Therapy of heart failure in hemodialysis patients
- Charles A Herzog, MD
Charles A Herzog, MD
- Professor of Medicine
- Hennepin County Medical Center/University of Minnesota
- William L Henrich, MD, MACP
William L Henrich, MD, MACP
- Professor of Medicine
- President of the Health Science Center
- University of Texas Health Science Center School of Medicine
- Alfred K Cheung, MD
Alfred K Cheung, MD
- Professor of Internal Medicine
- University of Utah School of Medicine
Systolic or diastolic ventricular dysfunction can lead to clinically evident heart failure (HF), even when the hemodialysis patient is at or near "dry weight." Myocardial disease and cardiovascular drugs can also reduce hemodynamic reserve, making the patient more vulnerable to episodes of hypotension during dialysis.
The following discussion will present the therapeutic approach to the hemodialysis patient with chronic HF.
To be able to follow clinical practice guidelines on the treatment of congestive heart failure (HF), a clinician (eg, nephrologist) must be able to assign a functional class to an individual patient. Classification schemes in heart failure (such as New York Heart Association [NYHA] functional class) do not account for the dynamic/tidal nature of volume status in hemodialysis patients. It would not be unusual for the same patient to have a higher (more severe) NYHA class 3 before hemodialysis session compared with shortly after. A proposed functional classification scheme, specifically for dialysis patients, was developed by the Acute Dialysis Quality Initiative (ADQI) XI Workgroup . The three elements of the proposed heart failure staging system are:
●Standardized echocardiographic evidence of structural and/or functional cardiac abnormalities (table 1)
●Dyspnea occurring in the absence of primary lung disease, including isolated pulmonary hypertension (ie, not due to elevation in pulmonary capillary wedge pressure)
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- FUNCTIONAL CLASSIFICATION
- Identifying associated conditions
- Volume control
- Pharmacologic therapy for systolic dysfunction
- - Beta blockers
- - Angiotensin-converting enzyme inhibitors
- - Angiotensin type II receptor blockers
- - Angiotensin-converting enzyme inhibitors plus angiotensin II receptor blockers
- - Digoxin
- - Aldosterone receptor antagonists
- - Our approach
- Treatment of heart failure with preserved ejection fraction (diastolic heart failure)
- Kidney transplantation
- Heart-kidney transplantation
- Cardiac defibrillators
- SUMMARY AND RECOMMENDATIONS