Sudden cardiac death in chronic kidney disease and dialysis: from descriptive epidemiology to mechanism-driven prevention

Abstract

Sudden cardiac death (SCD) is a leading cause of mortality across the chronic kidney disease (CKD) continuum and becomes particularly prominent in dialysis‐dependent kidney failure. In hemodialysis, SCD accounts for roughly one quarter to one third of all deaths and up to 60%–75% of cardiovascular mortality, with marked temporal clustering around the long interdialytic interval and the first post‐interval session. Traditional views have emphasized descriptive epidemiology and presumed ventricular tachyarrhythmias. More recent device‐based studies challenge this paradigm, revealing a heterogeneous arrhythmic spectrum in which bradyarrhythmias, pauses, and conduction system disease are often at least as frequent as sustained ventricular tachycardia or fibrillation. This narrative, non‐systematic review synthesizes epidemiologic, mechanistic, and interventional data on SCD in CKD and dialysis, with particular emphasis on insights from implantable loop recorder and implantable cardioverter–defibrillator cohorts and on modifiable dialytic and pharmacologic factors. A framework for prevention is proposed around three interacting domains: the structural myocardial substrate, the electrophysiologic milieu, and dialysis‐related triggers. Within this framework, contemporary heart failure and CKD therapies (including sodium–glucose cotransporter 2 inhibitors, angiotensin receptor–neprilysin inhibitors, mineralocorticoid receptor antagonists, and beta‐blockers), individualized dialysis prescriptions (targeting potassium, calcium, bicarbonate, ultrafiltration, and scheduling), and selective use of device therapy are considered complementary components of mechanism‐driven SCD prevention. Methodological challenges in defining and adjudicating SCD in CKD are discussed, and priorities are outlined for improved phenotyping, continuous rhythm monitoring, and CKD‐specific risk stratification, with the overarching aim of moving from descriptive statistics to effective risk modification.