Are Dialysis Patients at Higher Risk During Hyperbaric Oxygen Therapy (HBOT)?

More than 15 million Americans have chronic kidney disease, of which approximately 500,000 require dialysis.¹ The annual death rate in the United States for dialysis patients in 2007 was 212 deaths per 1,000 patient-years.¹ Cardiovascular disease remains the leading cause of death among both hemodialysis and peritoneal dialysis patients.¹ Arrhythmic mechanisms or sudden cardiac arrest are implicated in 60% of all cardiac deaths in dialysis patients in the United States Renal Data System (USRDS) database.¹⁻³

Dialysis and the Risk of Cardiac Arrest

Dialysis patients sustaining cardiac arrest or an arrhythmia suffer poor long-term survival, with a two-year mortality rate of 74%.⁴ Karnik et al.¹⁰ reported a 48-hour mortality rate of 60% in a study of 400 cardiac arrest patients on dialysis. In a study of 74 in-hospital dialysis patients, long-term survival after CPR was strikingly poor at 92%, with a six-month mortality rate of 97%.¹² A retrospective study that reviewed 24 patients who had CPR during dialysis in a small medical center over a three-year period reported a mortality rate of 100%.¹³

Prevalent Cardiac Conditions in Dialysis Patients

It is difficult to accurately apportion the absolute percentage of cardiac deaths directly attributable to complications of ischemic heart disease or arrhythmia mechanisms, as almost every dialysis patient has some level of underlying cardiac disease—placing them at risk for sudden death.¹

Common Cardiovascular Risk Factors

Hypertension, myocardial hypertrophy, coronary artery disease, and congestive heart failure are extremely common in the dialysis population.⁶ Over 90% of dialysis patients have hypertension, a key risk factor for sudden cardiac death.⁵ Continued hypertension leads to increased left ventricular hypertrophy (present in 75% of dialysis patients¹⁹), and the prevalence of cardiomyopathy increases with time on dialysis.⁹

Electrical Instability and QT Changes

While structural disease is important, baseline problems with cardiac electrical activity are also common in dialysis patients—often associated with coronary artery disease and electrolyte imbalances. The QT interval, a measure of re-polarization and predictor of sudden death, is often prolonged in dialysis patients.⁷ The QT dispersion (variation in QT interval across different ECG leads) is also increased and recognized as another risk factor.⁸ Cardiac abnormalities tend to worsen the longer a patient remains on dialysis.

Fluid Shifts and Electrolyte Stress During Dialysis

End-stage kidney disease with dialysis introduces unique physiologic stressors not typically seen in the general population with heart disease.

Volume and Pressure Changes

Hemodialysis causes significant fluid shifts, leading to repeated bouts of pre-dialysis volume overload and intra- or post-dialysis hypotension. Each represents a potent cardiovascular stressor on its own.

Electrolyte Imbalances and Timing

Potassium and other electrolytes also undergo large fluctuations with dialysis. Both hyperkalemia and hypokalemia are known to precipitate sudden death and/or cardiac arrhythmias.¹⁰ Notably, retrospective studies report nearly a 50% increased frequency of sudden cardiac death on Mondays (for patients dialyzing Monday, Wednesday, and Friday) and a similar trend on Tuesdays for the Tuesday, Thursday, Saturday cohort.¹⁰ ¹¹

A separate study reviewing cardiac arrests at community outpatient dialysis centers over 14 years identified 102 cardiac arrests — 10 occurred before, 72 during, and 20 after hemodialysis.¹⁷ All were related to ventricular fibrillation or tachycardia. Importantly, the overwhelming majority of sudden deaths in dialysis patients occur outside of dialysis centers.¹⁸

HBOT Protocol Considerations for Dialysis Patients

Recommended Pre-Treatment Assessment

A more aggressive pre-HBOT work-up is warranted, including:

• A 12-lead EKG

• Chest x-ray

• Additional tests based on findings

  
  

Lab values may be less useful due to variability between dialysis sessions. However, patient weight prior to each treatment may help identify volume overload.

Best Practices During HBOT

• Pre- and post-HBOT vital signs should be taken with caution — never on the arm with an arteriovenous fistula or shunt.

• No blood draws, including fingerstick blood glucose tests, should be done on the affected arm.

• Manual blood pressure readings are preferred, offering an opportunity to detect irregular pulses.

Post-Treatment Monitoring

Chamber operators should closely monitor dialysis patients throughout treatment. Any signs of distress or clinical concerns should result in immediate termination of the session. After each treatment, the HBO physician must assess the patient to ensure stability prior to discharge.

Strategic Scheduling Recommendations

Most evidence suggests that HBOT should be provided post-dialysis, when patients are at their most hemodynamically stable. Based on the typical dialysis schedule, HBOT sessions on Monday and Tuesday mornings should be avoided altogether until dialysis is completed.

This may require coordination with dialysis centers to adjust treatment timing, ensuring safer care delivery and minimizing cardiovascular risk.

SHS Spotlight

Shared Health Services equips hospitals and physician practices with the tools, guidance, and peer-to-peer expertise needed to treat high-risk populations safely and effectively. From compliance to care coordination, we help teams deliver hyperbaric therapy with confidence and precision.

References

1. US Renal Data System: USRDS 2009 Annual Data Report. Bethesda, Maryland, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease, 2009.

   
   

2. Herzog CA. Cardiac arrest in dialysis patients: Approaches to alter an abysmal outcome. Kidney International. 2003; 63 (Suppl 84): S197-S200.

   
   

3. US Renal Data System: USRDS 2001 Annual Data Report. Bethesda, Maryland, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease, 2001.

   
   

4. Herzog CA. Ma JZ, Collins AJ. Poor long-term survival after acute myocardial infarction among patients on long term dialysis. New England Journal of Medicine. 1998; 339: 799-805.

   
   

5. Siscovick DS, Raghunathan TE, Psaty BN. et al. Diuretic therapy for hypertension and the risk of primary cardiac arrest. New England Journal of Medicine. 1994; 330: 1852-1857.

   
   

6. Bleyer AJ, Hartman J, Brannon PC. Et al. Characteristics of sudden death in hemodialysis patients. Kidney International. 2006; 69: 2268-2273.

   
   

7. Raizada V, Skipper B, Luo W, Garza L. et al. Renin-angiotrnsin polymorphisms and QTc interval prolongation in end-stage renal disease. Kidney International. 2005; 68: 1186-1189.

   
   

8. Cupisti A, Galetta F, Caprioli R, et al. Potassium removal increases the QTc interval dispersion during hemodialysis. Nephron. 1999; 82: 122-126.

   
   

9. Foley R, Parfrey P, Sarnak M. Clinical epidemiology of cardiovascular disease in chronic renal disease. American Journal of Kidney Disease. 1998; (5 Suppl 3): S112-S119.

   
   

10. Karnik JA, Young BS, Lew NL. et al. Cardiac arrest and sudden death in dialysis units. Kidney International. 2001; 60: 350-357.

    
    

11. Bleyer AJ, Russell GB, Satko SG. Sudden and cardiac death rates in hemodialysis patients. Kidney International. 1999;55: 15553-1559.

    
    

12. Moss AH, Holley JL, Upton MB. Outcomes of cardiopulmonary resuscitation in dialysis patients. Journal of the American Society of Nephrology. 1992; 3: 1238-1243.

    
    

13. Lai M, Hung K, Huang J, et al. Clinical findings and outcomes of intra hemodialysis cardiopulmonary resuscitation. American Journal of Nephrology. 1999; 19: 468-473.

    
    

14. Gilbertson DT, Liu J, Xue JL. et al. Projecting the number of patients with end stage renal disease in the United States to the year 2015. Journal of the American Society of Nephrology. 2005; 16: 3736-3741.

    
    

15. Culleton BF, Larson MG, Wilson PW. et al. Cardiovascular disease and mortality in a community based cohort with mild renal insufficiency. Kidney International. 1999; 56: 2214-2219.

    
    

16. Henry RM, Kostense PJ, Bos G, et al. Mild renal insufficiency is associated with increased cardiovascular mortality: the Hoorn study. Kidney International. 2002; 62: 1402-1407.

    
    

17. Davis TR, Young BA, Eisenberg MS. et al. Outcome of cardiac arrests attended by emergency medical services staff at community outpatient dialysis centers: cardiac arrest in dialysis facilities. Kidney International. 2008; 73: 933-939.

    
    

18. Herzog CA. Mangrum JM, Passmen R. Non-coronary heart disease in dialysis patients: Sudden cardiac death in dialysis patients. Seminars in Dialysis. 2008; 21 (4): 300-307.

    
    

19. Amann K, Rychlik I, Miltrnberger-Milteny G, Ritz E. et al. Left ventricular hypertrophy in renal failure. Kidney International. 1998; 54 (Suppl 68): S78-S85.

    
    

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