Cardiac arrhythmias in patients on scheduled hemodialysis as predictors of adverse outcomes: A pilot prospective observational cohort study

Background. Cardiovascular disease is the leading cause of death among hemodialysis patients, with up to 40% of deaths attributed to sudden cardiac death. A major risk factor contributing to this event is cardiac arrhythmia. However, data on the prevalence of arrhythmias and their role in the prognosis of patients receiving renal replacement therapy remain controversial.

Objective. To analyze 48-hour ambulatory electrocardiography data across different phases of the dialysis cycle, assess the five-year incidence of adverse cardiovascular events in patients on maintenance hemodialysis, and compare the obtained results.

Methods. A pilot prospective observational cohort study was conducted (2014–2025), enrolling 88 patients aged 18 years or older on maintenance hemodialysis for at least six months. Exclusion criteria were defined as a history of cardiac arrhythmias, severe cardiovascular diseases, and severe comorbidities. On the first day of the dialysis cycle (Tuesday/Wednesday, following the interdialytic interval), participants underwent 48-hour Holter monitoring analyzed across 12 fourhour periods. The 1–4 h window fully corresponded to the hemodialysis procedure, with data collection initiated 15 minutes prior to the patient’s connection to the machine. The subsequent prospective follow-up lasted 64 [61; 67] months and included comprehensive laboratory testing. This manuscript was prepared in accordance with the STROBE guidelines. Statistical analysis was performed using Python (Python Software Foundation, USA) and Statistica, v.12.0 (StatSoft, USA) via nonparametric methods, ROC analysis (with a 70/30 train-test split), regression modeling, and Holm’s correction for multiple comparisons. The level of significance was set at p < 0.05 after correction.

Results. Arrhythmias were found to have a cyclical pattern that depended on the phase of the dialysis cycle. The intradialytic period (first 4 h) was predominated by supraventricular arrhythmias: supraventricular extrasystoles were observed in 100% of patients, and paroxysmal atrial fibrillation was noted in 25.0%. On the interdialytic day (24–48 h), the frequency and complexity of ventricular arrhythmias increased: the number of patients with high Lown grades of ventricular extrasystoles increased from 51.1% to 63.6%; episodes of nonsustained ventricular tachycardia emerged. The overall five-year case fatality rate was 40.9%, of which 66.7% were due to cardiovascular causes. ROC analysis (training sample, n = 62) was used to determine the threshold level of supraventricular extrasystoles (> 18.9 episodes per 4 h) associated with death (sensitivity 0.65, specificity 0.60, AUC = 0.623). For the test sample (n = 26), sensitivity was 0.58, specificity was 0.62, and AUC was 0.581. The presence of paroxysmal atrial fibrillation during the intradialytic period was associated with an increased risk of death (OR = 19.62; 95% CI: 2.38 to 161.67; p = 0.001), and a high burden of supraventricular extrasystoles (> 18.9) was associated with a 3.34-fold increased risk of death (OR = 3.34; 95% CI: 1.37 to 8.12; p = 0.0068).

Conclusion. The hemodialysis procedure is a critical period for the development of proarrhythmic conditions. Given the pilot nature of this study, the findings should be considered hypothesis-generating. Atrial fibrillation and a high burden of supraventricular extrasystoles (> 18.9 episodes per 4 hours) recorded during a dialysis session are promising markers of an increased risk of death within five years; however, they require mandatory validation in larger independent cohorts. 

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