Relationship between dialytic parameters and reviewer confirmed arrhythmias in hemodialysis patients in the monitoring in dialysis study

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Abstract

Background

Hemodialysis patients have high rates of sudden death, but relationships between serum electrolytes, the dialysis prescription, and intra-dialytic shifts in fluid and electrolyte with arrhythmia are uncertain.

Methods

We analyzed sixty-six hemodialysis patients who underwent loop recorder implantation with continuous electrocardiographic monitoring, weekly to bi-weekly testing of pre- and post-dialysis electrolytes, and detailed capture of dialysis prescription and flow sheet data for 6 months. The incidence rate ratio (IRR) of reviewer confirmed arrhythmias (RCA) during dialysis through 8 h after dialysis and associations with serum chemistries and dialytic parameters were assessed using adjusted, negative-binomial regression.

Results

Among 66 individuals with a mean age of 56 years, 12,480 events were detected in 64 (97%) patients. RCA nadired 12–24 h after dialysis and increased during the final 12 h of the inter-dialytic interval through the first 8 h after dialysis. Higher pre-dialysis serum magnesium concentration was associated with lower incidence rate ratio for arrythmia (IRR per 1 mg/dL increase 0.49, 95% CI; 0.25, 0.94), as was dialysate calcium concentration > 2.5 mEq/L vs. 2.5 mEq/L (IRR 0.52, 95% CI: 0.39, 0.70). Neither intradialytic serum potassium nor weight change were significantly associated with RCA rate. However, there was effect modification such that arrhythmia rate was maximal with concurrently high intradialytic volume and potassium removal (P _interaction = 0.01).

Conclusions

Intra and post-dialytic arrhythmias are common in hemodialysis. Additional studies designed to further elucidate whether modification of the serum magnesium concentration, dialysate calcium concentration, and the extent of intradialytic potassium and fluid removal reduces the risk of per-dialytic arrhythmia are warranted.

Trial registration

Clinicaltrials.gov NCT01779856. Prospectively registered on January 22, 2013.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1212-6) contains supplementary material, which is available to authorized users.

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Most cited references 19

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The elephant in uremia: oxidant stress as a unifying concept of cardiovascular disease in uremia.

Jonathan Himmelfarb, Peter Stenvinkel, T Alp Ikizler … (2002)

Cardiovascular disease is the leading cause of mortality in uremic patients. In large cross-sectional studies of dialysis patients, traditional cardiovascular risk factors such as hypertension and hypercholesterolemia have been found to have low predictive power, while markers of inflammation and malnutrition are highly correlated with cardiovascular mortality. However, the pathophysiology of the disease process that links uremia, inflammation, and malnutrition with increased cardiovascular complications is not well understood. We hereby propose the hypothesis that increased oxidative stress and its sequalae is a major contributor to increased atherosclerosis and cardiovascular morbidity and mortality found in uremia. This hypothesis is based on studies that conclusively demonstrate an increased oxidative burden in uremic patients, before and particularly after renal replacement therapies, as evidenced by higher concentrations of multiple biomarkers of oxidative stress. This hypothesis also provides a framework to explain the link that activated phagocytes provide between oxidative stress and inflammation (from infectious and non-infections causes) and the synergistic role that malnutrition (as reflected by low concentrations of albumin and/or antioxidants) contributes to the increased burden of cardiovascular disease in uremia. We further propose that retained uremic solutes such as beta-2 microglobulin, advanced glycosylated end products (AGE), cysteine, and homocysteine, which are substrates for oxidative injury, further contribute to the pro-atherogenic milieu of uremia. Dialytic therapy, which acts to reduce the concentration of oxidized substrates, improves the redox balance. However, processes related to dialytic therapy, such as the prolonged use of catheters for vascular access and the use of bioincompatible dialysis membranes, can contribute to a pro-inflammatory and pro-oxidative state and thus to a pro-atherogenic state. Anti-oxidative therapeutic strategies for patients with uremia are in their very early stages; nonetheless, early studies demonstrate the potential for significant efficacy in reducing cardiovascular complications.

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Long interdialytic interval and mortality among patients receiving hemodialysis.

Robert N Foley, David T Gilbertson, Thomas Pinkney Murray … (2011)

Patients with end-stage renal disease requiring dialysis have limited tolerance of metabolic and volume-related deviations from normal ranges; in addition, the prevalence of cardiovascular disease is high among such patients. Given these problems, we hypothesized that a long interdialytic interval is associated with adverse events in patients receiving hemodialysis. We studied 32,065 participants in the End-Stage Renal Disease Clinical Performance Measures Project, a nationally representative sample of U.S. patients receiving hemodialysis three times weekly, at the end of calendar years 2004 through 2007. We compared rates of death and cardiovascular-related hospital admissions on the day after the long (2-day) interdialytic interval with rates on other days. The mean age of the cohort was 62.2 years; 24.2% of the patients had been receiving dialysis treatment for 1 year or less. Over a mean follow-up interval of 2.2 years, the following event rates were higher on the day after the long interval than on other days: all-cause mortality (22.1 vs. 18.0 deaths per 100 person-years, P<0.001), mortality from cardiac causes (10.2 vs. 7.5, P<0.001), infection-related mortality (2.5 vs. 2.1, P = 0.007), mortality from cardiac arrest (1.3 vs. 1.0, P = 0.004), mortality from myocardial infarction (6.3 vs. 4.4, P<0.001), and admissions for myocardial infarction (6.3 vs. 3.9, P<0.001), congestive heart failure (29.9 vs. 16.9, P<0.001), stroke (4.7 vs. 3.1, P<0.001), dysrhythmia (20.9 vs. 11.0, P<0.001), and any cardiovascular event (44.2 vs. 19.7, P<0.001). The long (2-day) interdialytic interval is a time of heightened risk among patients receiving hemodialysis. (Funded by the National Institutes of Health.).

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The Framingham predictive instrument in chronic kidney disease.

Andrew Levey, Mark J. Sarnak, Obi L. Griffith … (2007)

We sought to determine the utility of the Framingham equations in individuals with chronic kidney disease (CKD). The Framingham equations predict incident coronary disease. The utility of these equations is unknown in CKD. We pooled individuals without pre-existing coronary disease age 45 to 74 years from the ARIC (Atherosclerosis Risk In Communities) and CHS (Cardiovascular Health Study) trials with CKD, defined by an estimated glomerular filtration rate of 15 to 60 ml/min/1.73 m(2). Using gender-specific models, we determined 5- and 10-year risk of incident myocardial infarction and fatal coronary disease, and evaluated discriminative and calibration ability of the Framingham equations for predicting coronary events. There were 577 women and 357 men with CKD. Thirty-five men (9.8%) and 30 women (5.2%) and 74 men (20.7%) and 56 women (9.7%) had cardiac events within 5 and 10 years, respectively; 5-year events were predicted in 6.0% and 1.9% and 10-year events in 13.9% and 4.8% of men and women, respectively. For 5-year events, C-statistics assessing discrimination were 0.62 and 0.77, while 10-year C-statistics were 0.60 and 0.73 for men and women, respectively. Calibration was also poor, with Framingham scores generally underpredicting events in individuals with CKD at 5 and 10 years. Discrimination was significantly improved by refitting models with population-specific coefficients, while recalibration improved prediction in women. The Framingham instrument demonstrates poor overall accuracy in predicting cardiac events in individuals with CKD, although refit models can substantially improve discrimination. Calibration in women can be moderately improved with adjustment for higher event rates. Development of CKD-specific equations is needed.

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Author and article information

Contributors

James A. Tumlin: jamestumlinmdnephronet@gmail.com

Prabir Roy-Chaudhury: proychaudhury@deptofmed.arizona.edu

Bruce A. Koplan: bkoplan@bwh.harvard.edu

Alexandru I. Costea: costeaai@ucmail.uc.edu

Vijay Kher: vijay.kher@medanta.org

Don Williamson: dwilliamson@nephrology-associates.com

Saurabh Pokhariyal: saurabh.p@manipalhospitals.com

David M. Charytan: (646) 501-9086 , david.charytan@nyulangone.org

Journal

Journal ID (nlm-ta): BMC Nephrol

Journal ID (iso-abbrev): BMC Nephrol

Title: BMC Nephrology

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2369

Publication date (Electronic): 5 March 2019

Publication date PMC-release: 5 March 2019

Publication date Collection: 2019

Volume: 20

Electronic Location Identifier: 80

Affiliations

[1 ]NephroNet Clinical Research Consortium, Atlanta, GA USA

[2 ]ISNI 0000 0004 0419 1924, GRID grid.413924.9, University of Arizona Health Sciences and Southern Arizona VA Health Care System, ; Tuscon, AZ USA

[3 ]ISNI 0000 0004 0378 8294, GRID grid.62560.37, Brigham & Women’s Hospital, ; Boston, MA USA

[4 ]ISNI 0000 0001 2179 9593, GRID grid.24827.3b, University of Cincinnati School of Medicine, ; Cincinnati, OH USA

[5 ]ISNI 0000 0004 1764 4857, GRID grid.429252.a, Medanta Kidney & Urology Institute, Medanta – The Medicity, ; Gurgaon, India

[6 ]Southeastern Clinical Research Institute, Augusta, GA USA

[7 ]Department of Nephrology & Renal Transplantation, HCMCT Manipal Hospital Pvt. Ltd, Dwarka, Delhi India

[8 ]ISNI 0000 0004 1936 8753, GRID grid.137628.9, Nephrology Division, New York University School of Medicine and NYU Langone Medical Center, ; New York, NY USA

Article

Publisher ID: 1212

DOI: 10.1186/s12882-019-1212-6

PMC ID: 6402171

PubMed ID: 30836948

SO-VID: c3be6968-0076-41e3-a43b-5cc1f51a888d

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 19 July 2018

Date accepted : 14 January 2019

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100004374, Medtronic;

Custom metadata

ScienceOpen disciplines: Nephrology

Keywords: end stage renal disease,hemodialysis,cardiovascular disease,arrhythmia

Data availability:

ScienceOpen disciplines: Nephrology

Keywords: end stage renal disease, hemodialysis, cardiovascular disease, arrhythmia

Relationship between dialytic parameters and reviewer confirmed arrhythmias in hemodialysis patients in the monitoring in dialysis study

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Abstract

Background

Methods

Results

Conclusions

Trial registration

Electronic supplementary material

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Karger: Nephrology

Most cited references 19

The elephant in uremia: oxidant stress as a unifying concept of cardiovascular disease in uremia.

Long interdialytic interval and mortality among patients receiving hemodialysis.

The Framingham predictive instrument in chronic kidney disease.

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