1. Arrhythmias in Chronic Kidney
Disease
Prof. Samir Morcos Rafla
FACC, FESC
Alexandria Univ.

2. Arrhythmias in chronic kidney disease
Heart 2011;97:766-773
Chronic kidney disease (CKD) is defined
as evidence of kidney damage or a
glomerular filtration rate (GFR) ≤60
). ml/min/1.73 m2 (table 1
The most common causes of CKD are
hypertension and diabetes mellitus. The
many causes of CKD are associated with
. different varying prognoses

3. The life expectancy of a 25-year-old
dialysis patient is 12 years, compared with
32 years for an age equivalent transplant
recipient and 52 years for a 25-year-old in
the general population.
Even patients with CKD stage 5 will only
have a 20–25% chance of surviving long
enough to require dialysis. The greatest
cause of death in CKD is premature
cardiovascular disease.
3

4. Both cardiac and renal systems appear to
be completely interdependent, further
emphasizing the concept of the
‘cardiorenal syndrome’. This is highlighted
when considering arrhythmias in patients
with impaired renal function.
4

5. The arrhythmia burden of the patient with
CKD is high, with the single greatest
contributor to mortality in end stage renal
disease (ESRD) being sudden cardiac
death (SCD).
5

6. Ventricular arrhythmias and sudden death in
patients with chronic kidney disease.
J Ren Care. 2010 May;36 Suppl 1:54-60.
One in four dialysis patients will die suddenly. Most do
not fall into the high-risk categories that are associated
with sudden death in the general population. The cause
of sudden death in the dialysis population is unknown. It
may be related to factors associated with chronic kidney
disease (CKD) itself, for example, inflammation, vascular
stiffness, left ventricular hypertrophy, coronary artery
disease, electrolyte/fluid abnormalities or autonomic
dysfunction.
6

7. Studies of patients with implantable cardioverter
defibrillators have shown that patients with CKD
are more likely to use their devices for ventricular
arrhythmias but in spite of this still have a high
associated mortality.
Minimising risk of SCD is by good control of basic
parameters such as fluid balance, electrolytes
and blood pressure, along with careful
assessment of all patients for evidence of
coronary artery disease and heart failure is the
mainstay of management of the CKD patient.
7

8. With regards to drug therapy, the following
key points are noted:
• Beta-blockers are advised, but sotalol
should be avoided.
• Drugs which are not affected by renal
metabolism may still have an altered
distribution or binding in CKD.
• All drug treatment must be closely
monitored and possible interactions sought
thoroughly
8

9. Chronic Kidney Disease and Mortality in
Implantable Cardioverter-Defibrillator Recipients
Cardiology Research and Practice. Volume 2010
Incidence of sudden cardiac death (SCD) in end-
stage renal disease (ESRD) remains high.
Limited data is available about whether
implantable cardioverter-defibrillators (ICDs) can
prevent arrhythmic death in patients with chronic
kidney disease (CKD). The purpose of this
retrospective study was to determine the impact
of CKD on all-cause and sudden cardiac death in
ICD recipients.
9

10. 441 pts were evaluated who underwent ICD
implantation. Mortality rate was higher in patients
with eGFR < 6 0 mL/min and those with ESRD on
hemodialysis (43%, and 54%, resp.) than in
patients with eGFR ≥ 6 0 mL/min
(23%; 𝑃 < . 0 0 0 5).
The SCD rate was also higher in the patients with
ESRD (50%) than in CKD patients not on dialysis
(10.2%; 𝑃 < . 0 0 0 5). Mortality rate for single-
chamber ICDs was 56.8% in comparison with
dual-chamber ICDs (38.1%) and for biventricular
ICDs (5.0%) (𝑃 < . 0 0 0 5).
10

11. The enrolled subjects had ICD implantation based on
the following criteria. (1) Nonsustained VT in patients
with coronary artery disease (CAD), previous myocardial
infarction (MI), left ventricular (LV) dysfunction, and
EF <35% who had induced sustained monomorphic VT
that was nonsuppressible with anti-arrhythmic drug.
(2) EF ≤30% in patients with a history of MI (MADIT II) .
(3) VF or sustained VT with syncope, or sustained VT
with an LVEF <40% and severe symptoms (syncope,
near syncope, CHF, angina) suggestive of hemodynamic
compromise. (4) Syncope of unknown origin in CAD
patients, and severe LV dysfunction who had inducible
sustained monomorphic VT with hemodynamic
compromise at EP study.
11

12. Potassium level changes – arrhythmia
contributing factor in chronic
kidney disease patients
Rom J Morphol Embryol 2011, 52(3 Suppl):1047–1050
The aim of the study was to determine in which
degree the serum potassium changes are
implicated in arrhythmias development in CKD
patients.
Methods: ECG , Holter
12

13. Results: we noticed, in our predialysis group, an
important correlation between
hyper-/hypokalemia and arrhythmias
appearance,
more frequent during hypokalemia episodes
(OR=4.04, respectively OR=7.5). The same
. situation was observed in chronic dialysis group
Conclusions: Hypokalemia is a stronger risk
factor than hyperkalemia, but all together, any
minimal changes in serum potassium levels
. could determine arrhythmia in CKD patients 13

14. 14

15. 15

16. 16

17. 17

18. Knowledge Gap
18

19. Excessive bleeding has been noted in pts
administered warfarin in therapeutic
doses. The clinical dilemma is that stroke
risk increases with declining kidney
function, but bleeding risk increases
.during warfarin anticoagulation
19

20. Risk of arrhythmic and nonarrhythmic death
in patients with heart failure and chronic
kidney disease
American Heart Journal Volume 161, Issue 1 , Pages 204-
209.e1, January 2011
Among 6,378 patients without an ICD (age 60 ±
10, LVEF 27 ± 6, male 86%), there were 421
arrhythmic and 1188 nonarrhythmic deaths over
a median follow-up of 34 months.
Worse HF or CKD stages were associated with
increased risk of both arrhythmic and
nonarrhythmic death
20

21. The increase in the risk of nonarrhythmic death
in the worst HF stage was disproportionately
higher than that of arrhythmic death, and this
disproportionate effect was more exaggerated in
the presence of more advanced CKD.
Conclusion
While advanced CKD and HF stages are
associated with increased risk of arrhythmic and
nonarrhythmic death, benefits of ICDs in
patients with more advanced disease may be
limited by the preponderance of nonarrhythmic
death. 21

22. 22

23. Figure shows the association of HF and CKD stage with
arrhythmic death. Subjects with the most advanced
stages of HF and CKD (HF 4/CKD 4) had 13.0 times
(95% CI 4.9-34.2) the hazard of dying of an arrhythmia
compared with patients in the least advanced stages
(HF 1/CKD 1). 23

24. 24

25. Summary of Studies on Noninvasive Risk
Assessment in Dialysis Patients
Investigated Outcome Patient
Studies Salient Findings
Marker Measure Characteristics
1253 patients with LVH associated with a
Krane et al,
LVH SCD type 2 diabetes on 60% higher relative
200924
HD risk of SCD
196 asymptomatic LF/HF ratio in HRV
Nishimura et
HRV+LVH SCD HD patients with was an independent
al37
LVH predictor of SCD
25

26. 26

27. Questions:
-What are the predictors of SD in CKD?
-What are the indications of ICD in CKD?
Answer :slide 13
- What is the appropriate INR in Marevan
treated CKD pts? Answer: 2
-What are suitable antiarrhythmic drugs in
CKD pts? Answer : Amiodarone,
Propafenon (if LV wall< 14 mm)
27

28. What are the predictors of SD in CKD?
-LVH
-LVF
-HR Variability
-Mutlivessel coronary disease
-Acute myocardial infarction
-K hyper or hypo
-Withdrawal
-Cardiomyopathy
28

29. 29

30. CONCLUSIONS
Chronic kidney disease was associated with
an increased risk of stroke or systemic
thromboembolism and bleeding among
patients with atrial fibrillation. Warfarin
treatment was associated with a decreased
risk of stroke or systemic thromboembolism
among pnts with CKD, whereas warfarin
and aspirin were associated with an
increased risk of bleeding.
30

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