Elevated levels of serum oxalate in patients with type 2 diabetes on hemodialysis (HD) increase their risk for sudden cardiac death and other serious cardiovascular events, new research suggests.

The finding is from a post hoc analysis of the randomized German Diabetes Dialysis Study (4D Study), which originally included 1255 European patients on HD who had type 2 diabetes mellitus. The median follow-up duration was 4 years. The current analysis included 1108 patients with baseline serum oxalate measurements. Of these, 548 patients died and 413 reached the primary endpoint of a composite of cardiac death, nonfatal myocardial infarction, and fatal or nonfatal stroke.

Compared with patients in the lowest oxalate quartile (29.6 µM or less), those in the highest oxalate quartile (59.7 µM or higher) had significant 40% and 62% increased risks for the primary endpoint and sudden cardiac death, respectively, in adjusted analyses, Anja Pfau, MD, of Charité Universitätsmedizin Berlin in Berlin, Germany, and colleagues reported in the Journal of the American Society of Nephrology. Patients in the highest vs lowest quartile had a nonsignificant 23% increased risk for all-cause mortality.

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“Our findings are consistent with a large body of clinical and pre-clinical evidence suggesting that oxalate is a uremic toxin,” the authors concluded. “Oxalate lowering strategies in dialysis patients are warranted to test whether our findings are causal in nature and could represent a novel treatment paradigm.”


Ffau A, Ermer T, Coca S, et al. High oxalate concentrations correlate with increased risk for sudden cardiac death in dialysis patients. J Am Soc Nephrol. Published online July 19, 2021.