From the Guidelines
Cardiac arrest in dialysis patients is most commonly caused by electrolyte imbalances, particularly hyperkalemia, which can disrupt normal heart rhythm, as evidenced by a study published in Circulation in 2010 1. The most significant risk factors for cardiac arrest in dialysis patients include:
- Electrolyte imbalances, such as high potassium (hyperkalemia) or low calcium levels, which can disrupt normal heart rhythm
- Fluid overload between dialysis sessions, putting strain on the heart
- Rapid fluid removal during dialysis, causing hypotension and reduced cardiac perfusion
- Underlying cardiovascular disease, making patients more vulnerable to cardiac events
- Dialysis-associated arrhythmias, developing during treatment due to shifts in electrolytes and blood volume
- Uremic toxins accumulating between sessions, having direct cardiotoxic effects
- Chronic inflammation, anemia, and malnutrition, contributing to cardiac stress
- Medication-related issues, including missed doses of cardiac medications or drug interactions, further increasing risk.
According to the K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients, published in the American Journal of Kidney Diseases in 2005 1, dialysis patients are at increased risk for dysrhythmias, cardiac arrest, and sudden cardiac death due to dynamic changes in electrolytes, volume status, blood pressure, and the use of multiple medications. The guidelines also suggest that the use of beta-blockers may be effective in preventing cardiac arrest in dialysis patients, as it is in the general population 1. However, it is essential to note that the evidence for these interventions in dialysis patients is limited, and further research is needed to confirm their effectiveness. In the meantime, careful monitoring of electrolytes, appropriate dry weight management, gradual ultrafiltration during dialysis, and comprehensive cardiovascular care are crucial for preventing cardiac arrest in dialysis patients.
From the Research
Causes of Cardiac Arrest in Dialysis Patients
- Severe hyperkalemia is a potentially life-threatening cardiac emergency that can lead to fatal arrhythmias, such as ventricular fibrillation or asystole, resulting in cardiac arrest 2
- Abnormal electrolytes, large-volume ultrafiltration, and prior history of cardiac disease are risk factors unique to hemodialysis patients that can contribute to sudden cardiac arrest 3
- Ventricular arrhythmia is the main mechanism of sudden cardiac deaths in dialysis patients, often triggered by electrolytic and plasma volume shifts during dialysis sessions 4
- Hyperkalemia can result in morbidity and mortality if not managed appropriately, with the most severe effect being various cardiac dysrhythmias that may result in cardiac arrest and death 5
Risk Factors and Management Strategies
- Patients undergoing hemodialysis have a 10 to 20 times higher risk of sudden cardiac arrest than the general population 4
- Identification of patients at risk, minimizing trigger events such as electrolytic shifts, and improving team skills in diagnosis and initial resuscitation are necessary to reduce incidence and improve survival in this high-risk population 4
- Electrolyte imbalances, frequently present in hemodialysis patients, could explain part of the arrhythmic phenomena, and the high incidence of sudden cardiac death in patients on peritoneal dialysis suggests that other risk factors due to cardiac comorbidities and uraemia per se may contribute to sudden mortality in end-stage kidney disease patients 6
- Management strategies include measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion, with dialysis being the most efficient means to enable removal of excess potassium 5