Authors’ Reply
Authors: Patrick H. Pun, Matthew E. Dupre, Clark Tyson, Sana M. Al-Khatib, Christopher B. Granger
Journal: Journal of the American Society of Nephrology (2019)

We appreciate the comments of the authors regarding the fact that sudden cardiac arrest is a highly lethal condition. Per previous reports, only half of patients who suffer a cardiac arrest in dialysis clinics survive to hospital admission and only one quarter survive to hospital discharge, a point that is highlighted in our significance statement and article introduction. In our study, overall survival from in-clinic cardiac arrest was very similar; 48% of patients survived to hospital admission, and 26% survived to hospital discharge. Although patients on dialysis have much higher overall mortality rates compared with the general population, we would point out that survival to hospital discharge after cardiac arrest in dialysis clinics is substantially higher than that for the out-of-hospital cardiac arrest in the general population, which was only about 10% in North Carolina during the study period.1 Additionally, recent studies in overall cardiac arrest populations show that most patients who survive to hospital discharge have good functional status and return to work.2 Nevertheless, as discussed by others previously,3,4 transparent and realistic discussions about the process of CPR, potential complications, and expected success rates should be part of routine advance care planning process for all patients on dialysis, and we agree with the authors that the confirmation of low overall survival rates and even lower rates of hospital discharge with favorable neurologic status in our study should be used by providers to counsel patients. Our study highlighted an important and readily actionable opportunity for dialysis providers to improve patient-centered care within dialysis clinics. Because patients with do-not-resuscitate orders were excluded, resuscitation should have been attempted for all of the patients in our study, but one in five patients did not receive resuscitation from staff, an obvious area for improvement. In addition, we feel that our study findings support a potential opportunity to readily improve survival outcomes in our patient population, where there are sadly few proven therapies that significantly reduce cardiovascular mortality and fewer still that reduce sudden cardiac death. The 15% absolute increase in survival associated with staff-provided CPR is far from a modest effect on mortality outcomes; put in terms of the number needed to treat, for every seven patients who received staff-provided CPR, one additional patient survived to hospital discharge. Comparatively, the use of primary prevention, implantable cardioverter defibrillators, an evidence-based and guideline-recommended therapy to reduce sudden cardiac death mortality in high-risk patients, was only associated with a 7% absolute reduction in mortality at 5 years in the largest clinical trial among patients without advanced kidney disease,5 and recent studies suggest that efficacy may be reduced or absent among patients on dialysis.6,7 Cardiopulmonary resuscitation training is comparatively inexpensive to provide, and can be performed by trained bystanders with limited or no equipment. Over recent years, we have made small but important gains in overall mortality among hemodialysis patients, which many have attributed to a focus on improving quality of care within dialysis clinics; unfortunately, none of these gains have been paralleled with reductions in the rate of sudden death, which has remained largely unchanged.8 As the authors state, information from our study9 can improve goal-concordant care by helping patients make informed decisions on advanced directives. For patients who elect to be resuscitated, we hope our study serves as a challenge to dialysis providers to improve patient-centered care and potentially influence survival outcomes by ensuring staff readiness to provide high-quality CPR. Disclosures None.