Type of arrhythmias and the risk of sudden cardiac death in dialysis patients: a systematic review and meta-analysis
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Abstract
Background
Patients on long-term dialysis for end-stage kidney disease have a high mortality rate, predominantly due to sudden cardiac death (SCD), which is associated with an increased risk of arrhythmias compared to the general population. Thus, the current systematic review and meta-analysis aimed to investigate the incidence of SCD among dialysis patients at risk of arrhythmia.
Methods
This systematic review and meta-analysis followed the PRISMA guidelines. PubMed, Cochrane Library, Google Scholar, Medline, and Europe PMC were searched for articles meeting our inclusion criteria. Studies with risk assessment of arrhythmias and the incidence of SCD in dialysis patients were considered for inclusion. Effect size from eligible studies was pooled using a random effects model and restricted maximum likelihood estimation. Heterogeneity was quantified using the I 2 statistic, and the risk of publication bias was evaluated by visually inspecting funnel plots.
Results
Our search strategy yielded 5861 studies, of which 1960 duplicate entries were removed in the prescreening stage, 3326 were excluded after title/abstract screening, and 519 after full-text screening for not meeting our inclusion criteria. Finally, 11 studies were included in the analysis, and two more were selected from the bibliography list of previous reviews. Eight included studies were randomized controlled trials, and five were cohort studies, which provided a pooled population size of 12,611 dialysis patients for the meta-analysis, which indicated a significantly larger effect size of arrhythmia [Cohen’s d = 110.38 (95%CI 42.72–178.05), p = 0.0]. Visual assessment of the funnel plot indicated no publication bias.
Conclusion
SCD remains a significant public health concern, particularly in patients undergoing dialysis. Meta-analysis results show that bradyarrhythmia is a common arrhythmic condition leading to SCD; however, other arrhythmias should also be considered.
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Peer review report
Title: Types of Arrhythmias and the risk of sudden cardiac death in dialysis patients: A Systematic Review and Meta-analysis
version: 1
Referee: Milaras Nikias
Institution: National and Kapodistrian University of Athens- Ippokrateion Hospital
email: nikiasmil@med.uoa.gr
ORCID iD: 0000-0001-7312-0976
General assessment
It is now well known that high cardiovascular mortality in ESRD patients is only partly due to atherothrombotic events. Ventricular tachyarrhythmias and electromechanical dissociation account for a significant amount of those deaths as was reported in landmark trials such as the MADIT II. VT or VF might be the mode of death in only a minority of those patients and this is extrapolated from the fact that ICD implantation in this population does not extend survival, whether due to high competing …
Peer review report
Title: Types of Arrhythmias and the risk of sudden cardiac death in dialysis patients: A Systematic Review and Meta-analysis
version: 1
Referee: Milaras Nikias
Institution: National and Kapodistrian University of Athens- Ippokrateion Hospital
email: nikiasmil@med.uoa.gr
ORCID iD: 0000-0001-7312-0976
General assessment
It is now well known that high cardiovascular mortality in ESRD patients is only partly due to atherothrombotic events. Ventricular tachyarrhythmias and electromechanical dissociation account for a significant amount of those deaths as was reported in landmark trials such as the MADIT II. VT or VF might be the mode of death in only a minority of those patients and this is extrapolated from the fact that ICD implantation in this population does not extend survival, whether due to high competing comorbidities or due to electromechanical dissociation being the cause of death. It is true that ESRD patients are underrepresented in such studies due to the high competing factor for non-cardiac death and no safe conclusion can yet be drawn. It remains yet to be seen whether a better risk stratification algorithm through Holter monitoring or programmed ventricular stimulation can unveil those truly at high risk for SCD.
This meta-analysis tries to unveil the mode of death and the high cardiovascular mortality in renal failure through a thorough literature search that included 11 studies. This systematic review/meta-analysis follows current writing and reporting guidelines.
The English used is adequate although some parts of the manuscript could be refined (eg 3rd paragraph in Introduction)
Essential revisions that are required to verify the manuscript
ESRD and ESKD are both discussed in the manuscript. I would personally prefer that the authors devoted more effort in commenting on the meta-analysis results and its implications. The included studies are not adequately annotated in the text, making reading difficult for the statistically unschooled reader who must understand the plots provided.
Decision
Verified with reservations: The content is academically sound but has shortcomings that must be improved.
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