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YURDAM F, TATLI MD. Is the magnesium phosphate ratio a predictor of arrhythmia in patients undergoing hemodialysis? JOURNAL OF HEALTH SCIENCES AND MEDICINE 2023. [DOI: 10.32322/jhsm.1207234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Aim: Koroner arter hastalığı, kalp yetmezliği, aritmi veya hiperkalemi nedenli ani ölüm son dönem böbrek yetmezliği hastalarında kardiyovasküler nedenlerin büyük çoğunluğunu oluşturmaktadır. Kanda bulunan Magnezyum, endotel fonksiyonu, damar tonusunun düzenlenmesi ve miyokardiyal uyarılabilirlik gibi kardiyovasküler fonksiyonları düzenleyen birçok süreçte önemli rol oynamaktadır. bu çalışmadaki amacımız; hemodiyaliz alan son dönem böbrek yetmezliği hastalarında Mg / P oranının aritmiyi öngörücülüğünü saptamaktır.
Material and method: 18 yaşından büyük, kardiyoloji polikliniğine başvuran, kronik böbrek yetmezliği nedeniyle hemodiyaliz almakta olan ardışık 103 hasta çalışmaya dahil edildi. Ocak 2018 – Ekim 2022 tarihleri arasında 24 saatlik ritm holter ECG ile monitörize hastalar alındı. Hastalar 24 saatlik ritm holter EKG’ de aritmi saptananlar (grup 1: 51 hasta) ve saptanmayanlar (grup 2: 52 hasta) olarak 2 gruba ayrılarak analiz edildi.
Result: Çalışmadaki hastaların yaş ortalamaları grup 1’ in grup 2’ ye kıyasla anlamlı daha yüksekti (66.96±10,27 ve 62,21±10,50, p=0.02, sırasıyla). Hastaların 24 saatlik ritm Holter EKG’ leri incelendiğinde en sık izlenen aritmi %18.4 (n=19)’ lük oran ile ventriküler ekstrasistol iken ikinci sırada %9.7 (n=10)’ lik oranı ile paroksismal AF’ ydi. ROC curve analizi (Resim-1) göstermiştir ki LVEF
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Affiliation(s)
- Ferhat YURDAM
- Bakırçay Üniversitesi Çiğli Eğitim ve Araştırma Hastanesi
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2
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Genovesi S, Boriani G, Covic A, Vernooij RWM, Combe C, Burlacu A, Davenport A, Kanbay M, Kirmizis D, Schneditz D, van der Sande F, Basile C. Sudden cardiac death in dialysis patients: different causes and management strategies. Nephrol Dial Transplant 2021; 36:396-405. [PMID: 31538192 DOI: 10.1093/ndt/gfz182] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/01/2019] [Indexed: 01/12/2023] Open
Abstract
Sudden cardiac death (SCD) represents a major cause of death in end-stage kidney disease (ESKD). The precise estimate of its incidence is difficult to establish because studies on the incidence of SCD in ESKD are often combined with those related to sudden cardiac arrest (SCA) occurring during a haemodialysis (HD) session. The aim of the European Dialysis Working Group of ERA-EDTA was to critically review the current literature examining the causes of extradialysis SCD and intradialysis SCA in ESKD patients and potential management strategies to reduce the incidence of such events. Extradialysis SCD and intradialysis SCA represent different clinical situations and should be kept distinct. Regarding the problem, numerically less relevant, of patients affected by intradialysis SCA, some modifiable risk factors have been identified, such as a low concentration of potassium and calcium in the dialysate, and some advantages linked to the presence of automated external defibrillators in dialysis units have been documented. The problem of extra-dialysis SCD is more complex. A reduced left ventricular ejection fraction associated with SCD is present only in a minority of cases occurring in HD patients. This is the proof that SCD occurring in ESKD has different characteristics compared with SCD occurring in patients with ischaemic heart disease and/or heart failure and not affected by ESKD. Recent evidence suggests that the fatal arrhythmia in this population may be due more frequently to bradyarrhythmias than to tachyarrhythmias. This fact may partly explain why several studies could not demonstrate an advantage of implantable cardioverter defibrillators in preventing SCD in ESKD patients. Electrolyte imbalances, frequently present in HD patients, could explain part of the arrhythmic phenomena, as suggested by the relationship between SCD and timing of the HD session. However, the high incidence of SCD in patients on peritoneal dialysis suggests that other risk factors due to cardiac comorbidities and uraemia per se may contribute to sudden mortality in ESKD patients.
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Affiliation(s)
- Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center - 'C.I. Parhon' University Hospital, Iasi, Romania.,'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Unité INSERM 1026, Université de Bordeaux, Bordeaux, France
| | - Alexandru Burlacu
- 'Grigore T. Popa' University of Medicine, Iasi, Romania.,Department of Interventional Cardiology - Cardiovascular Diseases Institute, Iasi, Romania
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, Division of Medicine, University College London, London, UK
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | | | - Daniel Schneditz
- Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Frank van der Sande
- Division of Nephrology, Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy.,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
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Bianchi S, Aucella F, De Nicola L, Genovesi S, Paoletti E, Regolisti G. Management of hyperkalemia in patients with kidney disease: a position paper endorsed by the Italian Society of Nephrology. J Nephrol 2019; 32:499-516. [PMID: 31119681 PMCID: PMC6588653 DOI: 10.1007/s40620-019-00617-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 05/05/2019] [Indexed: 12/11/2022]
Abstract
Hyperkalemia (HK) is the most common electrolyte disturbance observed in patients with kidney disease, particularly in those in whom diabetes and heart failure are present or are on treatment with renin-angiotensin-aldosterone system inhibitors (RAASIs). HK is recognised as a major risk of potentially life threatening cardiac arrhythmic complications. When an acute reduction of renal function manifests, both in patients with chronic kidney disease (CKD) and in those with previously normal renal function, HK is the main indication for the execution of urgent medical treatment and the recourse to extracorporeal replacement therapies. In patients with end-stage renal disease, the presence of HK not responsive to medical therapy is an indication at the beginning of chronic renal replacement therapy. HK can also be associated indirectly with the progression of CKD, because the finding of high potassium values leads to withdrawal of treatment with RAASIs, which constitute the first choice nephro-protective treatment. It is therefore essential to identify patients at risk of developing HK, and to implement therapeutic interventions aimed at preventing and treating this dangerous complication of kidney disease. Current strategies aimed at the prevention and treatment of HK are still unsatisfactory, as evidenced by the relatively high prevalence of HK also in patients under stable nephrology care, and even in the ideal setting of randomized clinical trials where optimal treatment and monitoring are mandatory. This position paper will review the main therapeutic interventions to be implemented for the prevention, detection and treatment of HK in patients with CKD on conservative care, in those on dialysis, in patients in whom renal disease is associated with diabetes, heart failure, resistant hypertension and who are on treatment with RAASIs, and finally in those presenting with severe acute HK.
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Affiliation(s)
- Stefano Bianchi
- Nephrology and Dialysis Unit, Department of Internal Medicine, Azienda ASL Toscana Nord Ovest, Livorno, Italy
| | - Filippo Aucella
- Nephrology and Dialysis Unit, IRCCS “Casa Sollievo della Sofferenza” Scientific Institute for Research and Health Care, San Giovanni Rotondo, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania, Naples, Italy
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano - Bicocca San Gerardo Hospital, Nephrology Unit, Monza, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis and Transplantation, University of Genoa and Policlinico, San Martino Genoa, Italy
| | - Giuseppe Regolisti
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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4
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Vijayakumar S, Butler J, Bakris GL. Barriers to guideline mandated renin-angiotensin inhibitor use: focus on hyperkalaemia. Eur Heart J Suppl 2019; 21:A20-A27. [PMID: 30837801 PMCID: PMC6392419 DOI: 10.1093/eurheartj/suy030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hyperkalaemia in patients with chronic disease states can be caused by both abnormalities of potassium homeostasis as well as extrinsic factors such as medication use and potassium intake. In patients with heart failure (HF), chronic kidney disease (CKD), diabetes mellitus (DM), and in those who use renin-angiotensin-aldosterone system inhibitors (RAASi), there is particularly increased risk of chronic or recurrent hyperkalaemia. Hyperkalaemia is often a reason for the suboptimal dosing or complete discontinuation of RAASi. This review presents current options for the management of hyperkalaemia in patients with chronic disease states. It also explores barriers to guideline-mediated RAASi prescribing patterns in these high-risk patients and highlights the unmet need for agents that adequately manage hyperkalaemia in patients with chronic diseases on concomitant RAASi therapy.
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Affiliation(s)
- Shilpa Vijayakumar
- Department of Medicine, Stony Brook University, 101 Nicolls Road, Stony Brook, NY, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, 2500 North State Street, Jackson, MS, USA
| | - George L Bakris
- Department of Medicine, Comprehensive Hypertension Center, The University of Chicago Medicine, 5481 S. Maryland Avenue MC 1027, Chicago, IL, USA
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5
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Pun PH. Dialysate potassium concentration: Should mass balance trump electrophysiology? Semin Dial 2018; 31:569-575. [PMID: 30027592 DOI: 10.1111/sdi.12738] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Nephrologists are faced with a difficult dilemma in choosing the ideal dialysis prescription to maintain neutral potassium mass balance. Should potassium mass balance goals prioritize the normalization of serum potassium levels using low potassium dialysate at the expense of provoking intradialytic arrhythmias, or should mass balance goals favor permissive hyperkalemia using higher dialysate potassium to avoid rapid intradialytic fluxes at the risk of more interdialytic arrhythmias? This review examines the factors that determine potassium mass balance among HD patients, the relationships between serum and dialysate potassium levels and outcomes, and concludes by examining currently available approaches to reducing risk of arrhythmias while managing potassium mass balance.
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Affiliation(s)
- Patrick H Pun
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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6
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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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Pun PH, Middleton JP. Dialysate Potassium, Dialysate Magnesium, and Hemodialysis Risk. J Am Soc Nephrol 2017; 28:3441-3451. [PMID: 28993507 DOI: 10.1681/asn.2017060640] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
One of the fundamental goals of the hemodialysis prescription is to maintain serum potassium levels within a narrow normal range during both the intradialytic and interdialytic intervals. Considering the extraordinarily high rate of cardiovascular mortality in the hemodialysis population, clinicians are obligated to explore whether factors related to dialytic potassium removal can be modified to improve clinical outcomes. Observational studies and circumstantial evidence suggest that extreme concentrations of serum and dialysate potassium can trigger cardiac arrest. In this review, we provide an overview of factors affecting overall potassium balance and factors modulating potassium dialysate fluxes in dialysis, and we review data linking serum and dialysate potassium concentrations with arrhythmias, cardiovascular events, and mortality. We explore potential interactions between serum and dialysate magnesium levels and risks associated with dialysate potassium levels. Finally, we conclude with proposed dialytic and novel nondialytic approaches to optimize outcomes related to potassium homeostasis in patients on hemodialysis. Dialysis clinicians need to consider changes in the overall clinical scenario when choosing dialysate potassium concentrations, and an effective change in practice will require more frequent serum potassium monitoring and responsive dialysis care teams.
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Affiliation(s)
- Patrick H Pun
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; and .,Duke Clinical Research Institute, Durham, North Carolina
| | - John P Middleton
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; and
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Abuelo JG. Treatment of Severe Hyperkalemia: Confronting 4 Fallacies. Kidney Int Rep 2017; 3:47-55. [PMID: 29340313 PMCID: PMC5762976 DOI: 10.1016/j.ekir.2017.10.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/08/2017] [Accepted: 10/02/2017] [Indexed: 01/03/2023] Open
Abstract
Severe hyperkalemia is a medical emergency that can cause lethal arrhythmias. Successful management requires monitoring of the electrocardiogram and serum potassium concentrations, the prompt institution of therapies that work both synergistically and sequentially, and timely repeat dosing as necessary. It is of concern then that, based on questions about effectiveness and safety, many physicians no longer use 3 key modalities in the treatment of severe hyperkalemia: sodium bicarbonate, sodium polystyrene sulfonate (Kayexalate [Concordia Pharmaceuticals Inc., Oakville, ON, Canada], SPS [CMP Pharma, Farmville, NC]), and hemodialysis with low potassium dialysate. After reviewing older reports and newer information, I believe that these exclusions are ill advised. In this article, I briefly discuss the treatment of severe hyperkalemia and detail why these modalities are safe and effective and merit inclusion in the treatment of severe hyperkalemia.
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Affiliation(s)
- J Gary Abuelo
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island, USA
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9
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Sacher F, Jesel L, Borni-Duval C, De Precigout V, Lavainne F, Bourdenx JP, Haddj-Elmrabet A, Seigneuric B, Keller A, Ott J, Savel H, Delmas Y, Bazin-Kara D, Klotz N, Ploux S, Buffler S, Ritter P, Rondeau V, Bordachar P, Martin C, Deplagne A, Reuter S, Haissaguerre M, Gourraud JB, Vigneau C, Mabo P, Maury P, Hannedouche T, Benard A, Combe C. Cardiac Rhythm Disturbances in Hemodialysis Patients: Early Detection Using an Implantable Loop Recorder and Correlation With Biological and Dialysis Parameters. JACC Clin Electrophysiol 2017; 4:397-408. [PMID: 30089568 DOI: 10.1016/j.jacep.2017.08.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/31/2017] [Accepted: 08/02/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The aim of this study was to identify using implantable loop recorder (ILR) monitoring the mechanisms leading to sudden death (SD) in patients undergoing hemodialysis (HD). BACKGROUND SD accounts for 11% to 25% of death in HD patients. METHODS Continuous rhythm monitoring was performed using the remote monitoring capability of the ILR device in patients undergoing HD at 8 centers. Clinical, biological, and technical HD parameters were recorded and analyzed. RESULTS Seventy-one patients (mean age 65 ± 9 years, 73% men) were included. Left ventricular ejection fraction was <50% in 16%. Twelve patients (17%) had histories of atrial fibrillation or flutter at inclusion. During a mean follow-up period of 21.3 ± 6.9 months, 16 patients died (14% patient-years), 7 (44%) of cardiovascular causes. Four SDs occurred, with progressive bradycardia followed by asystole. The incidence of patients presenting with significant conduction disorder and with ventricular arrhythmia was 14% and 9% patient-years, respectively. In multivariate survival frailty analyses, a higher risk for conduction disorder was associated with plasma potassium >5.0 mmol/l, bicarbonate <22 mmol/l, hemoglobin >11.5 g/dl, pre-HD systolic blood pressure >140 mm Hg, the longer interdialytic period, history of coronary artery disease, previous other arrhythmias, and diabetes mellitus. A higher risk for ventricular arrhythmia was associated with potassium <4.0 mmol/l, no antiarrhythmic drugs, and previous other arrhythmias. With ILR monitoring, de novo atrial fibrillation or flutter was diagnosed in 14 patients (20%). CONCLUSIONS ILR may be considered in HD patients prone to significant conduction disorders, ventricular arrhythmia, or atrial fibrillation or flutter to allow early identification and initiation of adequate treatment. Therapeutic strategies reducing serum potassium variability could decrease the rate of SD in these patients. (Implantable Loop Recorder in Hemodialysis Patients [RYTHMODIAL]; NCT01252823).
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Affiliation(s)
- Frederic Sacher
- IHU LIRYC - Universite de Bordeaux, INSERM 1045, Bordeaux, France; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Laurence Jesel
- Hôpitaux Universitaires de Strasbourg and Medical School of Strasbourg, Strasbourg, France
| | - Claire Borni-Duval
- Hôpitaux Universitaires de Strasbourg and Medical School of Strasbourg, Strasbourg, France
| | | | | | | | | | | | | | - Julien Ott
- Centre Hospitalier de Haguenau, Haguenau, France
| | - Helene Savel
- Unité de Soutien Méthodologique à la Recherche Clinique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Yahsou Delmas
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Dorothée Bazin-Kara
- Hôpitaux Universitaires de Strasbourg and Medical School of Strasbourg, Strasbourg, France
| | - Nicolas Klotz
- IHU LIRYC - Universite de Bordeaux, INSERM 1045, Bordeaux, France; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Sylvain Ploux
- IHU LIRYC - Universite de Bordeaux, INSERM 1045, Bordeaux, France; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | - Philippe Ritter
- IHU LIRYC - Universite de Bordeaux, INSERM 1045, Bordeaux, France; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Virginie Rondeau
- Unité de Soutien Méthodologique à la Recherche Clinique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Pierre Bordachar
- IHU LIRYC - Universite de Bordeaux, INSERM 1045, Bordeaux, France; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Claire Martin
- IHU LIRYC - Universite de Bordeaux, INSERM 1045, Bordeaux, France; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | | | - Michel Haissaguerre
- IHU LIRYC - Universite de Bordeaux, INSERM 1045, Bordeaux, France; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | - Cécile Vigneau
- Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Philippe Mabo
- Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Philippe Maury
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Thierry Hannedouche
- Hôpitaux Universitaires de Strasbourg and Medical School of Strasbourg, Strasbourg, France
| | - Antoine Benard
- Unité de Soutien Méthodologique à la Recherche Clinique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Christian Combe
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Unité INSERM 1026, Universite de Bordeaux, Bordeaux, France
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Sabzghabaei F, Heydariezade SA, Joodat RS. The effects of different electrolyte composition in dialysate on QTc interval; a controlled trial. J Renal Inj Prev 2016; 5:153-6. [PMID: 27689113 PMCID: PMC5040003 DOI: 10.15171/jrip.2016.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 04/05/2016] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Hemodialysis (HD) has impact on the cardiovascular system by inducing changes in the characteristics of body fluids such as PH, temperature and electrolyte concentrations. In the previous studies, prolongation of the QT interval and increase of QT dispersion have been reported during HD sessions. These changes were more significant while using solutions with less potassium and higher bicarbonate during dialysis. OBJECTIVES The aim of our study was to investigate the effects of different potassium and bicarbonate concentrations on electrocardiography (ECG) parameters and the electrochemical balance of cell membranes. PATIENTS AND METHODS This is a double blind controlled clinical trial with crossover design. This interventional study has been conducted on 36 patients over 18 years who undergoing HD 3 times a week for at least 6 months. Twelve-lead ECG has been obtained before starting and one hour after end of each HD session. The QTc was measured and changes recorded by a cardiologist. Correlations were evaluated by univariate regression analysis. RESULTS 54.38 years (16 to 77 years), 66.7% were male. No significant increase in QT interval has been seen while dialyzing with 2 meq/l potassium and 24 meq/l bicarbonate, 2 meq/l potassium and 28 meq/l bicarbonate and 3 meq/l potassium and 24 meq/l bicarbonate beside high calcium (2.5 meq/l) dialysate was conducted. Age, gender, serum calcium and serum bicarbonate level before HD session did not influence the mean QT intervals before and after dialysis. CONCLUSION Concentration of potassium beside moderate dose of bicarbonate in dialysis bath had not any significant influence on QT intervals after dialysis.
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Affiliation(s)
- Foroogh Sabzghabaei
- Department of Medicine, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | - Rashin S Joodat
- Department of Medicine, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
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Di Lullo L, Rivera R, Barbera V, Bellasi A, Cozzolino M, Russo D, De Pascalis A, Banerjee D, Floccari F, Ronco C. Sudden cardiac death and chronic kidney disease: From pathophysiology to treatment strategies. Int J Cardiol 2016; 217:16-27. [PMID: 27174593 DOI: 10.1016/j.ijcard.2016.04.170] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 04/27/2016] [Accepted: 04/30/2016] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD) patients demonstrate higher rates of cardiovascular mortality and morbidity; and increased incidence of sudden cardiac death (SCD) with declining kidney failure. Coronary artery disease (CAD) associated risk factors are the major determinants of SCD in the general population. However, current evidence suggests that in CKD patients, traditional cardiovascular risk factors may play a lesser role. Complex relationships between CKD-specific risk factors, structural heart disease, and ventricular arrhythmias (VA) contribute to the high risk of SCD. In dialysis patients, the occurrence of VA and SCD could be exacerbated by electrolyte shifts, divalent ion abnormalities, sympathetic overactivity, inflammation and iron toxicity. As outcomes in CKD patients after cardiac arrest are poor, primary and secondary prevention of SCD and cardiac arrest could reduce cardiovascular mortality in patients with CKD.
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Affiliation(s)
- L Di Lullo
- Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro, Rome, Italy.
| | - R Rivera
- Division of Nephrology, S. Gerardo Hospital, Monza, Italy
| | - V Barbera
- Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro, Rome, Italy
| | - A Bellasi
- Department of Nephrology and Dialysis, S. Anna Hospital, Como, Italy
| | - M Cozzolino
- Department of Health Sciences, Renal Division, San Paolo Hospital, University of Milan, Italy
| | - D Russo
- Division of Nephrology, University of Naples "Federico II", Naples, Italy
| | - A De Pascalis
- Department of Nephrology and Dialysis, Vito Fazzi Hospital, Lecce, Italy
| | - D Banerjee
- Consultant Nephrologist and Reader, Clinical Sub Dean, Renal and Transplantation Unit, St George's University, London, UK
| | - F Floccari
- Department of Nephrology and Dialysis, S. Paolo Hospital, Civitavecchia, Italy
| | - C Ronco
- International Renal Research Institute, S. Bortolo Hospital, Vicenza, Italy
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12
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Charytan DM, Foley R, McCullough PA, Rogers JD, Zimetbaum P, Herzog CA, Tumlin JA. Arrhythmia and Sudden Death in Hemodialysis Patients: Protocol and Baseline Characteristics of the Monitoring in Dialysis Study. Clin J Am Soc Nephrol 2016; 11:721-34. [PMID: 26763255 DOI: 10.2215/cjn.09350915] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Dialysis patients have high rates of cardiovascular morbidity and mortality, but data on arrhythmia burden, arrhythmia type, arrhythmia triggers, and the identity of terminal arrhythmias have historically been limited by an inability to monitor heart rhythm for prolonged periods. OBJECTIVES To investigate arrhythmia and its association with sudden death in dialysis-dependent ESRD, describe the potential for implantable devices to advance study of dialysis physiology, review the ethical implications of using implantable devices in clinical studies, and report on the protocol and baseline results of the Monitoring in Dialysis Study (MiD). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this multicenter, interventional-observational, prospective cohort study, we placed implantable loop recorders in patients undergoing long-term hemodialysis. The proportion of patients experiencing clinically significant arrhythmias was the primary endpoint. For 6 months, we captured detailed data on the primary endpoint, symptomatic arrhythmias, other electrocardiographic variables, dialysis prescription, electrolytes, dialysis-related variables, and vital signs. We collected additional electrocardiographic data for up to 1 year. RESULTS Overall, 66 patients underwent implantation in sites in the United States and India. Diabetes was present in 63.6% of patients, 12.1% were age ≥70 years, 69.7% were men, and 53.0% were black. Primary and secondary endpoint data are expected in 2016. CONCLUSIONS Cardiac arrhythmia is an important contributor to cardiovascular morbidity and mortality in dialysis patients, but available technology has previously limited the ability to estimate its true burden and triggers and to define terminal rhythms in sudden death. Use of implantable technology in observational studies raises complex issues but may greatly expand understanding of dialysis physiology. The use of implantable loop recorders in MiD is among the first examples of such a trial, and the results are expected to provide novel insights into the nature of arrhythmia in hemodialysis patients.
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Affiliation(s)
- David M Charytan
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts;
| | - Robert Foley
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
| | - Peter A McCullough
- Department of Medicine, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas; Department of Medicine, Division of Cardiology, The Heart Hospital, Plano, Texas
| | - John D Rogers
- Department of Cardiology, Scripps Clinic, Torrey Pines, California
| | - Peter Zimetbaum
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; and
| | - Charles A Herzog
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
| | - James A Tumlin
- Department of Medicine, University of Tennessee, Chattanooga College of Medicine, Chattanooga, Tennessee
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Silva RT, Martinelli Filho M, Peixoto GDL, de Lima JJG, de Siqueira SF, Costa R, Gowdak LHW, de Paula FJ, Kalil Filho R, Ramires JAF. Predictors of Arrhythmic Events Detected by Implantable Loop Recorders in Renal Transplant Candidates. Arq Bras Cardiol 2015; 105:493-502. [PMID: 26351983 PMCID: PMC4651408 DOI: 10.5935/abc.20150106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 05/21/2015] [Accepted: 06/01/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The recording of arrhythmic events (AE) in renal transplant candidates (RTCs) undergoing dialysis is limited by conventional electrocardiography. However, continuous cardiac rhythm monitoring seems to be more appropriate due to automatic detection of arrhythmia, but this method has not been used. OBJECTIVE We aimed to investigate the incidence and predictors of AE in RTCs using an implantable loop recorder (ILR). METHODS A prospective observational study conducted from June 2009 to January 2011 included 100 consecutive ambulatory RTCs who underwent ILR and were followed-up for at least 1 year. Multivariate logistic regression was applied to define predictors of AE. RESULTS During a mean follow-up of 424 ± 127 days, AE could be detected in 98% of patients, and 92% had more than one type of arrhythmia, with most considered potentially not serious. Sustained atrial tachycardia and atrial fibrillation occurred in 7% and 13% of patients, respectively, and bradyarrhythmia and non-sustained or sustained ventricular tachycardia (VT) occurred in 25% and 57%, respectively. There were 18 deaths, of which 7 were sudden cardiac events: 3 bradyarrhythmias, 1 ventricular fibrillation, 1 myocardial infarction, and 2 undetermined. The presence of a long QTc (odds ratio [OR] = 7.28; 95% confidence interval [CI], 2.01-26.35; p = 0.002), and the duration of the PR interval (OR = 1.05; 95% CI, 1.02-1.08; p < 0.001) were independently associated with bradyarrhythmias. Left ventricular dilatation (LVD) was independently associated with non-sustained VT (OR = 2.83; 95% CI, 1.01-7.96; p = 0.041). CONCLUSIONS In medium-term follow-up of RTCs, ILR helped detect a high incidence of AE, most of which did not have clinical relevance. The PR interval and presence of long QTc were predictive of bradyarrhythmias, whereas LVD was predictive of non-sustained VT.
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Affiliation(s)
- Rodrigo Tavares Silva
- Instituto do Coração do Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Martino Martinelli Filho
- Instituto do Coração do Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Giselle de Lima Peixoto
- Instituto do Coração do Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - José Jayme Galvão de Lima
- Instituto do Coração do Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Sérgio Freitas de Siqueira
- Instituto do Coração do Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Roberto Costa
- Instituto do Coração do Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Luís Henrique Wolff Gowdak
- Instituto do Coração do Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Flávio Jota de Paula
- Unidade de Transplante Renal - Divisão de Urologia do
Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo,
SP - Brazil
| | - Roberto Kalil Filho
- Instituto do Coração do Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - José Antônio Franchini Ramires
- Instituto do Coração do Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
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14
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Huang CW, Lee MJ, Lee PT, Hsu CY, Huang WC, Chen CL, Chou KJ, Fang HC. Low Potassium Dialysate as a Protective Factor of Sudden Cardiac Death in Hemodialysis Patients with Hyperkalemia. PLoS One 2015; 10:e0139886. [PMID: 26440515 PMCID: PMC4595334 DOI: 10.1371/journal.pone.0139886] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/19/2015] [Indexed: 11/18/2022] Open
Abstract
AIM Hyperkalemia increases the risk of sudden cardiac death (SCD) in hemodialysis patients. Our objective was to determine the association between administering low potassium dialysate to hyperkalemic hemodialysis patients and SCD. METHODS We conducted a retrospective cohort study with patients undergoing maintenance hemodialysis from May 1, 2006, through December 31, 2013. The dialysate composition was adjusted over time according to monthly laboratory results. A 1.0 mEq/L potassium dialysate was applied in patients with predialysis hyperkalemia (>5.5 mEq/L) and was included as a time-dependent confounding factor. The clinical characteristics of enrolled patients, the incidence and timing of SCD and risk factors for all-cause mortality and SCD were analyzed. RESULTS There were 312 patients on maintenance hemodialysis during the study period. One hundred and fifty-seven patients had been dialyzed against a 1.0 mEq/L potassium dialysate at least once. The rates of all-cause mortality and SCD were 48.17 and 20.74 per 1000 patient-years, respectively. A 1.12-fold increase in the risk of SCD in the 24-hour period starting with the hemodialysis procedure and a 1.36-fold increase in the 24 hours preceding a weekly cycle were found (p = 0.017). Multivariate Cox proportional hazards models showed that age, diabetes mellitus and predialysis hyperkalemia (>5.0 mEq/L) were significant predictors of all-cause mortality and SCD. Exposure to 1.0 mEq/L potassium dialysate, Kt/V, and serum albumin were independent protective factors against all-cause mortality. Only exposure to 1.0 mEq/L potassium dialysate significantly prevented SCD (hazard ratio = 0.33, 95% CI = 0.13-0.85). CONCLUSIONS Using low potassium dialysate in hyperkalemic hemodialysis patients may prevent SCD.
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Affiliation(s)
- Chien-Wei Huang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Min-Jing Lee
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Po-Tsang Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, School of Medicine, Taipei, Taiwan
| | - Chih-Yang Hsu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wei-Chieh Huang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chien-Liang Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, School of Medicine, Taipei, Taiwan
| | - Kang-Ju Chou
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, School of Medicine, Taipei, Taiwan
| | - Hua-Chang Fang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, School of Medicine, Taipei, Taiwan
- * E-mail:
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15
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Locatelli F, La Milia V, Violo L, Del Vecchio L, Di Filippo S. Optimizing haemodialysate composition. Clin Kidney J 2015; 8:580-9. [PMID: 26413285 PMCID: PMC4581377 DOI: 10.1093/ckj/sfv057] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/17/2015] [Indexed: 11/25/2022] Open
Abstract
Survival and quality of life of dialysis patients are strictly dependent on the quality of the haemodialysis (HD) treatment. In this respect, dialysate composition, including water purity, plays a crucial role. A major aim of HD is to normalize predialysis plasma electrolyte and mineral concentrations, while minimizing wide swings in the patient's intradialytic plasma concentrations. Adequate sodium (Na) and water removal is critical for preventing intra- and interdialytic hypotension and pulmonary edema. Avoiding both hyper- and hypokalaemia prevents life-threatening cardiac arrhythmias. Optimal calcium (Ca) and magnesium (Mg) dialysate concentrations may protect the cardiovascular system and the bones, preventing extraskeletal calcifications, severe secondary hyperparathyroidism and adynamic bone disease. Adequate bicarbonate concentration [HCO3−] maintains a stable pH in the body fluids for appropriate protein and membrane functioning and also protects the bones. An adequate dialysate glucose concentration prevents severe hyperglycaemia and life-threating hypoglycaemia, which can lead to severe cardiovascular complications and a worsening of diabetic comorbidities.
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Affiliation(s)
- Francesco Locatelli
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Vincenzo La Milia
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Leano Violo
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Lucia Del Vecchio
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Salvatore Di Filippo
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
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16
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Abuelo JG. Low dialysate potassium concentration: an overrated risk factor for cardiac arrhythmia? Semin Dial 2014; 28:266-75. [PMID: 25488729 DOI: 10.1111/sdi.12337] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Serum potassium concentrations rise with dietary potassium intake between dialysis sessions and are often at hyperkalemic levels by the next session. Conversely, potassium concentrations fall during each hemodialysis, and sometimes reach hypokalemic levels by the end. Low potassium dialysate, which rapidly decreases serum potassium and often brings it to hypokalemic levels, is almost universally considered a risk factor for life-threatening arrhythmias. While there is little doubt about the threat of lethal arrhythmias due to hyperkalemia, convincing evidence for the danger of low potassium dialysate and rapid or excess potassium removal has not been forthcoming. The original report of more frequent ventricular ectopy in early dialysis that was improved by reducing potassium removal has received very little confirmation from subsequent studies. Furthermore, the occurrence of ventricular ectopy during dialysis does not appear to predict mortality. Studies relating sudden deaths to low potassium dialysate are countered by studies with more thorough adjustment for markers of poor health. Dialysate potassium concentrations affect the excursions of serum potassium levels above or below the normal range, and have the potential to influence dialysis safety. Controlled studies of different dialysate potassium concentration and their effect on mortality and cardiac arrests have not been done. Until these results become available, I propose interim guidelines for the setting of dialysate potassium levels that may better balance risks and benefits.
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Affiliation(s)
- J Gary Abuelo
- Division of Kidney Disease and Hypertension, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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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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18
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Abstract
Disordered potassium homeostasis is a common complication of chronic kidney disease and traditional management focuses on restricting potassium intake to avoid hyperkalemia. Permissive potassium intake carries the risk of hyperkalemia and hyperphosphatemia, and possibly may contribute to the development of uremic neuropathy. Excessive potassium restriction and removal by dialysis carries the risk of worsened chronic hypertension, intradialytic hypotension, renal fibrosis and cyst formation, and ventricular arrhythmias. Cohort studies have associated both hypokalemia and hyperkalemia with increased mortality in CKD. A single study of potassium intake in hemodialysis patients found increased intake associated with increased mortality despite adjustment for serum potassium concentration. We recommend avoiding mandatory potassium restriction in early chronic kidney disease. We endorse routine potassium restriction in advanced chronic kidney disease requiring hemodialysis and close monitoring of serum potassium concentration in any patients receiving renin-angiotensin-aldosterone system blockers.
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Affiliation(s)
- Arjun D Sinha
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
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19
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Green D, Ritchie JP, Abidin N, New DI, Kalra PA. The association of ECG and echocardiographic abnormalities with sudden cardiac death in a dialysis patient cohort. J Nephrol 2013; 27:81-6. [PMID: 24519866 DOI: 10.1007/s40620-013-0013-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 06/05/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cardiovascular mortality is greater in dialysis patients than the general population. More specifically, sudden cardiac death (SCD) accounts for 26% of dialysis patient deaths. However, SCD risk assessment tools used in the general population are not adequate for dialysis patients indicating that the hierarchy of pathopysiological factors appears to be different. The aim of this study was to use simple bedside tests to determine parameters independently predictive of cardiovascular mortality and SCD in dialysis patients. METHOD AND RESULTS This was a sub-study of the Chronic Renal Insufficient Standards Implementations Study, a longitudinal cohort study of outcomes in CKD. ECG and echocardiographic abnormalities were assessed in a cross-section of prevalent dialysis patients. Patients were followed up until death or transplantation. Forward stepwise Cox regression then determined factors independently associated with all-cause, cardiovascular and SCD mortality. 323 patients were included (age 61.5 ± 14.6 years, 113 deaths, 66 cardiovascular deaths, 18 SCD). A number of factors were independently associated with all-cause mortality. These were age, time on dialysis, smoking, the difference between QRS and T-wave axes, resting heart rate, and pulmonary artery pressure (PAP) >35 mmHg. The only parameters predictive of SCD were elevated PAP (HR = 5.99, p = 0.05) and mitral regurgitation (HR = 6.71, p = 0.01). CONCLUSION That PAP is associated with SCD in dialysis patients demonstrates that the pathophysiological mechanism is likely to be different in these patients compared to the general population. Because of this, a population specific approach to risk stratification is advisable.
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20
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Lacquaniti A, Donato V, Lucisano S, Buemi A, Buemi M. A Biotechnological T-Shirt Monitors the Patient’s Heart during Hemodialysis. Ren Fail 2012; 34:818-20. [DOI: 10.3109/0886022x.2012.673530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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GREEN DARREN, BATCHVAROV VELISLAV, WIJESEKARA CHANDRAKUMARA, KALRA PHILIPA, CAMM ALANJ. Dialysis-Dependent Changes in Ventricular Repolarization. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:703-10. [DOI: 10.1111/j.1540-8159.2012.03364.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Rodriguez-Fernandez R, Infante O, Perez-Grovas H, Hernandez E, Ruiz-Palacios P, Franco M, Lerma C. Visual three-dimensional representation of beat-to-beat electrocardiogram traces during hemodiafiltration. Artif Organs 2011; 36:543-51. [PMID: 22188600 DOI: 10.1111/j.1525-1594.2011.01382.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This study evaluated the usefulness of the three-dimensional representation of electrocardiogram traces (3DECG) to reveal acute and gradual changes during a full session of hemodiafiltration (HDF) in end-stage renal disease (ESRD) patients. Fifteen ESRD patients were included (six men, nine women, age 46 ± 19 years old). Serum electrolytes, blood pressure, heart rate, and blood urea nitrogen (BUN) were measured before and after HDF. Continuous electrocardiograms (ECGs) obtained by Holter monitoring during HDF were used to produce the 3DECG. Several major disturbances were identified by 3DECG images: increase in QRS amplitude (47%), decrease in T-wave amplitude (33%), increase in heart rate (33%), and occurrence of arrhythmia (53%). Different arrhythmia types were often concurrent and included isolated supraventricular premature beats (N = 5), atrial fibrillation or atrial bigeminy (N = 2), and isolated premature ventricular beats (N = 6). Patients with decrease in T-wave amplitude had higher potassium and BUN (both before HDF and total removal) than those without decrease in T-wave amplitude (P < 0.05). Concurrent acute and gradual ECG changes during HDF are identified by the 3DECG, which could be useful as a preventive and prognostic method.
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Affiliation(s)
- Rodrigo Rodriguez-Fernandez
- Departamento de Instrumentación Electromecánica, Instituto Nacional de Cardiología Ignacio Chávez, Tlalpan, Mexico, DF Mexico
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23
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Green D, Roberts PR, New DI, Kalra PA. Sudden cardiac death in hemodialysis patients: an in-depth review. Am J Kidney Dis 2011; 57:921-9. [PMID: 21496983 DOI: 10.1053/j.ajkd.2011.02.376] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 02/22/2011] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Darren Green
- Salford Royal Hospital, Stott Lane, Salford, United Kingdom
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24
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Abstract
Annual cardiovascular mortality in patients with chronic kidney disease (CKD) is much higher than in the general population. The rate of sudden cardiac death increases as the stage of CKD increases and could be responsible for 60% of cardiac deaths in patients undergoing dialysis. In hemodialysis units treating patients with CKD, cardiac arrest occurs at a rate of seven arrests per 100,000 hemodialysis sessions. Important risk factors for sudden cardiac death in patients with CKD include hospitalization within the past 30 days, a drop of 30 mmHg in systolic blood pressure during hemodialysis, duration of life on hemodialysis, time since the previous dialysis session, and the presence of concomitant diabetes mellitus. As a result of the adverse cardiomyopathic and vasculopathic milieu in CKD, the occurrence of arrhythmias, conduction abnormalities, and sudden cardiac death could be exacerbated by electrolyte shifts, divalent ion abnormalities, diabetes, sympathetic overactivity, in addition to inflammation and perhaps iron deposition. Impaired baroreflex effectiveness and sensitivity, as well as obstructive sleep apnea, might also contribute to the risk of sudden death in CKD. The likelihood of survival following cardiac arrest is very low in dialysis patients. Primary and secondary prevention of cardiac arrest could reduce cardiovascular mortality in patients with CKD. Cardioverter-defibrillator implantation decreases the risk of sudden death in patients with CKD. The decision to implant a cardioverter-defibrillator should be influenced by the patient's age and stage of CKD.
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27
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Differential effects of hemofiltration and of coupled plasma filtration adsorption on cardiac repolarization in pigs with hyperdynamic septic shock. Shock 2010; 33:101-5. [PMID: 19487980 DOI: 10.1097/shk.0b013e3181ab6359] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim was to investigate effects of continuous hemofiltration (CHF) and of coupled plasma filtration adsorption (CPFA) on electrophysiological properties of the septic heart. Sepsis was induced in anesthetized pigs by fecal peritonitis and continued for 22 h either without intervention (control sepsis) or with intervention (CHF or CPFA) applied for the last 10 h of this period. Electrocardiograms were recorded at baseline, before induction of peritonitis, and 22 h later, at the end of in vivo experiment. In vitro, action potentials were recorded in right ventricular trabeculae. RR, QT, and QTc (QT corrected for heart rate) intervals were shortened by sepsis. Action potential durations (APDs) were shortened by CHF, but not by CPFA, compared with control sepsis. Continuous hemofiltration prolonged APD. Coupled plasma filtration adsorption filtrate did not exert any effect on APD. Plasma separated during CPFA prolonged APD. Continuous hemofiltration shortened cardiac repolarization, and this effect was reversed by the hemofiltrate. In contrast, neither CPFA nor the CPFA filtrate influenced APD. The data indicate that some inflammatory mediators able to delay cardiac repolarization were removed from plasma to hemofiltrate by CHF but not by CPFA.
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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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Kouidi EJ, Grekas DM, Deligiannis AP. Effects of Exercise Training on Noninvasive Cardiac Measures in Patients Undergoing Long-term Hemodialysis: A Randomized Controlled Trial. Am J Kidney Dis 2009; 54:511-21. [DOI: 10.1053/j.ajkd.2009.03.009] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 03/20/2009] [Indexed: 11/11/2022]
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Mohi-ud-din K, Bali HK, Banerjee S, Sakhuja V, Jha V. Silent Myocardial Ischemia and High-Grade Ventricular Arrhythmias in Patients on Maintenance Hemodialysis. Ren Fail 2009. [DOI: 10.1081/jdi-48236] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Bozbas H, Atar I, Yildirir A, Ozgul A, Uyar M, Ozdemir N, Muderrisoglu H, Ozin B. Prevalence and Predictors of Arrhythmia in End Stage Renal Disease Patients on Hemodialysis. Ren Fail 2009; 29:331-9. [PMID: 17497448 DOI: 10.1080/08860220701191237] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Sudden death is common in end-stage renal disease (ESRD). Cardiac arrhythmia is observed frequently in patients with ESRD and is thought to be responsible for this high rate of sudden death. This study investigated the prevalence and the predictors of arrhythmia in patients on maintenance dialysis. METHODS Ninety-four patients on hemodialysis program were enrolled in the study. Routine laboratory results were noted. Arrhythmia, periods of silent ischemia, and heart-rate variability analyses were obtained from 24-hour Holter monitor recordings. Corrected QT (QTc) dispersion was calculated from 12-lead surface EKG. Echocardiographic and tissue Doppler examinations were performed on interdialytic days as well. Ventricular arrhythmia was classified according to Lown classification; classes 3 and above were accepted as complex ventricular arrhythmia (CVA). RESULTS The mean age was 52.5+/-13.2 years; 44 (46.8%) were women. Ventricular premature contractions were detected in 80 (85.1%) patients, of whom 35 (37.2%) were classified as complex ventricular arrhythmia (CVA). Coronary artery disease, hypertension, and QTc dispersion appeared as independent factors predictive of CVA development. Atrial premature contractions (APC) were detected in 53 patients (56.4%) and supraventricular arrhythmia in 15 (16%) patients; all were identified as atrial fibrillation. Duration of dialysis therapy was found as an independent predictor of APC. CONCLUSION Arrhythmia is frequently observed in ESRD patients receiving hemodialysis and may be responsible for the high rate of sudden mortality. Hypertension, CAD, and QTc dispersion are independent predictors of CVA, and duration of dialysis therapy is an independent factor affecting APC development in these patients.
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Affiliation(s)
- Huseyin Bozbas
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey.
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Continuous hemofiltration in pigs with hyperdynamic septic shock affects cardiac repolarization*. Crit Care Med 2008; 36:3198-204. [DOI: 10.1097/ccm.0b013e31818f9eda] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Burton JO, Korsheed S, Grundy BJ, McIntyre CW. Hemodialysis-induced left ventricular dysfunction is associated with an increase in ventricular arrhythmias. Ren Fail 2008; 30:701-9. [PMID: 18704819 DOI: 10.1080/08860220802212908] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Conventional hemodialysis results in intradialytic cardiac ischemia in a significant proportion of patients. Segmental myocardial ischemia results in the development of left ventricular regional wall motion abnormalities. Sudden death is the most common cause of mortality in hemodialysis patients. This study looked to examine any association between the development of left ventricular regional wall motion and cardiac arrhythmias. Forty established hemodialysis patients had 24-hour Holter recordings, which commenced immediately before a dialysis session. Frequency of isolated ectopy was classified as a percentage of the total beats on the Holter monitor record. Ventricular arrhythmias were stratified according to the Lown classification. Classes 3 and above were taken as complex ventricular arrhythmias. Patients also underwent baseline and intradialytic echocardiography to assess the development of concurrent regional wall motion abnormalities. Premature ventricular complexes and complex ventricular arrhythmias were both more common during hemodialysis than in the subsequent monitored period. Patients who developed regional wall motion abnormalities (n = 27) had significantly more premature ventricular complexes during hemodialysis than afterward (p < 0.001). Patients with ischemic heart disease and left ventricular hypertrophy both had a higher frequency of premature ventricular complexes during hemodialysis than those without (p < 0.03 and p < 0.02, respectively). Cardiac arrhythmias are common in hemodialysis patients. The frequency of premature ventricular complexes is significantly higher during hemodialysis in patients who develop regional wall motion abnormalities and may be related to factors associated with demand ischemia.
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Affiliation(s)
- James O Burton
- Department of Renal Medicine, Derby City General Hospital, Derby, UK
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Rachoin JS, Weisberg LS. Opinion: How Should Dialysis Fluid Be Individualized for the Chronic Hemodialysis Patient? Semin Dial 2008; 21:223-5. [DOI: 10.1111/j.1525-139x.2008.00430.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abuelo JG, Shemin D, Chazan JA. Acute Symptoms Produced by Hemodialysis: A Review of Their Causes and Associations. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.1993.tb00257.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Drighil A, Madias JE, Benjelloun M, Kamoum H, Bennis A, Azzouzi L, Yazidi A, Ramdani B. Changes in the QT intervals, QT dispersion, and amplitude of T waves after hemodialysis. Ann Noninvasive Electrocardiol 2007; 12:137-44. [PMID: 17593182 PMCID: PMC6932080 DOI: 10.1111/j.1542-474x.2007.00152.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Increased QT dispersion (QTd) has been associated with an increased risk for ventricular arrhythmias and sudden death in the general population and in various clinical states. METHODS We investigated the impact of hemodialysis (HD) on QT, QTd, and T-wave amplitude in subjects with end-stage renal failure. Data on 49 patients on chronic HD were studied. The QT, QTd, and the sum of amplitude of T waves (SigmaT) in millimetre in the 12 ECG leads, along with a host of other ECG parameters, body weight, blood pressure, heart rate, electrolytes, and hemoglobin/hematocrit were measured before and immediately after HD. RESULTS QT decreased (380.9 +/- 38.4-363.5 +/- 36.8 ms, P = 0.001), the QTc did not change (406.2 +/- 30.8-405.4 +/- 32.2 ms, P = 0.8), the QTd increased (31.3 +/- 14.6-43.9 +/- 18.6 ms, P = 0.003), and the SigmaT decreased (32.3 +/- 15.7-25.9 +/- 12.6 mm, P = 0.0001) after HD. There was no correlation between the change in QTd and the changes in serum cations, heart rate, the subjects' weight, T-wave duration, and SigmaT. However, the change in QTc correlated inversely with the change in serum Ca(++) (r =-0.339, P = 0.021). CONCLUSION QTd increased, the SigmaT decreased, and the QTc and T-wave duration remained stable, after HD. The QTd increase, although may be real, could also reflect measurement errors stemming from the decrease in the amplitude of T waves (as shown recently), imparted by HD; this requires clarification, to use QTd in patient on HD.
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Affiliation(s)
| | - John E. Madias
- Mount Sinai School of Medicine, New York University, New York, NY
- Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY
| | - Meryem Benjelloun
- Department of Nephrology, Ibn Rochd University Hospital, Casablanca, Morocco
| | | | | | | | - Asma Yazidi
- Department of Nephrology, Ibn Rochd University Hospital, Casablanca, Morocco
| | - Benyouness Ramdani
- Department of Nephrology, Ibn Rochd University Hospital, Casablanca, Morocco
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Buemi M, Aloisi E, Coppolino G, Loddo S, Crascì E, Aloisi C, Barillà A, Cosentini V, Nostro L, Caccamo C, Floccari F, Romeo A, Frisina N, Teti D. The effect of two different protocols of potassium haemodiafiltration on QT dispersion. Nephrol Dial Transplant 2005; 20:1148-54. [PMID: 15784641 DOI: 10.1093/ndt/gfh770] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The risk of developing cardiovascular diseases is higher in patients on haemodialysis than in the general population. These patients may develop arrhythmias that depend on the extra- and intracellular concentrations of potassium. ECG findings, particularly the QT interval and its dispersion (QT(d)) and the QT(c) (QT interval corrected for heart rate according to Bazett's formula) and its dispersion (QT(cd)), may be direct indicators of the risk of developing arrhythmia. METHODS Our cohort comprised 28 patients who were dialysed for 3.5-4 h three times per week, first with haemodiafiltration with a constant potassium concentration (HDF) in the dialysis bath then with haemodiafiltration with variable concentrations of potassium (HDF(k)). ECGs were done at different time intervals: at the start of dialysis (T(0)), at 15 (T(15)), 45 (T(45)), 90 (T(90)) and 120 min (T(120)) after the beginning of the session, and at the end of treatment (T(end)). ECG-derived data (QT, QT(d), QT(c) and QT(cd)) were measured. At the same time points, plasma electrolytes, intra-erythrocytic potassium and the electrical membrane potential at rest (REMP) of the erythrocytic membrane were measured. RESULTS Plasma potassium concentration diminished more gradually in HDF(k) than in HDF, the difference being statistically significant at T(15) and T(45) (P<0.05), and T(90) (P<0.01). The intra-erythrocytic potassium concentration remained constant throughout the observation period. In both HDF and HDF(k), REMP was lower at all points after T(0) (P<0.05), but the reduction was greater and more significant in HDF than in HDF(k) at T(15) and T(120) (P<0.05). ECG revealed a statistically significant diminution in HDF(k) vs HDF in the measures of dispersion of QT and QT(c) at T(15), T(90), T(120) and T(end) (P<0.01) and of QT(cd) at T(45) (P<0.05). The mean of QT(d), adjusted for plasma potassium, increased over time in HDF with large alternate mean increase and decrease peaks and error intervals. In HDF(k), instead, there was a progressive and constant diminution with minor error intervals. QT(cd) adjusted for plasma potassium had the same trend. A marked difference was found between the final values in standard HDF and those in HDF(k). CONCLUSIONS HDF and HDF(k) have significantly different effects on QT(c). ECG data demonstrate that the risk of arrhythmia could be lower, with a variable removal of potassium during haemodialysis. With HDF but not HDF(k), hyperpolarization of the cell membrane is detected, and this could have a destabilizing effect on different types of cardiac cell, giving rise to retrograde circuits.
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Affiliation(s)
- Michele Buemi
- Department of Internal Medicine, University of Messina, Italy.
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Locatelli F, Covic A, Chazot C, Leunissen K, Luño J, Yaqoob M. Optimal composition of the dialysate, with emphasis on its influence on blood pressure. Nephrol Dial Transplant 2004; 19:785-96. [PMID: 15031331 DOI: 10.1093/ndt/gfh102] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
UNLABELLED Introduction. From the beginning of the dialysis era, the most appropriate composition of the dialysate has been one of the central topics in the delivery of dialysis treatment. METHODS A discussion is employed to achieve a consensus on key points relating to the composition of the dialysate, focusing on the relationships with blood pressure behaviour. RESULTS Sodium balance is the cornerstone of intra-dialysis cardiovascular stability and good inter-dialysis blood pressure control. Hypernatric dialysis carries the risk of positive sodium balance, with the consequent possibility of the worsening sense of thirst and hypertension. Conversely, hyponatric dialysis may lead to negative sodium balance, with the possibility of intra-dialysis cardiovascular instability and 'disequilibrium' symptoms including fatigue, muscle cramps and headache. The goal is to remove with dialysis the exact amount of sodium that has accumulated in the inter-dialysis interval. The conductivity kinetic model is applicable on-line at each dialysis session and has been proved to be able to improve intra-dialytic cardiovascular stability in hypotension-prone patients. Therefore, it should be regarded as a promising tool to be implemented in everyday clinical practice. Serum potassium concentration and variations during dialysis treatment certainly play a role in the genesis of cardiac arrhythmia. Potassium profiling, with a constant gradient between plasma and dialysate, should be implemented in clinical practice to minimize the arrhythmogenic potential of dialysis. Calcium plays a role both in myocardial contractility and in peripheral vascular resistance. Therefore, an increase in dialysate calcium concentration may be useful in cardiac compromised hypotension-prone patients. Acid-buffering by means of base supplementation is one of the major roles of dialysis. Bicarbonate concentration in the dialysate should be personalized in order to reach a midweek pre-dialysis serum bicarbonate concentration of 22 mmol/l. The role of convective dialysis techniques in cardiovascular stability is still under debate. It has been demonstrated that dialysate temperature and sodium balance play a role and this should be taken into account. Whether removal of vasoactive, middle-sized compounds by convection plays an independent role in improving cardiovascular stability is still uncertain. CONCLUSIONS The prescription of dialysis fluid is moving from a pre-fixed, standard dialysate solution to individualization of electrolyte and buffer composition, not only during the dialysis session, but also within the same session (profiling) in order to provide patients with an optimal blood purification coupled with a high degree of tolerability.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Ospedale A. Manzoni, Via Dell'Eremo 11, 23900 Lecco, Italy.
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Herzog CA. Cardiac arrest in dialysis patients: approaches to alter an abysmal outcome. KIDNEY INTERNATIONAL. SUPPLEMENT 2003:S197-200. [PMID: 12694343 DOI: 10.1046/j.1523-1755.63.s84.17.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiac disease is the major cause of death in dialysis patients, accounting for 45% of all-cause mortality. Sudden cardiac death may be implicated in 60% of these cardiac deaths in dialysis patients. The combination of obstructive coronary artery disease, electrolyte shifts (in hemodialysis patients), left ventricular hypertrophy, and abnormal myocardial ultrastructure and function may contribute to the vulnerability of ESRD patients to sudden death. In this review, the epidemiology of cardiac arrest in dialysis patients is presented, including the high lethality associated with cardiac arrest. Clinical strategies to reduce the likelihood of fatal cardiac arrest include the identification of high-risk patients, alteration of dialysis prescription to avoid large volume and electrolyte shifts, and reduction of myocardial ischemic burden. Implantable cardioverter defibrillators may potentially reduce the risk of fatal cardiac arrest in dialysis patients and improve long-term cardiac survival.
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Affiliation(s)
- Charles A Herzog
- Department of Internal Medicine, Division of Cardiology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota 55415, USA.
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Howse M, Sastry S, Bell GM. Changes in the corrected QT interval and corrected QT dispersion during haemodialysis. Postgrad Med J 2002; 78:273-5. [PMID: 12151568 PMCID: PMC1742352 DOI: 10.1136/pmj.78.919.273] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The link between increased QT dispersion and cardiac death in subjects with diabetes and arterial disease is well recognised. Corrected QT dispersion was studied in subjects with end stage renal failure on haemodialysis. Thirty one stable, chronic subjects on haemodialysis had 12-lead electrocardiograms (ECGs) taken before and after a single haemodialysis session. The QT interval was measured manually in each and the corrected QT and corrected QT dispersion calculated. Serum concentrations of potassium, calcium, and magnesium were measured at the same time as ECG acquisition. Corrected QT dispersion increased from a mean (SEM) 90.6 (5.8) to 117.7 (10.2) ms (p=0.002). Serum potassium and magnesium decreased from 5.0 (0.14) to 3.5 (0.09) mmol/l and 0.95 (0.04) to 0.89 (0.09) mmol/l respectively, while serum calcium increased from 2.56 (0.04) to 2.77 (0.04) mmol/l. Intradialytic weight fell by a mean of 2.1 kg. There was no significant correlation between the change in QTc dispersion and the changes in measured serum anions or the subjects' weight during dialysis. Corrected QT dispersion was higher in subjects on haemodialysis than previously suggested normal values, and was significantly increased by haemodialysis. This reflects increased inhomogeneous ventricular repolarisation, which may lead to an increased risk of arrhythmias and sudden death. Studies looking at QT dispersion in subjects on dialysis should standardise the timing of ECG recordings taken with respect to dialysis.
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Affiliation(s)
- M Howse
- Department of Nephrology, Royal Liverpool University Hospital, Liverpool, UK.
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Abstract
Serious hyperkalemia is common in patients with end-stage renal disease (ESRD) and accounts for considerable morbidity and death. Mechanisms of extrarenal disposal of potassium (gastrointestinal excretion and cellular uptake) play a crucial role in the defense against hyperkalemia in this population. In this article we review extrarenal potassium homeostasis and its alteration in patients with ESRD. We pay particular attention to the factors that influence the movement of potassium across cell membranes. With that background we discuss the emergency treatment of hyperkalemia in patients with ESRD. We conclude with a review of strategies to reduce the risk of hyperkalemia in this population of patients.
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Affiliation(s)
- J Ahmed
- Duane L. Waters Hospital, Jackson, Michigan, USA
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Karnik JA, Young BS, Lew NL, Herget M, Dubinsky C, Lazarus JM, Chertow GM. Cardiac arrest and sudden death in dialysis units. Kidney Int 2001; 60:350-7. [PMID: 11422771 DOI: 10.1046/j.1523-1755.2001.00806.x] [Citation(s) in RCA: 257] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND For patients with end-stage renal disease and their providers, dialysis unit-based cardiac arrest is the most feared complication of hemodialysis. However, relatively little is known regarding its frequency or epidemiology, or whether a fraction of these events could be prevented. METHODS To explore clinical correlates of dialysis unit-based cardiac arrest, 400 reported arrests over a nine-month period from October 1998 through June 1999 were reviewed in detail. Clinical characteristics of patients who suffered cardiac arrest were compared with a nationally representative cohort of> 77,000 hemodialysis patients dialyzed at Fresenius Medical Care North America-affiliated facilities. RESULTS The cardiac arrest rate was 400 out of 5,744,708, corresponding to a rate of 7 per 100,000 hemodialysis sessions. Cardiac arrest was more frequent during Monday dialysis sessions than on other days of the week. Case patients were nearly twice as likely to have been dialyzed against a 0 or 1.0 mEq/L potassium dialysate on the day of cardiac arrest (17.1 vs. 8.8%). Patients who suffered a cardiac arrest were on average older (66.3 +/- 12.9 vs. 60.2 +/- 15.4 years), more likely to have diabetes (61.8 vs. 46.8%), and more likely to use a catheter for vascular access (34.1 vs. 27.8%) than the general hemodialysis population. Sixteen percent of patients experienced a drop in systolic pressure of 30 mm Hg or more prior to the arrest. Thirty-seven percent of patients who suffered cardiac arrest had been hospitalized within the past 30 days. Sixty percent of patients died within 48 hours of the arrest, including 13% while in the dialysis unit. CONCLUSIONS Cardiac arrest is a relatively infrequent but devastating complication of hemodialysis. To reduce the risk of adverse cardiac events on hemodialysis, the dialysate prescription should be evaluated and modified on an ongoing basis, especially following hospitalization in high-risk patients.
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Affiliation(s)
- J A Karnik
- Divisions of Nephrology, Moffitt-Long Hospitals and UCSF-Mt. Zion Medical Center, Department of Medicine, University of California, San Francisco, USA
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Munger MA, Ateshkadi A, Cheung AK, Flaharty KK, Stoddard GJ, Marshall EH. Cardiopulmonary events during hemodialysis: effects of dialysis membranes and dialysate buffers. Am J Kidney Dis 2000; 36:130-9. [PMID: 10873882 DOI: 10.1053/ajkd.2000.8285] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Adverse cardiac and pulmonary events are frequently observed during hemodialysis and contribute to significant morbidity and mortality. The temporal relationship between these events during the intradialytic period has not been well defined. To examine the event rate and timing of silent ischemia, cardiac ectopy, and hypoxemia, we conducted a prospective, single-blind, randomized study of 10 subjects undergoing maintenance hemodialysis with four contiguous combinations of dialysis membranes (cuprammonium or polysulfone) and dialysates (acetate or bicarbonate). The frequency of oxygen desaturation events peaked during the first 2 hours, whereas silent myocardial ischemia and supraventricular ectopies occurred more often in the later hours. Ventricular ectopy occurred steadily throughout the intradialytic period. The combination of acetate dialysis and cuprammonium membrane is associated with the most frequent events. We conclude that cardiopulmonary events can occur frequently during hemodialysis, and the frequency is dependent on the type of dialysis membrane and dialysate buffer used.
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Affiliation(s)
- M A Munger
- Department of Pharmacy Practice, Division of Nephrology and Hypertension, School of Medicine, University of Utah, Salt Lake City, UT 84112, USA.
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Vaitkus PT. Current status of prevention, diagnosis, and management of coronary artery disease in patients with kidney failure. Am Heart J 2000; 139:1000-8. [PMID: 10827380 DOI: 10.1067/mhj.2000.105300] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with kidney failure have a heavy burden of coronary artery disease. The results of preventive, diagnostic, and therapeutic measures developed in nonuremic populations cannot automatically be extrapolated to this unique group of patients. METHODS AND RESULTS Articles were reviewed if they contained English language text or an abstract identified by MEDLINE search from 1980 to 1999, supplemented by manual review of bibliographies of published articles and abstract issues of national cardiology meetings, studies on diagnostic techniques, risk modification measures, pharmacologic agents, and coronary revascularization procedures in patients with uremia. Descriptive and quantitative data as appropriate were extracted. Lipid-lowering agents may be safely administered to uremic patients. Direct evidence of lipid lowering in this population is not available and is not likely to be forthcoming. Erythropoietin therapy is effective in reversing the cardiovascular perturbations of uremic anemia, but an approach of normalizing the hematocrit cannot be recommended. Glycoprotein IIb/IIIa inhibitors used in acute coronary syndromes require downward dose adjustment or are contraindicated. Thrombolytic agents are underutilized in the management of myocardial infarction. Noninvasive testing is less accurate than in nonuremic populations. Coronary revascularization offers relative clinical advantages over medical therapy similar to non-kidney failure populations, even though the results in uremic patients is significantly less favorable than for nonuremic patients. Stenting is the preferred revascularization approach, and conventional balloon percutaneous transluminal coronary angioplasty the least favorable. CONCLUSIONS Many but not all of the benefits of therapies developed in nonuremic patients extend to patients with kidney failure. Physicians should be familiar with the advantages and limitations of each of these modalities in this population.
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Affiliation(s)
- P T Vaitkus
- Cardiology Division, University Hospitals of Cleveland and Case Western Reserve University, OH, USA
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Girgis I, Contreras G, Chakko S, Perez G, McLoughlin J, Lafferty J, Gualberti L, Ammazzalorso M, Constantino T, Bresznyak ML, Kleiner M, McGinn TG, Myerburg RJ. Effect of hemodialysis on the signal-averaged electrocardiogram. Am J Kidney Dis 1999; 34:1105-13. [PMID: 10585321 DOI: 10.1016/s0272-6386(99)70017-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The presence of late potentials (LPs) on signal-averaged electrocardiography (SAECG) is predictive of ventricular tachycardia. The effect of hemodialysis (HD) on SAECG has not been well studied. SAECG was evaluated in 28 patients with chronic renal failure immediately before and after HD. In each SAECG, QRS duration, low-amplitude signal duration (LASd), and root-mean-square voltage of the terminal 40 milliseconds of the QRS (RMS40) were measured. To evaluate the effect of fluid removal on SAECG, the last 12 patients were studied during two different HD sessions, one with and one without fluid removal. Two-dimensional echocardiography was performed before and after HD on these 12 patients. At baseline, four patients met the criteria for LPs on SAECG. Only one patient met the criteria for LPs on SAECG after HD. After HD, the mean LASd decreased (28.3 +/- 12.9 to 24.9 +/- 10.1 milliseconds; P = 0.041) and RMS40 increased (63.0 +/- 56.9 to 79.0 +/- 59.2 microV; P = 0. 006). Among the 12 patients who underwent HD with and without fluid removal, left ventricular end-diastolic dimension decreased with (5. 4 +/- 0.6 to 5.1 +/- 0.6 cm; P = 0.024) but not without fluid removal (5.2 +/- 0.3 to 5.1 +/- 0.4 cm; P = not significant [NS]). RMS40 improved with (43.8 +/- 23.1 to 53.2 +/- 22.6 microV; P = 0. 03) but not without fluid removal (51.0 +/- 26.5 to 51.5 +/- 24.2 microV; P = NS). A significant negative correlation was found between change in body weight and change in RMS40 parameter (r = 0. 456; P = 0.0381). SAECG parameters are abnormal in a significant proportion of patients with chronic renal failure and improve with HD despite electrolyte and other proarrhythmic changes. Decreased left ventricular dimension because of fluid removal during HD is one possible explanation for this improvement.
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Affiliation(s)
- I Girgis
- Divisions of Cardiology and Nephrology, University of Miami School of Medicine, Miami, FL, USA.
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Jassal SV, Coulshed SJ, Douglas JF, Stout RW. Autonomic neuropathy predisposing to arrhythmias in hemodialysis patients. Am J Kidney Dis 1997; 30:219-23. [PMID: 9261032 DOI: 10.1016/s0272-6386(97)90055-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Arrhythmias are frequent among the dialysis population and can cause symptoms of palpitations or dizziness. Since autonomic disturbances are known to cause an increased arrhythmogenic stimulus, we questioned whether the presence of central autonomic neuropathy increased the frequency of arrhythmias as identified by 24-hour electrocardiographic monitoring in dialysis patients. Seventy-one patients were randomly chosen from patients established on dialysis in two centers. The mean age of the patients was 71.3 years (median age, 67 years) and median duration on dialysis was 17.0 months (range, 1 to 175 months). Four patients had diabetes. Each patient was tested for autonomic control of blood pressure and heart rate, and underwent Holter electrocardiographic monitoring, commencing 30 minutes before dialysis, for a 24-hour period. The tapes were then analyzed for ventricular and atrial rhythm changes. There was a significantly increased incidence of arrhythmias in individuals with abnormal blood pressure responses (P = 0.005), heart rate responses (P = 0.01), and combined blood pressure and heart rate responses (P = 0.004). We conclude that patients with autonomic dysfunction had an increased frequency of arrhythmias during dialysis.
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Affiliation(s)
- S V Jassal
- Department of Geriatric Medicine, Queen's University, Belfast, United Kingdom.
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Redaelli B, Locatelli F, Limido D, Andrulli S, Signorini MG, Sforzini S, Bonoldi L, Vincenti A, Cerutti S, Orlandini G. Effect of a new model of hemodialysis potassium removal on the control of ventricular arrhythmias. Kidney Int 1996; 50:609-17. [PMID: 8840293 DOI: 10.1038/ki.1996.356] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The primary aim of this multicenter, prospective, randomized cross-over study was to clarify whether a new model of hemodialysis (HD) potassium (K) removal using a decreasing intra-HD dialysate K concentration and a constant plasma-dialysate K gradient (treatment B) is capable of reducing the arrhythmogenic effect of standard HD, which has a constant dialysate K concentration and decreasing plasma-dialysate K gradient (treatment A). The secondary aim was to verify whether this new model is clinically safe. In treatment B, the initial dialysate K concentration had to be 1.5 mEq/liter less than the plasma K concentration, and exponentially decrease to 2.5 mEq/liter at the end of HD. Forty-two chronic HD patients with an increase in premature ventricular complexes (PVC) during dialysis were enrolled from 18 participating centers, and randomly assigned to either sequence 1 (ABA) or sequence 2 (BAB). A pool of 333 of 378 expected ECG Holter recordings were checked for signal quality; 269 (71%) from 36 patients (86%) had a satisfactory signal quality and 108 were selected for analysis (1 per patient per period). There was a difference in the natural logarithm of the increase in PVC/hr and PVC couplets/hr during HD between treatments A and B (1.70 +/- 1.59 vs. 1.09 +/- 1.76 and 0.94 +/- 0.86 vs. 0.64 +/- 1.01, a reduction of 36% and 32%, P = 0.011 and 0.047, respectively) without any carry over effect (P = 0.61 and 0.24, respectively). The fact that this decrease of one third is due to a lower plasma-dialysate K gradient is supported by the observation that it was more evident during the first than the last two hours of HD (a reduction in the natural logarithm of the increase in PVC/hr and PVC couplets/hr of 60% and 60%, P 0.002 and 0.009, vs. 26% and 17%, P = 0.098 and 0.332, respectively): the initial plasma-dialysate K gradient was 2.3 times lower during treatment B than during treatment A, without adversely affecting pre-HD plasma K levels. These results could have a considerably clinical impact not only because of the possibility of physiologically decreasing the arrhythmogenic effect of HD, but also because this effect can be considered a "marker" of the electrophysiological derangement induced by the administration of standard HD three times a week for years ("electric disequilibrium syndrome").
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Affiliation(s)
- B Redaelli
- Division of Nephrology and Dialysis, Hospital S. Gerardo, Milan, Italy
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Affiliation(s)
- M A Alpert
- Department of Internal Medicine, University of South Alabama College of Medicine, Mobile, Alabama 36617
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Affiliation(s)
- A Kenny
- Regional Cardiac Unit, Papworth Hospital, Cambridge, United Kingdom
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