dialysis patients are required to validate existing device eligibility criteria in this unique population. Novel indications for this intervention in dialysis patients should also be identified.
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Pun PH, Middleton JP. Sudden cardiac death in hemodialysis patients: a comprehensive care approach to reduce risk. Blood Purif 2012; 33:183-9. [PMID: 22269796 DOI: 10.1159/000334154] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Sudden cardiac death is a major problem in hemodialysis patients, and our understanding of this disease is underdeveloped. The lack of a precise definition tailored for use in the hemodialysis population limits the reliability of epidemiologic reports. Efforts should be directed toward an accurate classification of all deaths that occur in this vulnerable population. The traditional paradigm of disease pathophysiology based on known cardiac risk factors appears to be inadequate to explain the magnitude of sudden cardiac death risk in chronic kidney disease, and numerous unique cofactors and exposures appear to determine risk in this population. Well-designed cohort studies will be needed for a basic understanding of disease pathophysiology and risk factors, and randomized intervention trials will be needed before best management practices can be implemented. This review examines available data to describe the characteristics of the high-risk patient and suggests a comprehensive common sense approach to prevention using existing cardiovascular medications and reducing and monitoring potential dialysis-related arrhythmic triggers. Other unproven cardiovascular therapies such as implantable cardioverter defibrillators should be used on a case-by-case basis, with recognition of the associated hazards that these devices carry among hemodialysis patients.
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Affiliation(s)
- Patrick H Pun
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA.
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Pun PH, Herzog CA, Middleton JP. Improving ascertainment of sudden cardiac death in patients with end stage renal disease. Clin J Am Soc Nephrol 2011; 7:116-22. [PMID: 22076878 DOI: 10.2215/cjn.02820311] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Data collected by the US Renal Data System (USRDS) identify sudden cardiac death (SCD) as the leading cause of death among hemodialysis patients. However, evidence suggests that clinical events captured on the USRDS death notification form may be inaccurate. A new method for classifying SCD was recently developed to enhance the accuracy of SCD classification. This study examined the performance characteristics of this refined definition using a cohort of hemodialysis patients who experienced a witnessed SCD as the reference standard. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This is a retrospective cohort study of 363 patients who experienced a witnessed SCD in US Gambro (DaVita) outpatient dialysis clinics. Sensitivity of SCD defined by death notification forms and SCD defined using additional administrative sources was compared. Clinical data recorded near time of death were also examined. RESULTS Existing USRDS death notification forms reported 70.8% of witnessed SCD as "cardiac arrest/cause unknown" or "arrhythmia." The refined definition significantly improved identification to 83.8% of witnessed SCD events (P<0.001). Verified SCD cases that were not identified by either definition were more likely to be reported on the death notification form as death due to myocardial infarction, hyperkalemia, sepsis, malignancy, or unknown cause. CONCLUSIONS Compared with the death notification form alone, the refined SCD definition significantly improves the sensitivity of reporting of witnessed SCD occurring within outpatient hemodialysis clinics. More accurate reporting of cardiac events by clinicians and refinements to existing death notification forms may further improve recognition and understanding of SCD.
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Affiliation(s)
- Patrick H Pun
- Division of Nephrology, Department ofMedicine, Duke University School of Medicine, Durham, North Carolina, USA.
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Matsue Y, Suzuki M, Nagahori W, Ohno M, Matsumura A, Hashimoto Y. β-blocker prevents sudden cardiac death in patients with hemodialysis. Int J Cardiol 2011; 165:519-22. [PMID: 21996409 DOI: 10.1016/j.ijcard.2011.09.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 09/12/2011] [Accepted: 09/15/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Beta blockers were shown to prevent SCD in cardiomyopathy or coronary artery disease patients. Dialysis patients show elevated mortality rates, predominantly due to cardiovascular disease. SCD is now one of the leading causes of death in this population. However, the prevention of SCD remains to be elucidated. METHODS We conducted a retrospective study of 316 patients from a database of all patients undergoing maintenance hemodialysis and followed up for 4.9 years. All patients were followed-up until death. Cox regression analysis was used to adjust the hazard ratio for beta blocker use with time until death. RESULTS SCD occurred during the study period in 3 (3.8%) patients in the beta blocker group and in 27 (11.4%) patients in the non-beta blocker group (P=0.047). Death from all causes occurred in 15 (18.8%) patients in the beta blocker group and in 97 (41.3%) patients in the non-beta blocker group (P<0.001). Kaplan-Meier curve showed that the rates of both SCD and all-cause death were lower in the beta blocker group (log-rank test, P=0.028 and P<0.001, respectively). In the Cox regression model, beta blocker use was significantly associated with lower adjusted risk of SCD (multivariate adjusted hazard ratio, 0.201; 95% confidence interval, 0.058-0.693; P=0.011). CONCLUSION In hemodialysis patients, beta blocker use was associated with lower risks of SCD and death from all causes. Thus, beta blocker use in this high-risk population may substantially improve outcome.
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Affiliation(s)
- Yuya Matsue
- Division of Cardiology, Department of Medicine, Kameda Medical Center, 929 Higashi-chou, Kamogawa-shi, Chiba 296-8602, Japan.
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Prevention of sudden cardiac arrest in dialysis patients: can we do more to improve outcomes? Kidney Int 2011; 79:147-9. [PMID: 21191388 DOI: 10.1038/ki.2010.433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Sudden cardiac arrest (SCA) is a leading cause of cardiac-associated mortality in dialysis patients. Risk factors unique to hemodialysis patients include abnormal electrolytes, large-volume ultrafiltration, and prior history of cardiac disease. Few randomized controlled trials of standard cardiac interventions have been completed in dialysis patients. Observational studies suggest that modification of the dialysis prescription may be one place to intervene. Prospective research is needed to determine mechanisms of SCA in hemodialysis patients.
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Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJLM, Brugger H, Deakin CD, Dunning J, Georgiou M, Handley AJ, Lockey DJ, Paal P, Sandroni C, Thies KC, Zideman DA, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2011; 81:1400-33. [PMID: 20956045 DOI: 10.1016/j.resuscitation.2010.08.015] [Citation(s) in RCA: 362] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
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Pun PH, Lehrich RW, Honeycutt EF, Herzog CA, Middleton JP. Modifiable risk factors associated with sudden cardiac arrest within hemodialysis clinics. Kidney Int 2011; 79:218-27. [DOI: 10.1038/ki.2010.315] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Soar J, Perkins G, Abbas G, Alfonzo A, Barelli A, Bierens J, Brugger H, Deakin C, Dunning J, Georgiou M, Handley A, Lockey D, Paal P, Sandroni C, Thies KC, Zideman D, Nolan J. Kreislaufstillstand unter besonderen Umständen: Elektrolytstörungen, Vergiftungen, Ertrinken, Unterkühlung, Hitzekrankheit, Asthma, Anaphylaxie, Herzchirurgie, Trauma, Schwangerschaft, Stromunfall. Notf Rett Med 2010. [DOI: 10.1007/s10049-010-1374-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Sakhuja R, Shah AJ, Hiremath S, Thakur RK. End-Stage Renal Disease and Sudden Cardiac Death. Card Electrophysiol Clin 2009; 1:61-77. [PMID: 28770789 DOI: 10.1016/j.ccep.2009.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Patients with end-stage renal disease (ESRD) are at a high risk for sudden cardiac death (SCD). SCD is the most common cause of death in this population and, as in the general population, ventricular arrhythmias seem to be the most common cause of SCD. The increased risk of SCD in ESRD is likely due to factors that are unique to the metabolic derangements associated with this state, as well as the increased prevalence of traditional risk factors. Despite this, the evidence base for the assessment and management of SCD in these patients is limited. This article reviews the current data on underlying risk factors for SCD in patients with ESRD, the role of common medical and device-based therapies for the prevention and treatment of SCD, and the applicability of common methods of risk stratification to patients with ESRD.
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Affiliation(s)
- Rahul Sakhuja
- Interventional Cardiology, Massachusetts General Hospital, 55 Fruit Street, GRB 800, Boston, MA 02114, USA
| | - Ashok J Shah
- Cardiac Electrophysiology, Thoracic and Cardiovascular Institute, Sparrow Health System, Michigan State University, 1215 E. Michigan Avenue, Lansing, MI 48912, USA
| | - Swapnil Hiremath
- Division of Nephrology, University of Ottawa, Ottawa Hospital - Civic Campus, 751 Parkdale Avenue, Suite 106, Ottawa, ON K1Y 1J7, Canada
| | - Ranjan K Thakur
- Arrhythmia Service, Thoracic and Cardiovascular Institute, Sparrow Health System, Michigan State University, 405 West Greenlawn, Suite 400, Lansing, MI 48910, USA
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Klein HU, Meltendorf U, Reek S, Smid J, Kuss S, Cygankiewicz I, Jons C, Szymkiewicz S, Buhtz F, Wollbrueck A, Zareba W, Moss AJ. Bridging a temporary high risk of sudden arrhythmic death. Experience with the wearable cardioverter defibrillator (WCD). PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 33:353-67. [PMID: 19889186 DOI: 10.1111/j.1540-8159.2009.02590.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The implantable cardioverter defibrillator (ICD) is able to reduce sudden arrhythmic death in patients who are considered to be at high risk. However, the arrhythmic risk may be increased only temporarily as long as the proarrhythmic conditions persist, left ventricular ejection fraction remains low, or heart failure prevails. The wearable cardioverter defibrillator (WCD) represents an alternative approach to prevent sudden arrhythmic death until either ICD implantation is clearly indicated or the arrhythmic risk is considered significantly lower or even absent. The WCD is also indicated for interrupted protection by an already implanted ICD, temporary inability to implant an ICD, and lastly refusal of an indicated ICD by the patient. The WCD is not an alternative to the ICD, but a device that may contribute to better selection of patients for ICD therapy. The WCD has the characteristics of an ICD, but does not need to be implanted, and it has similarities with an external defibrillator, but does not require a bystander to apply lifesaving shocks when necessary. The WCD was introduced into clinical practice about 8 years ago, and indications for its use are currently expanding. This article describes the technological aspects of the WCD, discusses current indications for its use, and reviews the clinical studies with the WCD. Additionally, data are reported on the clinical experience with the WCD based on 354 patients from Germany hospitalized between 2000 and 2008 who wore the WCD for a mean of 3 months.
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Affiliation(s)
- Helmut U Klein
- University of Rochester Medical Center, Heart Research Follow-up Program, Rochester, New York 14642, USA.
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Herzog CA, Mangrum JM, Passman R. NON-CORONARY HEART DISEASE IN DIALYSIS PATIENTS: Sudden Cardiac Death and Dialysis Patients. Semin Dial 2008; 21:300-7. [DOI: 10.1111/j.1525-139x.2008.00455.x] [Citation(s) in RCA: 216] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Ritz E, Wanner C. The Challenge of Sudden Death in Dialysis Patients:
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Sherman RA. Briefly Noted. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.2007.00296.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pun PH, Lehrich RW, Smith SR, Middleton JP. Predictors of survival after cardiac arrest in outpatient hemodialysis clinics. Clin J Am Soc Nephrol 2007; 2:491-500. [PMID: 17699456 DOI: 10.2215/cjn.02360706] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest (CA) is the most common cause of death in hemodialysis patients, and factors that improve survival after arrest are unknown. This study sought to identify modifiable factors that are associated with survival after CA in hemodialysis clinics. Patients who experienced in-center CA in the Gambro Healthcare System in the United States from 2002 to 2005 were identified. Patient characteristics at the time of arrest were compared between survivors and nonsurvivors at 24 h and 6 mo after CA. A total of 729 patients sustained in-clinic CA; 310 (42.5%) patients survived 24 h, and 80 (11%) patients survived 6 mo. Traditional risk factors, including cardiovascular comorbidities, diabetes, hemoglobin, and dialysis adequacy, did not predict survival at either time point. After adjustment for case-mix factors, presence of indwelling catheter, and concomitant medications, only use of beta blockers (BBL), calcium-channel blockers (CCB), and angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) remained significantly associated with survival (BBL odds ratio [OR] 0.32 [95% confidence interval (CI) 0.17 to 0.61]; CCB OR 0.42 [95% CI 0.23 to 0.76]; ACEI/ARB OR 0.51 [95% CI 0.28 to 0.95]). The beneficial effect of ACEI/ARB and BBL on survival increased sequentially with higher medication dosages. Prescription of BBL at the time of the event was the only predictive variable of survival at 24 h. Therefore, traditional cardiovascular risk factors were not associated with survival after CA in this hemodialysis cohort. The benefits that are associated with BBL, CCB, and ACEI/ARB suggest that these medications may improve the chances of survival after CA.
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Affiliation(s)
- Patrick H Pun
- Department of Medicine, Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA
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