One quarter of all hemodialysis patients will succumb to sudden cardiac death (SCD), a rate far exceeding that
observed in the general population. A high prevalence of atherosclerotic coronary artery disease amongst patients with
end-stage kidney disease (ESKD) partly explains this exaggerated risk. However, uremia and dialysis related factors are
also of critical importance.
Interventions aimed at preventing SCD have been inadequately studied in patients with ESKD. Data extrapolated from
non-renal populations cannot necessarily be applied to hemodialysis patients, who possess relatively unique risk factors
for SCD including “uremic cardiomyopathy”, electrolyte shifts, fluctuations in intravascular volume and derangements of
mineral and bone metabolism.
Pending data derived from proposed randomized controlled clinical trials, critical appraisal of existing evidence and the
selective application of guidelines developed for the general population to dialysis patients are required if therapeutic
nihilism, or excessive intervention, are to be avoided. We discuss the evidence supporting a role for medical therapies,
dialysis prescription refinements, revascularization procedures and electrical therapies as potential interventions to prevent
SCD amongst hemodialysis patients. Based on current best available evidence, we present suggested strategies for the
prevention of arrhythmia-mediated death in this highly vulnerable patient population.