Can We Prevent Sudden Cardiac Death in Dialysis Patients?

End-stage renal disease (ESRD) patients are at high risk for mortality. The annual death rate for prevalent US dialysis patients in 2004 was 230 deaths per 1000 patient-years (1). Cardiac disease is the largest single cause of death for both hemodialysis and peritoneal dialysis patients, accounting for 43% of all-cause mortality (1). In the United States Renal Data System (USRDS) database, arrhythmic mechanisms account for 58% of cardiac deaths (25% of all deaths) among peritoneal dialysis patients, and 64% of cardiac deaths (27% of all deaths) among hemodialysis patients (1). In the Hemodialysis (HEMO) (2) and Die Deutsche Diabetes-Dialyse Study (4D) (3) trials, sudden death accounted for 25 to 26% of the observed total mortality. The USRDS Cardiovascular Special Studies Center estimated a sudden cardiac death rate among 2002 prevalent US dialysis patients of approximately 7% per year (1).ESRD patients are particularly vulnerable to sudden cardiac death. Myocardial ischemia in the setting of obstructive coronary artery disease is likely an important contributor, but if it were the major contributor we would expect dialysis patients undergoing surgical coronary artery revascularization to be at low long-term risk for subsequent arrhythmic death. To the contrary, the annual mortality of dialysis patients ascribed to arrhythmic mechanisms after coronary artery bypass surgery was 7% per year, similar to the entire prevalent dialysis population, which implies that primary reliance on amelioration of myocardial ischemia may be an inadequate clinical strategy (4). Left ventricular hypertrophy (present in at least 75% of dialysis patients), rapid …