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Authors’ Interview
Dr Darren Green, Research Fellow in Nephrology, University of Manchester
Professor Philip Kalra, Consultant Nephrologist, Salford Royal Hospital and University of Manchester
Sudden Cardiac Death in Hemodialysis Patients: An In-Depth Review.
Green D, Roberts PR, New DI, Kalra PA.
Am J Kidney Dis. 2011 Apr 14.
Salford Royal Hospital, Salford, United Kingdom.
What are the main findings of the study?
Sudden or unexpected death accounts for as many as one in four deaths in dialysis patients, yet we know little about the pathological processes which lead to this, or how we can prevent these events. In the general population, most sudden deaths are of cardiac origin and most of these will be due to a “shockable” ventricular arrhythmia. If the same were true of dialysis patients, there would be potential to use implanted cardioverter-defibrillator devices as primary prevention. However, three vital questions must be addressed before this can be considered.
Firstly, what evidence do we have that sudden deaths are usually cardiac in origin in dialysis patients? Though this would be expected given the high rate of cardiovascular disease, dialysis patients also have a high rate of intra-cranial events, diabetes, seizures, and aortic aneurysm, all of which can lead to sudden death.
Second, are arrhythmic deaths in dialysis usually due to ventricular fibrillation or tachycardia? There is a higher rate of autonomic dysfunction and phenomena such as vascular calcification and rapid ultrafiltration that may lead to bradycardic and asystolic deaths.
Finally, what evidence is there that can help us identify the most at-risk patients? Our review attempted to address each of these questions and touch on the debate of using implanted defibrillators in dialysis patients.
Were any of the findings unexpected?
It is well established that the two most likely times for sudden death in a dialysis patient are the 12 hours before the first dialysis session of the week and the 12 hours from the start of a dialysis session. We know that ectopy, arrhythmia and some repolarisation abnormalities occur more frequently during dialysis than at other times, and it may be that sudden death occurring on the dialysis unit is a distinct entity separate to sudden death at other times. To support this, whilst some studies have shown that coronary artery disease and heart failure are not risk factors for sudden death in dialysis patients, others have shown that in cases of cardiac arrest occurring specifically during dialysis, patients with CAD and heart failure actually are at greater risk than other patients. We may actually need to be considering two processes in future research. These seem likely to be “unexpected death in a dialysis patient” and “dialysis-associated arrhythmic death”.
What should clinicians and patients take away from this study?
Standard risk assessment tools for sudden cardiac death are not adequate for use in dialysis patients, and we know that cardiovascular disease behaves differently in CKD. However, what may be an alternative view is to say that the same risk factors apply to dialysis patients as other patients but it is the relative importance of each that is different. In addition to the example regarding coronary artery disease and heart failure mentioned above, studies which have used echocardiography as a baseline risk assessment tool have not shown LVH to be a risk factor but a much larger study of ECG criteria for LVH in diabetic patients showed that LVH is associated with a 60% increase in risk of sudden death. What the nephrologist can learn from this is that, in the absence of any reliable primary prevention tool, aggressive control of cardiovascular risk through blood pressure management, glycemic control and good patient health education may actually be the only effective tool we have in trying to reduce the rate of sudden death in our dialysis patients.
What recommendations do you have for nephrology health care providers as a result of your study?
Thus far, we have not produced any guidance on who to assess or how to risk stratify for sudden death in dialysis patients. It is likely that this is because we are attempting to devise a single screening tool for a heterogeneous group of disease processes. Unfortunately, the way that cause of death data are reported will vary geographically and this makes epidemiological analysis of sudden death difficult. In the UK at least, there is often an assumption that sudden death is due to cardiovascular disease and it will be reported as such without interrogation through post-mortem analysis.
Furthermore, the definition of terminology used will vary. “Sudden death”, “sudden cardiac death” and “sudden cardiac arrest” should not be confused. Similarly, the difference between deaths which are “sudden” and those which are “unexpected” will affect the disease processes being included in analysis. We cannot hope to improve outcome for our patients if we do not ensure that we are accurately and comprehensively recording cause of death data. It may be unrealistic to expect a surge in elective post-mortem analyses, but an agreement on definitions for use by epidemiologists may be achievable.
Dr Darren Green, Research Fellow in Nephrology, University of Manchester
Professor Philip Kalra, Consultant Nephrologist, Salford Royal Hospital and University of Manchester
ABSTRACT
Sudden Cardiac Death in Hemodialysis Patients: An In-Depth Review.
Green D, Roberts PR, New DI, Kalra PA.
Am J Kidney Dis. 2011 Apr 14.
Salford Royal Hospital, Salford, United Kingdom.
Sudden cardiac death (SCD) is the leading cause of death in hemodialysis patients, accounting for death in up to one-quarter of this population. Unlike in the general population, coronary artery disease and heart failure often are not the underlying pathologic processes for SCD; accordingly, current risk stratification tools are inadequate when assessing these patients.
Factors assuming greater importance in hemodialysis patients may include left ventricular hypertrophy, electrolyte shift, and vascular calcification. Knowledge regarding SCD in hemodialysis patients is insufficient, in part reflecting the lack of an agreed-on definition of SCD in this population, although epidemiologic studies suggest the most common times for SCD to occur are toward the end of the long 72-hour weekend interval between dialysis sessions and in the 12 hours immediately after hemodialysis. Accordingly, it is hypothesized that the dialysis procedure itself may have important implications for SCD.
Supporting this is recognition that hemodialysis is associated with both ventricular arrhythmias and dynamic electrocardiographic changes. Importantly, echocardiography and electrocardiography may show changes that are modifiable by alterations to dialysis prescription.
The most effective preventative strategy in the general population, implanted cardioverter-defibrillator devices, are less effective in the presence of chronic kidney disease and have not been studied adequately in dialysis patients.
Last, many dialysis patients experience SCD despite not fulfilling current criteria for implantation, making appropriate allocation of defibrillators uncertain.
Author Interviews: hemodialysis
- Dialysis - ESRD - CKD |
| Mesenteric Ischemia in Patients with End-Stage Renal Disease |
| Estimated Glomerular Filtration Rate and Prognosis in Heart Failure |
| Reduction in Bloodstream Infections in Outpatient Hemodialysis Centers Participating in CDC Collaborative |
| Risk Factors for Dialysis Withdrawal |
| One-Year Assessment of Quality Indicators in Acute Dialysis Program Operated by a Large Dialysis Provider |
| Characteristics of patients most likely to have a missed Dialysis session |
| More Frequent HB measurements & ESA titrations not Associated with Inreased Time in Target HB range |
Study Shows Daily Home Hemodialysis Patients More Likely to Receive Kidney Transplant
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| Characterizing Missed Dialysis Sessions in the ESRD Patient population |
| Hemoglobin Recovery following Hospitalization in ESRD patients |
| Association of Serum Sodium Levels with Mortality in Non-Dialysis Dependent Chronic Kidney Disease |
| Talking Control Support in Hemodialysis Results in Higher Patient Satisfaction Survey Response |
| Use of Fondparinux in Severe Renal Impairment & Hemodialysis |
| Contribution of CA, phosphorus & 25-VitD to the excessive severity of sPTH in African-Americans with CKD |
| Comparison of Risk Prediction Using the CKD-EPI Equation & the MDRD Study Equation for eGFR |
| Iron-Based Phosphate Binder PA21: Effective and Well Tolerated in CKD Hemodialysis Patients |
| Hemoglobin Recovery following Hospitalization in ESRD patients |
| Disease Management Program ESRD Patients Have Lower Overall Medical Costs |
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While Reducing Epoetin Alfa Dose: A Propensity Score Matched Study |
| Perceptions & Roles of Nephrology Social Worker Within the Suicide Continuum of Care |
| Reduced Use of ESAs and IV Iron with Ferric Citrate: A Medicare Bundle Cost-Offset Model |
| Video Education Increases Patient Knowledge About Phosphorus Control |
| Effect of a plasma sodium biofeedback system applied to HFR on the intradialytic cardiovascular stability |
| Hemodialysis Access and Age-related Postoperative Outcomes: Which Fistula First? |
| Coronary Artery Calcification & Pre-Hemodialysis Bicarbonate Levels in Hemodialysis |
| Protein/omega-3 supplementation during regular dialysis sessions & inflammatory indices in hemodialysis |
| VDRA and improved survival in dialysis patients with serum intact PTH ≤150 pg/mL |
| Relation of social support to mental health and locus of control in Chronic Kidney Disease |
| Depression and anxiety in patients with chronic renal failure |
| Self -esteem in Greek dialysis patients: The contribution of health locus of control |
| Medication adherence in Greek hemodialysis patients: Contribution of depression and health cognition. |
| Association of insomnia with kidney disease quality of life reported by patients on maintenance dialysis |
| Comorbidities/ inactivity & long-term outcomes of CABG in small number of men on chronic hemodialysis |
| Complete Recovery From Acute Kidney Injury With Incident CKD Stage 3 and All-Cause Mortalit |
| Outcomes of patients with ESRD under chronic hemodialysis requiring CRRT & in AKI requiring CRRT |
| Radiologically Placed Tunneled Hemodialysis Catheters: Pediatric Institutional Experience of 120 Patients |
| Preload dependence of gated cardiac SPECT-derived ventricular volumes in hemodialysis |
| Effect of Hemoglobin Target on Progression of Kidney Disease |
| eGFR at Reinitiation of Dialysis & Mortality in Failed Kidney Tranplant Recipients |
| Biomarkers Determining Cardiovascular Risk in Kidney Disease |
| Rural and Micropolitan Residence & Mortality in Dialysis |
| Urinalysis is more specific & urinary NGAL is more sensitive for early AKI detection |
| Vascular Klotho Deficiency Potentiates Development of Arterial Calcification & Mediates FGF23 Resistance |
| Efficacy of preventing hemodialysis catheter infections with citrate lock: Hemodialysis Int'l |
| Learn about dialysis options from a Home Dialysis Therapy Nurse |
| Optimal fluid control can normalize CV risk markers and limit LV hypertrophy in thrice weekly dialysis |
| LDL, atherosclerosis and mortality in hemodialysis |
| Pulmonary hypertension in chronic kidney disease on dialysis/ without dialysis |
| Predictors of steal syndrome in hemodialysis Hemodialysis Int'l |
| Sodium intake and blood pressure in renal transplant recipients Nephrology Dialysis Transplant |
| HIV-associated nephropathy patients with & without apolipoprotein L1 gene variants Kidney International |
| Depression and nonadherence predict mortality in hemodialysis treated ESRD patients Hemodialysis Int'l |
| Serum Metabolite Concentrations and Decreased GFR in the General Population AJKD |
| High Volume Peritoneal Dialysis in Acute Kidney Injury CJASN |
| Trial of Catheters of Different Lengths to Achieve Right Atrium vs SVC Placement for CRRT AJKidneyDs |
Pre-kidney transplant ESA agence responsiveness with post-transplant outcomes
Nephrology Dialysis Transplant |
| Prognostic Value of 48-Hour Ambulatory BP & CV Mortality in Hemodialysis Kidney Blood Press Res |
| Darbepoetin-α Cardiovascular Geometry and CKD -Cardiorenal Med |
| Influenza Vaccine Effectiveness in Patients on Hemodialysis Arch Intern Med |
| Bioelectrical Impedance Analysis & Skinfold Thickness Sum in Body Fat Mass in Dialysis J.Renal Nutrition |
| Pre-Diabetes after Renal Transplantation Nephrology Dialysis Transplant |
| Essential trace element status and clinical outcomes in long-term dialysis |
| End-of-Life Decision-Making Confidence in Surrogates of AA Dialysis Patients Is Overly Optimistic |
| Comparison of Cardiac PET Perfusion Defects During Stress Induced by Hemodialysis vs Adenosine AJKD |
| Mental Health over Time & Cardiac Outcomes in HEMO Study CJASN |
| Cholesterol Synthesis, Cholesterol Absorption, & Mortality in Hemodialysis CJASN |
| Statins, Risk & Outcome in Acute Kidney Injury in Community-Acquired Pneumonia CJASN |
| Dialysis-Dependent Changes in Ventricular Repolarization |
| High Burden of Kidney Disease in Youth-Onset Type 2 Diabetes Diabetes Care |
| Late Start Dialysis & Outcomes in Japanese Dialysis: Therapeutic Apheresis & Dialysis |
| Pica in Pediatric Dialysis - J.Renal Nutrition |
| Elemental Concentrations in Scalp Hair in Hemodialysis Patients Therapeutic Apheresis & Dialysis |
Health-related QOL was not improved by targeting higher hemoglobin in the Normal Hematocrit Trial
Kidney Int'l |
| Sevelamer on HbA1c, Inflammation, & Advanced Glycation End Products in Diabetic Kidney Disease CJASN |
| Increasing organ donation via anticipated regret proposed protocol |
| Statins on Chronic Inflammation and Nutrition status in Renal Dialysis |
| Emergency Department Use of Urinary Biomarkers of Nephron Damage |
| Preemptive renal transplant survival, access to care, & renal function at listing Nephrology Dialysis Transplant |
| Effect of Diuretic Use on 30-Day Postdialysis Mortality in Critically Ill Patients Receiving Acute Dialysis Dr. Ko |
| FGF23 predicts incident cardiovascular event before but not after the start of dialysis Dr. Isaka |
| Mortality Prediction by Surrogates of Body Composition: An Examination of the Obesity Paradox in Hemodialysis Using Composite Ranking Score Analysis: Drs. Miklos Z Molnar & Kamyar Kalantar-Zadeh |
| Plasma Sodium & Blood Pressure in Hemodialysis J.Human Hypertension |
| Increased Risk of Death in Young African American Dialysis Patient: Dr. Norman |
| Nutritional Management of Stage 5 CKD J. Renal Nutrition |
A proposed management algorithm for fistulae between hemodialysis access circuits and adjacent veins
Vasc Access |
| Percutaneous approach in maintenance & salvage of dysfunctional autologous vascular access for dialysis |
| The Kidney Disease Quality of Life Cognitive Function Subscale and Cognitive Performance in Maintenance Hemodialysis Patients Amer. J Kidney Diseases |
| Absolute Interdialytic Weight Gain is more important than Percent Weight Gain for Intradialytic Hypotension in heavy hemodialysis patients: Dr. Chen Nephrology |
| Postdialysis BP rise predicts outcomes in hemodialysis: Dr Yang BMC Nephrology |
| APOL1 allelic variants are associated with lower age of dialysis initiation Nephrology Dialysis Transplant |
| Effects of Six versus Three Times per Week Hemodialysis on Physical Performance, Health, and Functioning: Frequent Hemodialysis Network (FHN) Randomized Trials Dr. Hall CJASN |
| Variability of blood pressure in dialysis patients: a new marker of cardiovascular risk Dr. Di Iorio |
| Assessment of Body Composition Using Dry Mass Index and Ratio of Total Body Water to Estimated Volume Based on Bioelectrical Impedance Analysis in CKD J. Renal Nutrition |
| Potential Role of Active Vitamin D Treatment in Telomere Length in Hemodialysis: Dr Valdivielso |
| CKD, severe arterial & arteriolar sclerosis & kidney neoplasia MELAS syndrome Dr. Piccoli BMC Nephrology |
| Pedometer-Assessed Physical Activity in Children and Young Adults with CKD |
| Effect of Frequent or Extended Hemodialysis on Cardiovascular Parameters Amer J. Kidney Ds |
Featured Hemodialysis Interviews |
Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
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National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
- You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
- You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
- There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
- There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
- You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
- You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
- You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
- You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
- You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
- Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
More from National Kidney Foundation Press Releases
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New Book to Help Educate Patients with Chronic Kidney Disease who may be facing Dialysis or Hemodialysis: |
Help, I Need Dialysis!
How to have a good future with kidney disease
By Dori Schatell, MS and Dr. John Agar
An internationally known nephrologist and life-long kidney patient educator explain how dialysis works, each of the ways to do it, and how your treatment choice may affect your diet, energy level, work, travel, sexuality and fertility, sleep, and survival. Comprehensive and fully referenced, this book is a must-read if you face the life-changing choices that come with kidney failure. |
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