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Sudden cardiac death in chronic kidney disease: epidemiology and prevention

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.

Key Points

  • Chronic kidney disease (CKD) is a risk factor for sudden cardiac death; the rate of sudden cardiac death increases as the stage of CKD increases

  • In hemodialysis units, cardiac arrest occurs at a rate of seven per 100,000 hemodialysis sessions

  • Survival following cardiac arrest is very poor

  • Adverse cardiomyopathic and vasculopathic milieu in CKD predispose to conduction abnormalities and arrhythmic events

  • Multiple risk factors and mechanisms can contribute to the risk of sudden death in CKD; primary and secondary prevention could reduce cardiovascular mortality in patients with CKD

  • Patients with CKD at risk of sudden cardiac death can be identified and the decision to implant a cardioverter-defibrillator should be influenced by age and stage of CKD

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Figure 1: Sudden cardiac death rate according to stage of chronic kidney disease.
Figure 2: Ratio of actual to expected number of occurrences of sudden death for each 12 h interval from the start of hemodialysis.
Figure 3: The pathophysiology of diseases that predispose patients with chronic kidney disease to cardiac arrest.
Figure 4: The pathophysiology of sudden cardiac death in patients with chronic kidney disease.
Figure 5: Pathophysiology of inflammation and cardiac death.

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Acknowledgements

C. P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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M. K. Shamseddin and P. S. Parfrey contributed equally to all aspects of this manuscript.

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Correspondence to Patrick S. Parfrey.

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Shamseddin, M., Parfrey, P. Sudden cardiac death in chronic kidney disease: epidemiology and prevention. Nat Rev Nephrol 7, 145–154 (2011). https://doi.org/10.1038/nrneph.2010.191

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