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1. Implantable Loop Recorder Monitoring and the Incidence of Previously Unrecognized Atrial Fibrillation in Patients on Hemodialysis

Author

Bruce A. Koplan, Wolfgang C. Winkelmayer, Alexandru I. Costea, Prabir Roy-Chaudhury, James A. Tumlin, Vijay Kher, Don E. Williamson, Saurabh Pokhariyal, David M. Charytan, Don Williamson, James Tumlin, Vikranth Reddy, Kowdle Chandrasekhar Prakash, David Charytan, Suresh Chandra Tiwari, Amber Podoll, Sanjeev Jasuja, G. Leslie Walters, Kraig Wangsnes, Alexandru Costea, Selcuk Tombul, Balbir Singh, Brajesh Mishra, Sachin Yalagudri, Abhijeet Shelke, Calambur Narasimhan, A.M. Karthigesan, Abraham Oomman, K P Pramod Kumar, Bruce Koplan, Upendra Kaul, Tapan Ghose, Ripen Gupta, Arvind Sethi, Nikhil Kumar, Ramesh Hariharan, Rajnish Sardana, Arif Wahab, N.N. Khanna, Mark Smith, Suresh Kamath, Claude Galphin, Puneet Sodhi, Rajsekara Chakravarthy, Subba Rao Budithi, Finnian McCausland, Sanjeev Gulati, Munawer Dijoo, Upendra Singh, Salil Jain, Vishal Saxena, Gaurav Sagar, Rachel Fissell, Robert Foley, Charles A. Herzog, Peter A. McCullough, John D. Rogers, Peter Zimetbaum, Manish Assar, and Mark Kremers

Subjects
medicine.medical_specialty, hemodialysis, implantable loop recorder, business.industry, Incidence (epidemiology), medicine.medical_treatment, end stage kidney diseae (ESKD), Atrial fibrillation, medicine.disease, Diseases of the genitourinary system. Urology, kidney failure, Nephrology, Internal medicine, Cardiology, medicine, Implantable loop recorder, atrial fibrillation, In patient, RC870-923, Hemodialysis, business, arrhythmias, Stroke, Dialysis
Abstract

Introduction: Atrial fibrillation (AF) is common in patients with kidney failure on hemodialysis (KF-HD). We determined both AF incidence and burden in patients with KF-HD using implantable loop recorder (ILR) monitoring. Methods: Patients with KF-HD were enrolled and received an ILR. In 6 monitoring months, the incidence of AF events lasting ≥6 minutes was captured. Demographic, clinical, and dialysis characteristics were collected, and associations with incident AF were estimated using negative binomial regression models and expressed as incidence rate ratios and 95% CIs. Results: We enrolled 66 patients with KF-HD (mean age = 56 years, 70% male); 59 (90%) were without previously diagnosed AF. AF lasting ≥6 minutes was detected in 18 of 59 subjects (31%) without previously diagnosed AF and in 5 of 7 subjects (71%) with a previous AF diagnosis. Among the 23 with detected AF, episodes were present on 16% of patient days. Although 14 of 23 patients (61%) had AF on 2.5 vs. 2.5 mEq/l: incidence rate ratio = 0.62; 95% CI, 0.48–0.80) was associated with lower AF risk whereas higher dialysate bicarbonate concentrations (>35 vs. 35 mEq/l: incidence rate ratio = 3.18; 95% CI, 1.13–8.94) were associated with higher AF risk. Conclusion: New AF was detected in approximately one-third of patients with KF-HD. AF affects a substantial proportion of patient days and may be an underappreciated cause of stroke in KF-HD.

Published
2022
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2. Characteristics and Outcomes of Individuals With Pre-existing Kidney Disease and COVID-19 Admitted to Intensive Care Units in the United States

Author

Jennifer E. Flythe, Magdalene M. Assimon, Matthew J. Tugman, Emily H. Chang, Shruti Gupta, Jatan Shah, Marie Anne Sosa, Amanda DeMauro Renaghan, Michal L. Melamed, F. Perry Wilson, Javier A. Neyra, Arash Rashidi, Suzanne M. Boyle, Shuchi Anand, Marta Christov, Leslie F. Thomas, Daniel Edmonston, David E. Leaf, Carl P. Walther, Samaya J. Anumudu, Justin Arunthamakun, Kathleen F. Kopecky, Gregory P. Milligan, Peter A. McCullough, Thuy-Duyen Nguyen, Shahzad Shaefi, Megan L. Krajewski, Sidharth Shankar, Ameeka Pannu, Juan D. Valencia, Sushrut S. Waikar, Zoe A. Kibbelaar, Ambarish M. Athavale, Peter Hart, Shristi Upadhyay, Ishaan Vohra, Adam Green, Jean-Sebastien Rachoin, Christa A. Schorr, Lisa Shea, Daniel L. Edmonston, Christopher L. Mosher, Alexandre M. Shehata, Zaza Cohen, Valerie Allusson, Gabriela Bambrick-Santoyo, Noor ul aain Bhatti, Bijal Mehta, Aquino Williams, Samantha K. Brenner, Patricia Walters, Ronaldo C. Go, Keith M. Rose, Lili Chan, Kusum S. Mathews, Steven G. Coca, Deena R. Altman, Aparna Saha, Howard Soh, Huei Hsun Wen, Sonali Bose, Emily A. Leven, Jing G. Wang, Gohar Mosoyan, Girish N. Nadkarni, Pattharawin Pattharanitima, Emily J. Gallagher, Allon N. Friedman, John Guirguis, Rajat Kapoor, Christopher Meshberger, Katherine J. Kelly, Chirag R. Parikh, Brian T. Garibaldi, Celia P. Corona-Villalobos, Yumeng Wen, Steven Menez, Rubab F. Malik, Carmen Elena Cervantes, Samir C. Gautam, Mary C. Mallappallil, Jie Ouyang, Sabu John, Ernie Yap, Yohannes Melaku, Ibrahim Mohamed, Siddhartha Bajracharya, Isha Puri, Mariah Thaxton, Jyotsna Bhattacharya, John Wagner, Leon Boudourakis, H. Bryant Nguyen, Afshin Ahoubim, Kianoush Kashani, Shahrzad Tehranian, Dheeraj Reddy Sirganagari, Pramod K. Guru, Yan Zhou, Paul A. Bergl, Jesus Rodriguez, Jatan A. Shah, Mrigank S. Gupta, Princy N. Kumar, Deepa G. Lazarous, Seble G. Kassaye, Tanya S. Johns, Ryan Mocerino, Kalyan Prudhvi, Denzel Zhu, Rebecca V. Levy, Yorg Azzi, Molly Fisher, Milagros Yunes, Kaltrina Sedaliu, Ladan Golestaneh, Maureen Brogan, Neelja Kumar, Michael Chang, Jyotsana Thakkar, Ritesh Raichoudhury, Akshay Athreya, Mohamed Farag, Edward J. Schenck, Soo Jung Cho, Maria Plataki, Sergio L. Alvarez-Mulett, Luis G. Gomez-Escobar, Di Pan, Stefi Lee, Jamuna Krishnan, William Whalen, David Charytan, Ashley Macina, Sobaata Chaudhry, Benjamin Wu, Frank Modersitzki, Anand Srivastava, Alexander S. Leidner, Carlos Martinez, Jacqueline M. Kruser, Richard G. Wunderink, Alexander J. Hodakowski, Juan Carlos Q. Velez, Eboni G. Price-Haywood, Luis A. Matute-Trochez, Anna E. Hasty, Muner M.B. Mohamed, Rupali S. Avasare, David Zonies, Meghan E. Sise, Erik T. Newman, Samah Abu Omar, Kapil K. Pokharel, Shreyak Sharma, Harkarandeep Singh, Simon Correa, Tanveer Shaukat, Omer Kamal, Wei Wang, Heather Yang, Jeffery O. Boateng, Meghan Lee, Ian A. Strohbehn, Jiahua Li, Ariel L. Mueller, Roberta Redfern, Nicholas S. Cairl, Gabriel Naimy, Abeer Abu-Saif, Danyell Hall, Laura Bickley, Chris Rowan, Farah Madhani-Lovely, Vasil Peev, Jochen Reiser, John J. Byun, Andrew Vissing, Esha M. Kapania, Zoe Post, Nilam P. Patel, Joy-Marie Hermes, Anne K. Sutherland, Amee Patrawalla, Diana G. Finkel, Barbara A. Danek, Sowminya Arikapudi, Jeffrey M. Paer, Peter Cangialosi, Mark Liotta, Jared Radbel, Sonika Puri, Jag Sunderram, Matthew T. Scharf, Ayesha Ahmed, Ilya Berim, Jayanth S. Vatson, Joseph E. Levitt, Pablo Garcia, Rui Song, Jingjing Zhang, Sang Hoon Woo, Xiaoying Deng, Goni Katz-Greenberg, Katharine Senter, Moh’d A. Sharshir, Vadym V. Rusnak, Muhammad Imran Ali, Anip Bansal, Amber S. Podoll, Michel Chonchol, Sunita Sharma, Ellen L. Burnham, Rana Hejal, Eric Judd, Laura Latta, Ashita Tolwani, Timothy E. Albertson, Jason Y. Adams, Ronald Reagan, Steven Y. Chang, Rebecca M. Beutler, Santa Monica, Carl E. Schulze, Etienne Macedo, Harin Rhee, Kathleen D. Liu, Vasantha K. Jotwani, Jay L. Koyner, Alissa Kunczt, Chintan V. Shah, Vishal Jaikaransingh, Stephanie M. Toth-Manikowski, Min J. Joo, James P. Lash, Nourhan Chaaban, Rajany Dy, Alfredo Iardino, Elizabeth H. Au, Jill H. Sharma, Sabrina Taldone, Gabriel Contreras, David De La Zerda, Hayley B. Gershengorn, Salim S. Hayek, Pennelope Blakely, Hanna Berlin, Tariq U. Azam, Husam Shadid, Michael Pan, Patrick O’ Hayer, Chelsea Meloche, Rafey Feroze, Rayan Kaakati, Danny Perry, Abbas Bitar, Elizabeth Anderson, Kishan J. Padalia, John P. Donnelly, Andrew J. Admon, Brent R. Brown, Amanda K. Leonberg-Yoo, Ryan C. Spiardi, Todd A. Miano, Meaghan S. Roche, Charles R. Vasquez, Amar D. Bansal, Natalie C. Ernecoff, Sanjana Kapoor, Siddharth Verma, Huiwen Chen, Csaba P. Kovesdy, Miklos Z. Molnar, Ambreen Azhar, S. Susan Hedayati, Mridula V. Nadamuni, Shani Shastri, Duwayne L. Willett, Samuel A.P. Short, Amanda D. Renaghan, Kyle B. Enfield, Pavan K. Bhatraju, A. Bilal Malik, Matthew W. Semler, Anitha Vijayan, Christina Mariyam Joy, Tingting Li, Seth Goldberg, Patricia F. Kao, Greg L. Schumaker, Nitender Goyal, Anthony J. Faugno, Caroline M. Hsu, Asma Tariq, Leah Meyer, Ravi K. Kshirsagar, Daniel E. Weiner, Aju Jose, Jennifer Griffiths, Sanjeev Gupta, Aromma Kapoor, Perry Wilson, Tanima Arora, and Ugochukwu Ugwuowo

Subjects
medicine.medical_specialty, 030232 urology & nephrology, Renal function, Original Investigations, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Intensive care, medicine, critical illness, 030212 general & internal medicine, Survival analysis, Kidney, business.industry, SARS-CoV-2, Confounding, COVID-19, Retrospective cohort study, medicine.disease, medicine.anatomical_structure, Respiratory failure, Nephrology, end stage kidney disease, dialysis, business, chronic kidney disease, Kidney disease
Abstract

Rationale & Objective Underlying kidney disease is an emerging risk factor for more severe COVID-19 illness. We examined the clinical courses of critically ill COVID-19 patients with and without pre-existing kidney disease and investigated the association between degree of underlying kidney disease and in-hospital outcomes. Study Design Retrospective cohort study Settings & Participants 4,264 critically ill COVID-19 patients (143 dialysis patients, 521 chronic kidney disease [CKD] patients, and 3,600 patients without CKD) admitted to ICUs at 68 hospitals in the United States. Predictor(s) Presence (versus absence) of pre-existing kidney disease Outcome(s) In-hospital mortality (primary); respiratory failure, shock, ventricular arrhythmia/ cardiac arrest, thromboembolic event, major bleed, and acute liver injury (secondary) Analytical Approach We used standardized differences to compare patient characteristics (values >0.10 indicate a meaningful difference between groups) and multivariable adjusted Fine and Gray survival models to examine outcome associations. Results Dialysis patients had a shorter time from symptom onset to ICU admission compared to other groups (median [quartile 1-quartile 3] days: 4 [2-9] for dialysis patients; 7 [3-10] for CKD patients; 7 [4-10] for patients without pre-existing kidney disease). More dialysis patients (25%) reported altered mental status than those with CKD (20%, standardized difference = 0.12) and no kidney disease (12%, standardized difference = 0.36). Half of dialysis and CKD patients died within 28-days of ICU admission versus 35% of patients without pre-existing kidney disease. Compared to patients without pre-existing kidney disease, dialysis patients had a higher risk of 28-day in-hospital death (adjusted HR 1.41; 95% CI 1.09, 1.81), while patients with CKD had an intermediate risk (adjusted HR 1.25; 95% CI 1.08, 1.44). Limitations Potential residual confounding Conclusions Findings highlight the high mortality of individuals with underlying kidney disease and severe COVID-19, underscoring the importance of identifying safe and effective COVID-19 therapies for this vulnerable population., Individuals with underlying kidney disease may be particularly vulnerable to severe COVID-19 illness, marked by multi-system organ failure, thrombosis, and a heightened inflammatory response. Among 4,264 critically ill adults with COVID-19 admitted to 68 intensive care units across the U.S., we found that both chronic kidney disease and dialysis patients had a ∼50% 28-day in-hospital mortality rate. Patients with underlying kidney disease had higher in-hospital mortality than patients without kidney disease, with patients on maintenance dialysis having the highest risk. As evidenced by differences in symptoms and clinical trajectories, patients with pre-existing kidney disease may have unique susceptibility to COVID-19-related complications which warrants additional study and special consideration in the pursuit and development of targeted therapies.

Published
2021
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5. Primary outcomes of the Monitoring in Dialysis Study indicate that clinically significant arrhythmias are common in hemodialysis patients and related to dialytic cycle

Author

Prabir Roy-Chaudhury, Jim A. Tumlin, Bruce A. Koplan, Alexandru I. Costea, Vijay Kher, Don Williamson, Saurabh Pokhariyal, David M. Charytan, James Tumlin, Vikranth Reddy, Kowdle Chandrasekhar Prakash, David Charytan, Suresh Chandra Tiwari, Amber Podoll, Sanjeev Jasuja, G. Leslie Walters, Kraig Wangsnes, Alexandru Costea, Selcuk Tombul, Balbir Singh, Brajesh Mishra, Sachin Yalagudri, Abhijeet Shelke, Calambur Narasimhan, A.M. Karthigesan, Abraham Oomman, K.P. Pramod Kumar, Bruce Koplan, Upendra Kaul, Tapan Ghose, Ripen Gupta, Arvind Sethi, Nikhil Kumar, Ramesh Hariharan, Rajnish Sardana, Arif Wahab, N.N. Khanna, Mark Smith, Suresh Kamath, Claude Galphin, Puneet Sodhi, Rajsekara Chakravarthy, Subba Rao Budithi, Finnian McCausland, Sanjeev Gulati, Munawer Dijoo, Upendra Singh, Salil Jain, Vishal Saxena, Gaurav Sagar, Rachel Fissell, Robert Foley, Charles A. Herzog, Peter McCullough, John D. Rogers, James A. Tumlin, Peter Zimetbaum, Manish Assar, Mark Kremers, and Wolfgang C. Winkelmayer

Subjects
Adult, Male, Bradycardia, medicine.medical_specialty, Time Factors, medicine.medical_treatment, 030232 urology & nephrology, India, 030204 cardiovascular system & hematology, Ventricular tachycardia, Risk Assessment, Sudden death, End stage renal disease, 03 medical and health sciences, 0302 clinical medicine, Heart Rate, Renal Dialysis, Risk Factors, Dialysis Solutions, Internal medicine, medicine, Humans, Prospective Studies, cardiovascular diseases, Asystole, Dialysis, Aged, business.industry, Incidence, Sodium, Arrhythmias, Cardiac, Atrial fibrillation, Middle Aged, medicine.disease, United States, Death, Sudden, Cardiac, Treatment Outcome, Nephrology, cardiovascular system, Cardiology, Kidney Failure, Chronic, Calcium, Female, Hemodialysis, medicine.symptom, business, Biomarkers
Abstract

Sudden death is one of the more frequent causes of death for hemodialysis patients, but the underlying mechanisms, contribution of arrhythmia, and associations with serum chemistries or the dialysis procedure are incompletely understood. To study this, implantable loop recorders were utilized for continuous cardiac rhythm monitoring to detect clinically significant arrhythmias including sustained ventricular tachycardia, bradycardia, asystole, or symptomatic arrhythmias in hemodialysis patients over six months. Serum chemistries were tested pre- and post-dialysis at least weekly. Dialysis procedure data were collected at every session. Associations with clinically significant arrhythmias were assessed using negative binomial regression modeling. Sixty-six patients were implanted and 1678 events were recorded in 44 patients. The majority were bradycardias (1461), with 14 episodes of asystole and only one of sustained ventricular tachycardia. Atrial fibrillation, although not defined as clinically significant arrhythmias, was detected in 41% of patients. With thrice-weekly dialysis, the rate was highest during the first dialysis session of the week and was increased during the last 12 hours of each inter-dialytic interval, particularly the long interval. Among serum and dialytic parameters, only higher pre-dialysis serum sodium and dialysate calcium over 2.5 mEq/L were independently associated with clinically significant arrhythmias. Thus, clinically significant arrhythmias are common in hemodialysis patients, and bradycardia and asystole rather than ventricular tachycardia may be key causes of sudden death in hemodialysis patients. Associations with the temporal pattern of dialysis suggest that modification of current dialysis practices could reduce the incidence of sudden death.

Published
2018
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