Death during Dialysis: Findings at Autopsy
J Shields, Y Zhang, L Li, M Ripple, D Fowler, A Burke. University of Maryland, Baltimore, MD; Office of the Chief Medical Examiner, Baltimore, MD
Background: Sudden cardiac death occurring during dialysis has not been extensively studied at autopsy.
Design: A retrospective review of autopsy records from a single calendar year at a state-wide medical examiner's office was performed. Cases of sudden deaths occurring during or within 6 hours after dialysis at outpatient facilities were retained for study. Causes of death and cardiac findings were tabulated. Cardiomegaly was determined based on body height and weight; mild cardiomegaly was defined as <50 grams above the 95% upper limit; moderate 50-99 grams; marked 100-200 grams; and massive >200 grams above the limit, respectively. Severe coronary atherosclerosis was defined as >75% area luminal narrowing.
Results: There were 14 sudden dialysis-related deaths, among a total of 435 autopsies of sudden cardiac death. The mean age was 63 years (range: 34-84 years); there were 8 males (58 ± 12 years), and 6 females (71 ± 8 years). There were 11 African Americans and 3 Caucasians. The mean body mass index (BMI) was 29.3 (range 22-54), with 9 decedents with a BMI > 25 and 5 with BMI > 30. Six patients had a diagnosis of diabetes mellitus (43%) and 11 were hypertensive (79%). Thirteen decedents became unresponsive and arrested during dialysis, and one became short of breath while on dialysis and expired en route to the hospital. The cause of death was natural and cardiac in all 14 autopsies. The mean heart weight was 612 g (range: 350-980g); cardiomegaly was present in 13 (93%), 4 moderate, 4 marked, and 5 massive. There was severe atherosclerosis in 6 cases (43%), involving 1 vessel (n=1), 2 vessels (n=3), and 3 vessels (n=2), including one patient with prior bypass graft surgery and 2 patients with healed transmural infarcts. Biventricular hypertrophy characterized the 13 hearts with cardiomegaly, 5 with left ventricular dilatation > 4 cm; histologically, there was diffuse myocyte hypertrophy and interstitial fibrosis. One patient (7%) had no morphologic arrhythmogenic substrates, and died of cardiac arrhythmia, with no other findings at autopsy.
Conclusions: In sudden death occurring during dialysis, the cause of death is related predominantly to concentric left ventricular hypertrophy, with concomitant coronary atherosclerosis in less than one-half of cases. There appears to be a predilection for African Americans and obesity.
Monday, March 22, 2010 1:45 PM
Platform Session: Section G, Monday Afternoon