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 HF, a clinician (eg, nephrologist) must be able to assign a functional class to an individual patient. Classification schemes in HF (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 HF 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)
- Chawla LS, Herzog CA, Costanzo MR, et al. Proposal for a functional classification system of heart failure in patients with end-stage renal disease: proceedings of the acute dialysis quality initiative (ADQI) XI workgroup. J Am Coll Cardiol 2014; 63:1246.
- Hickson LJ, Negrotto SM, Onuigbo M, et al. Echocardiography Criteria for Structural Heart Disease in Patients With End-Stage Renal Disease Initiating Hemodialysis. J Am Coll Cardiol 2016; 67:1173.
- K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 45:S1.
- Cice G, Ferrara L, D'Andrea A, et al. Carvedilol increases two-year survivalin dialysis patients with dilated cardiomyopathy: a prospective, placebo-controlled trial. J Am Coll Cardiol 2003; 41:1438.
- Agarwal R, Sinha AD, Pappas MK, et al. Hypertension in hemodialysis patients treated with atenolol or lisinopril: a randomized controlled trial. Nephrol Dial Transplant 2014; 29:672.
- Weir MA, Dixon SN, Fleet JL, et al. β-Blocker dialyzability and mortality in older patients receiving hemodialysis. J Am Soc Nephrol 2015; 26:987.
- Shroff GR, Herzog CA. β-Blockers in dialysis patients: a nephrocardiology perspective. J Am Soc Nephrol 2015; 26:774.
- Zannad F, Kessler M, Lehert P, et al. Prevention of cardiovascular events in end-stage renal disease: results of a randomized trial of fosinopril and implications for future studies. Kidney Int 2006; 70:1318.
- Knoll GA, Sahgal A, Nair RC, et al. Renin-angiotensin system blockade and the risk of hyperkalemia in chronic hemodialysis patients. Am J Med 2002; 112:110.
- Suzuki H, Kanno Y, Sugahara S, et al. Effect of angiotensin receptor blockers on cardiovascular events in patients undergoing hemodialysis: an open-label randomized controlled trial. Am J Kidney Dis 2008; 52:501.
- Takahashi A, Takase H, Toriyama T, et al. Candesartan, an angiotensin II type-1 receptor blocker, reduces cardiovascular events in patients on chronic haemodialysis--a randomized study. Nephrol Dial Transplant 2006; 21:2507.
- Cice G, Di Benedetto A, D'Isa S, et al. Effects of telmisartan added to Angiotensin-converting enzyme inhibitors on mortality and morbidity in hemodialysis patients with chronic heart failure a double-blind, placebo-controlled trial. J Am Coll Cardiol 2010; 56:1701.
- Chan KE, Ikizler TA, Gamboa JL, et al. Combined angiotensin-converting enzyme inhibition and receptor blockade associate with increased risk of cardiovascular death in hemodialysis patients. Kidney Int 2011; 80:978.
- Chan KE, Lazarus JM, Hakim RM. Digoxin associates with mortality in ESRD. J Am Soc Nephrol 2010; 21:1550.
- Walsh M, Manns B, Garg AX, et al. The Safety of Eplerenone in Hemodialysis Patients: A Noninferiority Randomized Controlled Trial. Clin J Am Soc Nephrol 2015; 10:1602.
- https://clinicaltrials.gov/ct2/show/NCT01848639?term=NCT01848639&rank=1 ALdosterone Antagonist Chronic HEModialsyis Interventional Survival Trial (ALCHEMIST) (Accessed on January 12, 2017).
- Ventura HO, Mehra MR. Improvement of heart failure after renal transplantation: the complex maze of cardio-renal interaction. J Am Coll Cardiol 2005; 45:1061.
- Wali RK, Wang GS, Gottlieb SS, et al. Effect of kidney transplantation on left ventricular systolic dysfunction and congestive heart failure in patients with end-stage renal disease. J Am Coll Cardiol 2005; 45:1051.
- Singh SM, Wang X, Austin PC, et al. Prophylactic defibrillators in patients with severe chronic kidney disease. JAMA Intern Med 2014; 174:995.
- 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