Management of heart failure in patients with ESKD

30 Dec 2021

Heart failure (HF) is highly prevalent in patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) and is strongly associated with mortality in these patients.1 HF in ESKD is defined based on patient-reported dyspnea assessed both pre- and post-ultrafiltration, in conjunction with echocardiography.1 The recent data from the United States Renal Data System (USRDS) states the overall prevalence of HF in all dialysis patients is around 43% with a higher proportion of HF in hemodialysis (HD) patients as compared to peritoneal dialysis (PD) patients.1 In CKD and ESKD, risk factors for HF include long-standing hypertension with often worsened blood pressure (BP) control as CKD worsens, salt and water retention causing excessive volume overload, and cardiomyopathic factors including left ventricular (LV) hypertrophy and fibrosis.1 Intermittent and chronic volume overload contributes to the development of cardiovascular disease in patients on maintenance HD.1 

Volume overload in HF is associated with worse outcomes.1 The retrospective cohort study of 34,107 HD patients examining the risk of all-cause mortality according to 3-month average inter-dialytic weight gain demonstrated that higher weight-gain increments were associated with increased risk of all-cause and cardiovascular death.1 Another retrospective study of HD patients evaluating the association between failed target weight achievement and short-term clinical outcomes among individuals receiving maintenance HD suggests that frequent post-dialysis weight ≥1.0kg above the prescribed target weight was associated with short-term ED visits and hospitalizations and target weight adjustment in the period immediately after hospital discharge was associated with a reduced risk of 30-day readmissions.1

Interestingly, the rate of fluid removal during dialysis was associated with cardiovascular mortality.1 The post hoc analysis of hemodialysis study demonstrated increased ultrafiltration rate resulted in a 71% increase in cardiovascular mortality and a 59% increase in overall mortality.1 Therefore, Professor Patrick Pun, Associate Professor of Medicine and the Member of the Duke Clinical Research Institute, emphasized the need for volume management of dialysis fluid by minimizing interdialytic weight gain, achieving target weight, reassessing target weight after hospitalization and avoiding high ultrafiltration for reducing the risk of HF.1 He further highlighted the approach to extend the dialysis when interdialytic weight gain is high to minimize the treatments with ultrafiltration greater than 13mL/min or schedule additional treatments.1

The evidence for the use of pharmacological agents in the treatment of HF for dialysis patients suggest beta blockers are one of the foundations for guideline directed therapy for HF.1 Organic nitrates demonstrate modest effects on cardiac structure in small PD and HD patients as demonstrated in the randomized controlled trials whereas diuretics and sodium-glucose co-transporter-2 (SGLT2) were unlikely to be effective in individuals without residual renal function.1

Notably, patients on dialysis are at high risk of complications related to implantable cardioverter defibrillator (ICD) implantation, therefore subcutaneous ICDs may be preferred over transvenous devices due to lower risk of bloodstream infection and interference with vascular access sites.1 The retrospective analysis of ICD implants from 2012 to 2018 among patients on dialysis demonstrated the overall risk of short-term complications is low and comparable with transvenous ICDs, but long-term data merits closer monitoring and further investigation as stated by Prof. Pun.1 The use of subcutaneous ICD increased from 5% in 2012 to 2013 to 20% of all implants in 2018 (Figure 1).1

Prof. Pun concluded that there are still some uncertainties regarding the guideline-based therapies in dialysis patients with HF.1 Therapies such as ICDs for the treatment of coronary artery disease (CAD) in CKD patients have significant limitations and should be used judiciously considering the associated risk factors for the HD population on a case-by-case basis.1 “Minimizing weight gain, achieving target weight and avoiding ultrafiltration appear to be important factors to reduce the impact of congestive HF”. Prof. Pun highlighted.

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