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

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 (Pinteraction = 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.

Keywords: Arrhythmia; Cardiovascular disease; End stage renal disease; Hemodialysis.

Conflict of interest statement

Ethics approval and consent to participate

All patients provided written informed consent, and the study was approved by the Partners Human Research Committee and the following institutional review boards or ethics committees: The Partners Human Research Committee, Western IRB, Chesapeake IRB, University Health Care System IRB, Care Hospital Institutional Ethics Committee, Flt. Lt. Rajan Dhall Charitable Trust Section B, Apollo Hospitals, Medanta Institutional Ethics Committee, and The Member Secretary Institutional Ethics Committee.

Consent for publication

Not applicable.

Competing interests

All of the authors received significant research support and/or consulting fees from Medtronic in relationship to the design and conduct of the study.

David M. Charytan-Expert witness fees related to dialysate composition-Fresenius (significant), Research Support-Medtronic. Research Support and Consulting Fees related to services on trial steering committee or Data Monitoring Committee-Zoll Medical, Allena Pharmaceuticals, Astra Zeneca(modest), Janssen Pharmaceuticals. Consulting fees-Medtronic, Fresenius(modest).

Jim A. Tumlin-None.

Don Williamson-None.

Alexandru I Costea – speaker’s bureau for Biotronik and Biosense Webster.

Vijay Kher – Research Funding – Novartis India, Sanofi Aventis India, Astellas India, Honoraria – Novartis India, Roche India, Astellas India, Torrent India, Reddy’s India, Scientific Advisor – Roche India, Novartis India, Torrent, Sanofi Aventis, Reddy’s India, Biocon India, Medtronis, Speakers Bureau – Novartis India, Roche India, Panacea India, Sanofi Aventis India, Intas India, Biocon India, Pfizer, Medtronic.

Bruce Koplan-Research Funding-No other conflicts.

Saurabh Pokhariyal-No other conflicts.

Prabir Roy-Chaudhury. Consultant or Advisory Board for: Medtronic, Bard Peripheral Vascular, WL Gore, Akebia, TVA, Cormedix, Humacyte, Proteon.

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Figures

Fig. 1

Rate of reviewer confirmed arrhythmia during and between dialysis sessions-- Reviewer confirmed arrhythmia rate over the course of the dialytic week. a RCA during the intradialytic interval or successive 12-h intervals from 1 session until the next dialysis session. HD1–3 Intra-1st, 2nd or 3rd, intradialytic interval of the week. b RCA during the intradialytic interval through 8 h after dialysis, 8–12 h after dialysis, or successive 12-h intervals until the next dialysis session. HD1–8, HD2–8, HD3–8—1st, 2nd or 3rd, intradialytic interval of the week through 8 h post dialysis. Blue, red, green-1st 2nd or 3rd dialysis session and subsequent inter-dialytic interval of the week. * signifies P < 0.05 compared to nadir rate for the week

Fig. 2

Incidence rate of reviewer confirmed arrhythmias according to intradialytic change in potassium and weight—Rate of reviewer confirmed arrhythmias per hour according to intra-dialytic change in potassium and the pre-post dialysis decrease in weight from the start of dialysis to 8 h post. The interaction term for intradialytic change in weight*intradialytic change in potassium was estimated as an IRR of 0.78 (95% CI: 0.66, 0.93)