Phenotype of patients receiving renal replacement therapy with programmed hemodialysis and who died suddenly during the interdialytic period

Introduction. Kidney replacement therapy – primarily maintenance hemodialysis (MHD) – has enabled patients with end-stage kidney disease to survive for decades despite the loss of kidney function. Consequently, mortality in this population is now largely driven by other causes, including cardiovascular disease, infections, including sepsis, and cancer. Risk factors for with sudden cardiac death (SCD) in patients receiving MHD only partially overlap with those in the general population: renal failure and hemodialysis significantly increase the risk of SCD compared with individuals who have preserved renal function.

The aim of our study was to identify a possible predictor phenotype for SCD in patients undergoing MHD. We analyzed the impact of echocardiographic (EchoCG), electrocardiographic (ECG), and laboratory parameters on overall and cardiac five-year survival in prospective single center patients cohort (n=212) undergoing MHD from 2001 till 2025.

Results: data from 14 deceased patients (31.1% of all cardiac deaths) met the criteria for non-dialytic SCD. We identified clinical profile characteristics of patients who experienced SCD during long-term MHD. The only echocardiographic parameter at baseline differed significantly in the SCD group was the end-diastolic volume (EDV). The median EDV in patients with SCD, regardless of left ventricle ejection fraction (LVEF), was markedly higher than in patients in other groups: 182.8 (144.9-226.2) ml in the SCD group (n=14), 101.0 (75.0-129.3) ml in the reduced LVEF group (n=52), 104.1 (101.2-167.0) ml in the other causes group (n=45), and 114.2 (81.7-140.5) ml in currently living patients (n=99, р=0.007). Compared with patients who died from other causes, those with SCD were younger, had LV dilation, and a relatively short dialysis vintage. Survival was particularly poor in SCD patients with LVEF <40%. Patients undergoing MHD who are under 55 years of age, had increased EDV (especially when accompanied by reduced LVEF), and have a short dialysis history should be considered at elevated risk for SCD on MHD.

Conclusion: the results of this study indicate that patients younger than 55 years, with a with a relatively short dialysis history and left ventricular dilation, especially when LVEF is reduced, carry a higher risk of SCD on MHD.

1. Bikbov B., Tomilina N.A. Replacement therapy of patients with chronic renal failure in the Russian Federation in 1998-2011 (Report on data from the Russian registry of renal replacement therapy. Part one). Nephrology and dialysis. 2014;16 (1):11-127

2. Tran M, Xu CA, Wilson J, Ephraim et al. Comparative Effectiveness Studies in Dialysis Patients Group. Distinguishing Among Causes of Death for Patients with Kidney Failure on Hemodialysis. Kidney360. 2025 Mar 1;6(3):432-440. DOI: 10.34067/KID.0000000681.

3. Makar MS, Pun PH. Sudden Cardiac Death Among Hemodialysis Patients. Am J Kidney Dis. 2017 May;69(5):684-695. DOI: 10.1053/j.ajkd.2016.12.006.

4. Genovesi S, Lieti G, Camm AJ. Sudden cardiac death in patients with kidney failure on renal replacement therapy: An unsolved problem. Heart Rhythm. 2025 Mar 21:S1547-5271(25)02232-5. DOI: 10.1016/j.hrthm.2025.03.1970.

5. Genovesi S, Boriani G, Covic A et al. EUDIAL Working Group of ERA-EDTA. Sudden cardiac death in dialysis patients: different causes and management strategies. Nephrol Dial Transplant. 2021 Feb 20;36(3):396-405. DOI: 10.1093/ndt/gfz182.

6. Zoccali C, Mallamaci F, Adamczak M et al. Cardiovascular complications in chronic kidney disease: a review from the European Renal and Cardiovascular Medicine Working Group of the European Renal Association. Cardiovasc Res. 2023 Sep 5;119(11):2017-2032. DOI: 10.1093/cvr/cvad083

7. Wan C, Herzog CA, Zareba W. Sudden cardiac arrest in hemodialysis patients with wearable cardioverter defibrillator. Ann Noninvasive Electrocardiol. 2014 May;19(3):247-57 DOI: 10.1111/anec.12119.

8. Franczyk ., Rysz J, Olszewski R, Gluba-Sagr A. Do Implantable Cardioverter-Defibrillators Prevent Sudden Cardiac Death in End-Stage Renal Disease Patients on Dialysis? J. Clin. Med. 2024, 13, 1176. DOI :10.3390/jcm13041176

9. Wong MC, Kalman JM, Pedagogos E et al. Temporal distribution of arrhythmic events in chronic kidney disease: Highest incidence in the long interdialytic period. Heart Rhythm. 2015 Oct;12(10):2047-55. DOI: 10.1016/j.hrthm.2015.06.033.

10. Roy-Chaudhury P, Tumlin J.A, Koplan BA, et al. MiD investigators and committees. Primary outcomes of the Monitoring in Dialysis Study indicate that clinically significant arrhythmias are common in hemodialysis patients and related to dialytic cycle. Kidney Int. 2018 Apr;93(4):941-951. DOI: 10.1016/j.kint.2017.11.019.

11. Liu P, Wang L, Han D, Sun, C et al. Acquired long QT syndrome in chronic kidney disease patients. Ren Fail. 2020 Nov;42(1):54-65. DOI: 10.1080/0886022X.2019.1707098.

12. Ismail S, Funk MJ, Flythe JE. Ondansetron and the Risk of Sudden Cardiac Death among Individuals Receiving Maintenance Hemodialysis. J Am Soc Nephrol. 2024 Jun 1;35(6):761-771. DOI: 10.1681/ASN.0000000000000336.

13. Assimon MM, Pun PH, Wang LC, et al. Analysis of Respiratory Fluoroquinolones and the Risk of Sudden Cardiac Death Among Patients Receiving Hemodialysis. JAMA Cardiol. 2022 Jan 1;7(1):75-83. DOI: 10.1001/jamacardio.2021.4234.

14. Mozhokinа G.N., Sаmoylovа A.G. Cardiac toxicity of fluoroquinolones and bedaquiline. Tuberculosis and Lung Diseases. 2019;97(4):56-62. (In Russ.) DOI:10.21292/2075-1230-2019-97-4-56-62

15. Gendlin GE, Shilo VYu, Ettinger OA, Shvetsova IK. Left ventricular myocardial hypertrophy as a risk factor for sudden death in patients undergoing program hemodialysis. Nephrology and Dialysis. 2011;13(3):298-299. (In Russ.)

16. Ivanova AA, Nesterets AM, Maksimov VN. Sudden cardiac death: epidemiology, etiology, pathogenesis, and risk factors. Complex issues of cardiovascular diseases. 2024; 13(4S): 159–167. (In Russ.) DOI:.org/10.17802/2306-1278-2024-13-4S-159-167

17. Karaboyas A, Zee J, Brunelli SM et al. Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS), 2025 г. DOI: 10.1053/j.ajkd.2016.09.015.

18. Banerjee D. Sudden cardiac death in haemodialysis: clinical epidemiology and mechanisms. J Electrocardiol. 2016 Nov-Dec;49(6):843-847. DOI: 10.1016/j.jelectrocard.2016.07.016. Epub 2016 Jul 28.

19. Pigolkin, Yu.I., Kaktursky, L.V., Shilova, M.A., Globa, I.V. Forensic Diagnostics of Sudden Death in Young People. Moscow: 2018. 98 p., ill. ISBN 978-5-907036-46-8. DOI: 10.31857/S9785907036468000001(In Russ.)