title: Modifiable practices associated with sudden death among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study.
abstract: OBJECTIVE
  Sudden death is common in hemodialysis patients, but whether modifiable practices affect the risk of sudden death remains unclear.
  
  
  METHODS
  This study analyzed 37,765 participants in 12 countries in the Dialysis Outcomes and Practice Patterns Study to explore the association of the following practices with sudden death (due to cardiac arrhythmia, cardiac arrest, and/or hyperkalemia): treatment time [TT] <210 minutes, Kt/V <1.2, ultrafiltration volume >5.7% of postdialysis weight, low dialysate potassium [K(D) <3]), and prescription of Q wave/T wave interval-prolonging drugs. Cox regression was used to estimate effects on mortality, adjusting for potential confounders. An instrumental variable approach was used to further control for unmeasured patient-level confounding.
  
  
  RESULTS
  There were 9046 deaths, 26% of which were sudden (crude mortality rate, 15.3/100 patient-years; median follow-up, 1.59 years). Associations with sudden death included hazard ratios of 1.13 for short TT, 1.15 for large ultrafiltration volume, and 1.10 for low Kt/V. Compared with K(D) ≥3 mEq/L, the sudden death rate was higher for K(D) ≤1.5 and K(D)=2-2.5 mEq/L. The instrumental variable approach yielded generally consistent findings. The sudden death rate was elevated for patients taking amiodarone, but not other Q wave/T wave interval-prolonging drugs.
  
  
  CONCLUSIONS
  This study identified modifiable dialysis practices associated with higher risk of sudden death, including short TT, large ultrafiltration volume, and low K(D). Because K(D) <3 mEq/L is common and easy to change, K(D) tailoring may prevent some sudden deaths. This hypothesis merits testing in clinical trials.
authors.affiliation: Department of Nephrology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium. Michel.Jadoul@uclouvain.be
authors.forename: Michel
authors.initials: M
authors.lastname: Jadoul
authors.forename: Jyothi
authors.initials: J
authors.lastname: Thumma
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Fuller
authors.forename: Francesca
authors.initials: F
authors.lastname: Tentori
authors.forename: Yun
authors.initials: Y
authors.lastname: Li
authors.forename: Hal
authors.initials: H
authors.lastname: Morgenstern
authors.forename: David
authors.initials: D
authors.lastname: Mendelssohn
authors.forename: Tadashi
authors.initials: T
authors.lastname: Tomo
authors.forename: Jean
authors.initials: J
authors.lastname: Ethier
authors.forename: Friedrich
authors.initials: F
authors.lastname: Port
authors.forename: Bruce M
authors.initials: BM
authors.lastname: Robinson
mesh_terms: D000368:Aged; D000638:Amiodarone / Q000009:adverse effects; D000889:Anti-Arrhythmia Agents / Q000009:adverse effects; D001145:Arrhythmias, Cardiac / Q000150:complications; D016757:Death, Sudden, Cardiac / Q000453:epidemiology* / Q000209:etiology; D015314:Dialysis Solutions / Q000009:adverse effects / Q000737:chemistry*; D005260:Female; D006801:Humans; D006947:Hyperkalemia / Q000150:complications; D008297:Male; D008875:Middle Aged; D011188:Potassium / Q000032:analysis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality*; D013997:Time Factors; D014462:Ultrafiltration / Q000009:adverse effects*
chemical_list: D000889:Anti-Arrhythmia Agents; D015314:Dialysis Solutions; D000638:Amiodarone; D011188:Potassium