Recognizing the Elephant in the Room: High Arrhythmia Risk in Hemodialysis Patients' Prescriptions

Background: Chronic kidney disease (CKD) patients on maintenance hemodialysis are at substantial risk of developing cardiovascular events, such as torsades de pointes and sudden cardiac death. QT-prolonging drugs have been well known, but the effect of these drugs on vulnerable populations, such as hemodialysis patients, has been understudied. This study aimed to analyse the prescription pattern for arrhythmogenic drugs in CKD patients on hemodialysis and evaluate for QT prolongation. Methods: The cross-sectional observational study was carried out in a tertiary care teaching hospital between November 2023 and March 2024 on CKD patients on maintenance hemodialysis for over three months. The demographic profile and biochemical investigations were recorded. An echocardiogram was performed to look for structural and functional abnormalities. An electrocardiogram (ECG) was obtained, and the QTc interval was calculated using the Fridericia formula. QTc prolongation was defined as > 440 ms in males and > 460 ms in females. QT-prolonging drugs were categorized using the CredibleMeds® classification into "known," "possible," and "conditional" risk groups. Results: Fifty CKD patients were studied, out of which polypharmacy was seen in 98% of prescriptions with a median of nine medications per prescription (interquartile range (IQR): 8-11), and 92% of patients were taking at least one QT-prolonging medication per prescription. Prolonged QT interval was seen in 42% of the patients. Diuretics and proton pump inhibitors were the most prescribed QT-prolonging medications. Conclusion: Prescription of QT-prolonging medications is widely prevalent in hemodialysis patients, with a substantial number of them developing QT prolongation. These findings underscore the need for cautious prescribing practices in hemodialysis patients.