Most Common Cause of Death in Hemodialysis Patients
Cardiovascular disease is the most common cause of death among hemodialysis patients, accounting for approximately 40-50% of all deaths in this population, with infections being the second leading cause. 1, 2
Primary Cause: Cardiovascular Disease
The evidence consistently demonstrates that cardiovascular disease dominates mortality in the hemodialysis population:
Cardiovascular disease accounts for at least 40% of deaths in end-stage renal failure patients, with some studies reporting up to half of all deaths attributed to cardiovascular causes including coronary heart disease, cerebrovascular disease, peripheral vascular disease, and heart failure 2, 3, 4
The risk of cardiovascular death is approximately 30 times higher in hemodialysis patients compared to the general population, and remains 10-20 times higher even after adjusting for age, gender, and diabetes 3, 4
Cardiac diseases are by far the most common cause of cardiovascular deaths in dialysis patients, justifying their prominent focus in clinical guidelines 2
Secondary Cause: Infections
While cardiovascular disease leads, infections represent the second most important cause of mortality:
Infections remain a leading cause of death, second only to cardiovascular disease, according to the most recent 2020 American Journal of Kidney Diseases guidelines 1
Infections account for a major share of hospitalizations in addition to mortality in this patient population 1
Specific Cardiovascular Mechanisms
The cardiovascular mortality burden manifests through several specific mechanisms:
Sudden cardiac death (SCD) is the leading cause of death within the cardiovascular category, accounting for death in up to one-quarter of the entire hemodialysis population 5
Nearly half of deaths on dialysis are secondary to myocardial infarction, cardiac arrest, malignant arrhythmias and other cardiac causes 6
Left ventricular hypertrophy is present in almost 80% of dialysis patients, serving as a substrate for both systolic and diastolic dysfunction 7
Approximately 31% of patients have heart failure at dialysis initiation and an additional 25% develop it during their course on dialysis, making it one of the most prevalent cardiovascular complications 7
Clinical Context and Timing
Understanding when cardiovascular deaths occur helps inform prevention strategies:
The most common times for sudden cardiac death are toward the end of the long 72-hour weekend interval between dialysis sessions and in the 12 hours immediately after hemodialysis 5
The dialysis procedure itself may have important implications for sudden cardiac death, as hemodialysis is associated with both ventricular arrhythmias and dynamic electrocardiographic changes 5
Hospitalization Patterns
Cardiovascular disease also drives the majority of hospitalizations:
- Cardiovascular disease is the most frequent cause for hospitalizations among hemodialysis patients (33.68%), with coronary heart disease (37.26%) and heart failure (14.51%) being the most common specific conditions 8, 9
Important Caveats
Traditional cardiovascular risk stratification tools from the general population are inadequate when assessing hemodialysis patients because coronary artery disease and heart failure often are not the underlying pathologic processes for sudden cardiac death in this population 5. Factors assuming greater importance include left ventricular hypertrophy, electrolyte shifts, and vascular calcification 5.