- Email: [email protected]
Cardiac arrests in hemodialysis patients: An ongoing challenge
co m m e nt a r y
putative offending medication, the use of corticosteroids should be considered in all patients with AIN. This consideration should take into account not only rapidity and completeness of return of renal function to normal but also potential long-term benefits in avoiding interstitial fibrosis and eventual chronic kidney disease. REFERENCES 1. 2. 3. 4.
Baker RJ, Pusey CD. The changing profile of acute tubulointerstitial nephritis. Nephrol Dial Transplant 2004; 19: 8–11. Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001; 60: 804–817. Bhatt P, Appel GB. Tubulo-interstitial diseases. In: ACP Medicine. WebMD Inc.: New York, 2006, 2027–2043. Clarkson MR, Giblin L, O’Connell FP et al. Acute interstitial nephritis: clinical features and response to corticosteroid therapy. Nephrol Dial
Transplant 2004; 19: 2778–2783. Joss N, Morris S, Young B, Geddes C. Granulomatous interstitial nephritis. Clin J Am Soc Nephrol 2007; 2: 222–230. 6. Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990; 5: 94–99. 7. Schwarz A, Krause PH, Kunzendorf U et al. The outcome of acute interstitial nephritis: risk factors for the transition from acute to chronic interstitial nephritis. Clin Nephrol 2000; 54: 179–190. 8. Bhaumik SK, Kher V, Arora P et al. Evaluation of clinical and histological prognostic markers in drug-induced acute interstitial nephritis. Ren Fail 1996; 18: 97–104. 9. Preddie DC, Markowitz GS, Radhakrishnan J et al. Mycophenolate mofetil for the treatment of interstitial nephritis. Clin J Am Soc Nephrol 2006; 1: 718–722. 10. González E, Gutiérrez E, Galeano C et al. Early steroid treatment improves the recovery of renal function in patients with drug-induced acute interstitial nephritis. Kidney Int 2008; 73: 940–946.
5.
see original article on page 933
Cardiac arrests in hemodialysis patients: An ongoing challenge M Ostermann1 Hemodialysis patients have significant cardiac-related mortality. Sudden cardiac arrests in the dialysis unit are infrequent events but carry a poor prognosis. The predominant rhythm is ventricular tachycardia/fibrillation. Although the exact etiologies are not clear, several studies have confirmed an increased incidence on the first day after the weekend interval. Use of cardioprotective drugs and possibly an implantable cardioverter defibrillator may improve the prognosis of survivors after a cardiac arrest. More research is needed in this field. Kidney International (2008) 73, 907–908. doi:10.1038/ki.2008.40
Dialysis patients have an incidence of cardiac-related death 10–20 times higher than that of the general population. 1 They are particularly vulnerable to a sudden cardiac arrest. In the Hemodialysis (HEMO) Study2 and Die Deutsche Diabetes Dialyse Studie (4D),3 1Guy’s Hospital, Department of Nephrology,
London, United Kingdom Correspondence: M Ostermann, Guy’s and St Thomas’ Hospital, Department of Nephrology, St Thomas Street, London SE1 9RT, United Kingdom. E-mail: [email protected] Kidney International (2008) 73
sudden death accounted for 25% of the observed total mortality. Analysis of the United States Renal Data System database showed similar results: between 2001 and 2003, 32% of all deaths among hemodialysis patients were due to sudden in- or out-of-hospital cardiac arrests.4 Interestingly, this risk was high in the first 6 months after starting dialysis, dropped to its lowest point by 6 months, and then progressively rose again with each year on dialysis. Data from the System Case Mix Adequacy Study of the United States Renal Data
System show that the proportion of sudden deaths in hemodialysis patients was significantly higher on Mondays and Tuesdays compared with other days.5 No other risk factors were identified. In a separate study, the same authors found a threefold increased risk of sudden cardiac arrest in the 12 hours before hemodialysis at the end of the weekend interval (Figure 1).6 The exact reasons for this phenomenon are not clear, but accumulation of fluid and electrolytes may potentially play a role. Cardiac arrests in the dialysis unit are relatively rare events but carry a poor prognosis. Karnik et al. showed a frequency of 7 cardiac arrests per 100,000 hemodialysis sessions. 7 Affected patients were older, more likely to have diabetes, and more likely to dialyze via a catheter than the general hemodialysis population. Eighty-one percent of cardiac arrests occurred while the patient was on dialysis. The vast majority of patients had no overt symptoms prior to the event. An abnormal rhythm was documented in only 17% of patients, with ventricular fibrillation/tachycardia being the predominant one (62%). Again, cardiac arrests were more frequent on Mondays than on other days. It was also noted that 37% of patients had been hospitalized within the previous 30 days, but there were no data on recent laboratory results, changes in medication, or reason for hospital admission. Outcome was poor: 60% of patients died within 48 hours of the arrest. Pun et al. showed that traditional risk factors, including cardiovascular comorbidities, diabetes, hemoglobin, and dialysis adequacy, did not predict prognosis in hemodialysis patients after a cardiac arrest.8 Only use of β-blockers, calcium-channel blockers, angiotensinconverting enzyme inhibitors, and angiotensin receptor blockers at the time of the event was significantly associated with a better outcome. According to data from Herzog et al., dialysis patients who survive a cardiac arrest may also benefit from an implantable cardioverter defibrillator (ICD).9 In this retrospective cohort study, dialysis patients with an ICD after a cardiac arrest had a 42% reduction in mortality compared with 907
co mmentar y
908
3.5 Ratio observed (expected deaths)
similar patients without an ICD. The paper by Davis et al.10 (this issue) adds to the existing knowledge about cardiac arrests in hemodialysis patients. The Emergency Medical Services database for emergency calls was screened for hemodialysis patients with a cardiac arrest while in an outpatient dialysis facility. One hundred ten patients were identified. The majority of arrests occurred during dialysis (65%). Ventricular fibrillation was the most commonly observed initial rhythm (65%). Again, more events occurred on the first day after the weekend interval. Seventysix percent of patients died immediately or later in the hospital, but 15% survived at least one year after the event. Ventricular fibrillation as the initial rhythm was associated with a slightly better long-term outcome (1-year survival 19%). The authors did not identify any precipitating factors and did not have access to any laboratory parameters immediately prior to the cardiac event. However, their data on the role of automated external defibrillators (AEDs) are very intriguing and warrant further evaluation. Although 34 cardiac arrests occurred at dialysis facilities with an AED on site, only 53% of these 34 patients were recorded to have had an AED attached when the emergency medical team arrived. The exact reasons for this underutilization of AEDs are not known and can only be speculated upon. Lack of awareness, training, and maintenance of skills among dialysis staff is the most likely explanation. Previously, Lehrich et al. also showed that placing an AED in outpatient hemodialysis clinics did not improve the chances of survival after a cardiac arrest, 11 but they did not explore whether the AEDs had always been applied correctly and appropriately. Sudden cardiac death among dialysis patients remains a clinical challenge. The exact precipitating factors are still unclear. However, on the basis of the existing data, preventive strategies should focus on simple maneuvers: attention to detail, avoidance of rapid electrolyte shifts, frequent evaluation of the dialysis prescription (especially after hospitalization, when the effects
3.0 2.5 2.0 1.5 1.0 0.5 0
0–12
12–24 24–36 36–48 48–60 Hours from start of dialysis
60–72
Figure 1 | Ratio of actual to expected number of occurrences of sudden death for each 12-hour interval beginning with the start of hemodialysis.6
of acute illness and medications and alterations in extracellular fluid volume may still prevail), and regular evaluation of the medication, especially cardioprotective drugs. In patients who survive a cardiac arrest, an ICD should be considered. It has been repeatedly shown that more cardiac arrests occur on the first day after the weekend break,7,8,12 but whether quotidian or more frequent hemodialysis reduces this risk is not known yet. It is also still unclear whether there is a role for AEDs in the dialysis unit even if they are used correctly. Despite the increasing number of publications on the outcome of cardiac arrests in hemodialysis patients, so far none has been able to answer the question of why cardiac arrests occur in the first place and whether they can be prevented effectively. The majority of dialysis patients want to be resuscitated in the event of a cardiac arrest,13 but outcome after a cardiac arrest is still poor. Even if 1-year survival may have improved slightly to 15%, as is suggested by Davis et al., 10 this is good news only if it is associated with reasonable functional and neurological recovery. Therefore, research in this field must continue.
3.
4.
5. 6. 7. 8.
9.
10.
11.
12.
REFERENCES 1. 2.
Foley RN. Epidemiology of cardiovascular disease in chronic renal disease. J Am Soc Nephrol 1998; 9: S16–S23. Cheung AK, Sarnak MJ, Guofen Y et al. Cardiac
13.
diseases in maintenance hemodialysis patients: results of the HEMO Study. Kidney Int 2004; 65: 2380–2389. Wanner C, Krane V, Marz W et al. Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. N Engl J Med 2005; 353: 238–248. United States Renal Data System. 2005 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA, 2005. Bleyer AJ, Russell GB, Satko SG. Sudden and cardiac death rates in hemodialysis patients. Kidney Int 1999; 55: 1553–1559. Bleyer AJ, Hartman J, Brannon PC et al. Characteristics of sudden death in hemodialysis patients. Kidney Int 2006; 69: 2268–2273. Karnik JA, Young BS, Lew NL et al. Cardiac arrest and sudden death in dialysis units. Kidney Int 2001; 60: 350–357. Pun PH, Lehrich RW, Smith SR, Middleton JP. Predictors of survival after cardiac arrest in outpatient hemodialysis clinics. Clin J Am Soc Nephrol 2007; 2: 491–500. Herzog CA, Li S, Weinhandl ED et al. Survival of dialysis patients after cardiac arrest and the impact of implantable cardioverter defibrillators. Kidney Int 2005; 68: 818–825. Davis TR, Young BA, Eisenberg MS et al. Outcome of cardiac arrests attended by emergency medical services staff at community outpatient dialysis centers. Kidney Int 2008; 73: 933–939. Lehrich RW, Pun PH, Tanenbaum ND et al. Automated external defibrillators and survival from cardiac arrest in the outpatient hemodialysis clinic. J Am Soc Nephrol 2007; 18: 312–320. Lafance JP, Nolin L, Senecal L, Leblanc M. Predictors and outcome of cardiopulmonary resuscitation (CPR) calls in a large haemodialysis unit over a seven-year period. Nephrol Dial Transplant 2006; 21: 1006–1012. Ostermann ME, Nelson SR. Haemodialysis patients’ views on their resuscitation status. Nephrol Dial Transplant 2003; 18: 1644–1647. Kidney International (2008) 73
putative offending medication, the use of corticosteroids should be considered in all patients with AIN. This consideration should take into account not only rapidity and completeness of return of renal function to normal but also potential long-term benefits in avoiding interstitial fibrosis and eventual chronic kidney disease. REFERENCES 1. 2. 3. 4.
Baker RJ, Pusey CD. The changing profile of acute tubulointerstitial nephritis. Nephrol Dial Transplant 2004; 19: 8–11. Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001; 60: 804–817. Bhatt P, Appel GB. Tubulo-interstitial diseases. In: ACP Medicine. WebMD Inc.: New York, 2006, 2027–2043. Clarkson MR, Giblin L, O’Connell FP et al. Acute interstitial nephritis: clinical features and response to corticosteroid therapy. Nephrol Dial
Transplant 2004; 19: 2778–2783. Joss N, Morris S, Young B, Geddes C. Granulomatous interstitial nephritis. Clin J Am Soc Nephrol 2007; 2: 222–230. 6. Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990; 5: 94–99. 7. Schwarz A, Krause PH, Kunzendorf U et al. The outcome of acute interstitial nephritis: risk factors for the transition from acute to chronic interstitial nephritis. Clin Nephrol 2000; 54: 179–190. 8. Bhaumik SK, Kher V, Arora P et al. Evaluation of clinical and histological prognostic markers in drug-induced acute interstitial nephritis. Ren Fail 1996; 18: 97–104. 9. Preddie DC, Markowitz GS, Radhakrishnan J et al. Mycophenolate mofetil for the treatment of interstitial nephritis. Clin J Am Soc Nephrol 2006; 1: 718–722. 10. González E, Gutiérrez E, Galeano C et al. Early steroid treatment improves the recovery of renal function in patients with drug-induced acute interstitial nephritis. Kidney Int 2008; 73: 940–946.
5.
see original article on page 933
Cardiac arrests in hemodialysis patients: An ongoing challenge M Ostermann1 Hemodialysis patients have significant cardiac-related mortality. Sudden cardiac arrests in the dialysis unit are infrequent events but carry a poor prognosis. The predominant rhythm is ventricular tachycardia/fibrillation. Although the exact etiologies are not clear, several studies have confirmed an increased incidence on the first day after the weekend interval. Use of cardioprotective drugs and possibly an implantable cardioverter defibrillator may improve the prognosis of survivors after a cardiac arrest. More research is needed in this field. Kidney International (2008) 73, 907–908. doi:10.1038/ki.2008.40
Dialysis patients have an incidence of cardiac-related death 10–20 times higher than that of the general population. 1 They are particularly vulnerable to a sudden cardiac arrest. In the Hemodialysis (HEMO) Study2 and Die Deutsche Diabetes Dialyse Studie (4D),3 1Guy’s Hospital, Department of Nephrology,
London, United Kingdom Correspondence: M Ostermann, Guy’s and St Thomas’ Hospital, Department of Nephrology, St Thomas Street, London SE1 9RT, United Kingdom. E-mail: [email protected] Kidney International (2008) 73
sudden death accounted for 25% of the observed total mortality. Analysis of the United States Renal Data System database showed similar results: between 2001 and 2003, 32% of all deaths among hemodialysis patients were due to sudden in- or out-of-hospital cardiac arrests.4 Interestingly, this risk was high in the first 6 months after starting dialysis, dropped to its lowest point by 6 months, and then progressively rose again with each year on dialysis. Data from the System Case Mix Adequacy Study of the United States Renal Data
System show that the proportion of sudden deaths in hemodialysis patients was significantly higher on Mondays and Tuesdays compared with other days.5 No other risk factors were identified. In a separate study, the same authors found a threefold increased risk of sudden cardiac arrest in the 12 hours before hemodialysis at the end of the weekend interval (Figure 1).6 The exact reasons for this phenomenon are not clear, but accumulation of fluid and electrolytes may potentially play a role. Cardiac arrests in the dialysis unit are relatively rare events but carry a poor prognosis. Karnik et al. showed a frequency of 7 cardiac arrests per 100,000 hemodialysis sessions. 7 Affected patients were older, more likely to have diabetes, and more likely to dialyze via a catheter than the general hemodialysis population. Eighty-one percent of cardiac arrests occurred while the patient was on dialysis. The vast majority of patients had no overt symptoms prior to the event. An abnormal rhythm was documented in only 17% of patients, with ventricular fibrillation/tachycardia being the predominant one (62%). Again, cardiac arrests were more frequent on Mondays than on other days. It was also noted that 37% of patients had been hospitalized within the previous 30 days, but there were no data on recent laboratory results, changes in medication, or reason for hospital admission. Outcome was poor: 60% of patients died within 48 hours of the arrest. Pun et al. showed that traditional risk factors, including cardiovascular comorbidities, diabetes, hemoglobin, and dialysis adequacy, did not predict prognosis in hemodialysis patients after a cardiac arrest.8 Only use of β-blockers, calcium-channel blockers, angiotensinconverting enzyme inhibitors, and angiotensin receptor blockers at the time of the event was significantly associated with a better outcome. According to data from Herzog et al., dialysis patients who survive a cardiac arrest may also benefit from an implantable cardioverter defibrillator (ICD).9 In this retrospective cohort study, dialysis patients with an ICD after a cardiac arrest had a 42% reduction in mortality compared with 907
co mmentar y
908
3.5 Ratio observed (expected deaths)
similar patients without an ICD. The paper by Davis et al.10 (this issue) adds to the existing knowledge about cardiac arrests in hemodialysis patients. The Emergency Medical Services database for emergency calls was screened for hemodialysis patients with a cardiac arrest while in an outpatient dialysis facility. One hundred ten patients were identified. The majority of arrests occurred during dialysis (65%). Ventricular fibrillation was the most commonly observed initial rhythm (65%). Again, more events occurred on the first day after the weekend interval. Seventysix percent of patients died immediately or later in the hospital, but 15% survived at least one year after the event. Ventricular fibrillation as the initial rhythm was associated with a slightly better long-term outcome (1-year survival 19%). The authors did not identify any precipitating factors and did not have access to any laboratory parameters immediately prior to the cardiac event. However, their data on the role of automated external defibrillators (AEDs) are very intriguing and warrant further evaluation. Although 34 cardiac arrests occurred at dialysis facilities with an AED on site, only 53% of these 34 patients were recorded to have had an AED attached when the emergency medical team arrived. The exact reasons for this underutilization of AEDs are not known and can only be speculated upon. Lack of awareness, training, and maintenance of skills among dialysis staff is the most likely explanation. Previously, Lehrich et al. also showed that placing an AED in outpatient hemodialysis clinics did not improve the chances of survival after a cardiac arrest, 11 but they did not explore whether the AEDs had always been applied correctly and appropriately. Sudden cardiac death among dialysis patients remains a clinical challenge. The exact precipitating factors are still unclear. However, on the basis of the existing data, preventive strategies should focus on simple maneuvers: attention to detail, avoidance of rapid electrolyte shifts, frequent evaluation of the dialysis prescription (especially after hospitalization, when the effects
3.0 2.5 2.0 1.5 1.0 0.5 0
0–12
12–24 24–36 36–48 48–60 Hours from start of dialysis
60–72
Figure 1 | Ratio of actual to expected number of occurrences of sudden death for each 12-hour interval beginning with the start of hemodialysis.6
of acute illness and medications and alterations in extracellular fluid volume may still prevail), and regular evaluation of the medication, especially cardioprotective drugs. In patients who survive a cardiac arrest, an ICD should be considered. It has been repeatedly shown that more cardiac arrests occur on the first day after the weekend break,7,8,12 but whether quotidian or more frequent hemodialysis reduces this risk is not known yet. It is also still unclear whether there is a role for AEDs in the dialysis unit even if they are used correctly. Despite the increasing number of publications on the outcome of cardiac arrests in hemodialysis patients, so far none has been able to answer the question of why cardiac arrests occur in the first place and whether they can be prevented effectively. The majority of dialysis patients want to be resuscitated in the event of a cardiac arrest,13 but outcome after a cardiac arrest is still poor. Even if 1-year survival may have improved slightly to 15%, as is suggested by Davis et al., 10 this is good news only if it is associated with reasonable functional and neurological recovery. Therefore, research in this field must continue.
3.
4.
5. 6. 7. 8.
9.
10.
11.
12.
REFERENCES 1. 2.
Foley RN. Epidemiology of cardiovascular disease in chronic renal disease. J Am Soc Nephrol 1998; 9: S16–S23. Cheung AK, Sarnak MJ, Guofen Y et al. Cardiac
13.
diseases in maintenance hemodialysis patients: results of the HEMO Study. Kidney Int 2004; 65: 2380–2389. Wanner C, Krane V, Marz W et al. Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. N Engl J Med 2005; 353: 238–248. United States Renal Data System. 2005 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA, 2005. Bleyer AJ, Russell GB, Satko SG. Sudden and cardiac death rates in hemodialysis patients. Kidney Int 1999; 55: 1553–1559. Bleyer AJ, Hartman J, Brannon PC et al. Characteristics of sudden death in hemodialysis patients. Kidney Int 2006; 69: 2268–2273. Karnik JA, Young BS, Lew NL et al. Cardiac arrest and sudden death in dialysis units. Kidney Int 2001; 60: 350–357. Pun PH, Lehrich RW, Smith SR, Middleton JP. Predictors of survival after cardiac arrest in outpatient hemodialysis clinics. Clin J Am Soc Nephrol 2007; 2: 491–500. Herzog CA, Li S, Weinhandl ED et al. Survival of dialysis patients after cardiac arrest and the impact of implantable cardioverter defibrillators. Kidney Int 2005; 68: 818–825. Davis TR, Young BA, Eisenberg MS et al. Outcome of cardiac arrests attended by emergency medical services staff at community outpatient dialysis centers. Kidney Int 2008; 73: 933–939. Lehrich RW, Pun PH, Tanenbaum ND et al. Automated external defibrillators and survival from cardiac arrest in the outpatient hemodialysis clinic. J Am Soc Nephrol 2007; 18: 312–320. Lafance JP, Nolin L, Senecal L, Leblanc M. Predictors and outcome of cardiopulmonary resuscitation (CPR) calls in a large haemodialysis unit over a seven-year period. Nephrol Dial Transplant 2006; 21: 1006–1012. Ostermann ME, Nelson SR. Haemodialysis patients’ views on their resuscitation status. Nephrol Dial Transplant 2003; 18: 1644–1647. Kidney International (2008) 73