Dialysate calcium concentration and the risk of sudden cardiac arrest in hemodialysis patients.
OBJECTIVE
The optimal dialysate calcium concentration to maintain normal mineralization and reduce risk of cardiovascular events in hemodialysis patients is debated. Guidelines suggest that dialysate Ca concentration should be lowered to avoid vascular calcification, but cardiac arrhythmias may be more likely to occur at lower dialysate Ca. Concurrent use of QT-prolonging medications may also exacerbate arrhythmic risk. This study examined the influence of serum Ca, dialysate Ca, and QT interval-prolonging medications on the risk of sudden cardiac arrest in a cohort of hemodialysis patients.


METHODS
This case-control study among 43,200 hemodialysis patients occurred between 2002 and 2005; 510 patients who experienced a witnessed sudden cardiac arrest were compared with 1560 matched controls. This study examined covariate-adjusted sudden cardiac arrest risk associations with serum Ca, dialysate Ca, serum dialysate Ca gradient, and prescription of QT-prolonging medications using logistic regression techniques.


RESULTS
Patients assigned to low Ca dialysate<2.5 mEq/L were more likely to be exposed to larger serum dialysate Ca gradient and had a greater fall in BP during dialysis treatment. After accounting for covariates and baseline differences, low Ca dialysate<2.5 mEq/L (odds ratio=2.00, 95% confidence interval=1.40-2.90), higher corrected serum Ca (odds ratio=1.10, 95% confidence interval=1.00-1.30), and increasing serum dialysate Ca gradient (odds ratio=1.40, 95% confidence interval=1.10-1.80) were associated with increased risk of sudden cardiac arrest, whereas there were no significant risk associations with QT-prolonging medications.


CONCLUSIONS
Increased risk of sudden cardiac arrest associated with low Ca dialysate and large serum dialysate Ca gradients should be considered in determining the optimal dialysate Ca prescription.
Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina 27710, USA. patrick.pun@duke.edu
Patrick H
PH
Pun
John R
JR
Horton
John P
JP
Middleton
D000368:Aged; D002118:Calcium / Q000009:adverse effects* / Q000097:blood; D016022:Case-Control Studies; D016757:Death, Sudden, Cardiac / Q000209:etiology*; D004305:Dose-Response Relationship, Drug; D004347:Drug Interactions; D005260:Female; D015312:Hemodialysis Solutions / Q000009:adverse effects*; D006801:Humans; D016015:Logistic Models; D008133:Long QT Syndrome / Q000209:etiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D006435:Renal Dialysis / Q000009:adverse effects*; D018570:Risk Assessment; D012307:Risk Factors
D015312:Hemodialysis Solutions; D002118:Calcium