Managing Heart Failure in Patients On Dialysis

Journal of Cardiac Failure Vol. 29 No.
1 2023
Review Article
Managing Heart Failure in Patients on Dialysis:
State-of-the-Art Review
MUHAMMAD SHAHZEB KHAN, MD, MSC,1 AYMEN AHMED, MBBS,2 STEPHEN J. GREENE, MD,1,3 MONA FIUZAT, PharmD,1
MICHELLE M. KITTLESON, MD, PhD,4 JAVED BUTLER, MD, MPH, MBA,5,6 GEORGE L. BAKRIS, MD,7 AND
GREGG C. FONAROW, MD8
Durham, Los Angeles, Jackson, Dallas, and Chicago, USA; and Karachi, Pakistan
ABSTRACT
Heart failure (HF) and end-stage kidney disease (ESKD) frequently coexist; 1 comorbidity wor-
sens the prognosis of the other. HF is responsible for almost half the deaths of patients on
dialysis. Despite patients’ with ESKD composing an extremely high-risk population, they have
been largely excluded from landmark clinical trials of HF, and there is, thus, a paucity of data
regarding the management of HF in patients on dialysis, and most of the available evidence is
observational. Likewise, in clinical practice, guideline-directed medical therapy for HF is often
down-titrated or discontinued in patients with ESKD who are undergoing dialysis; this is due
to concerns about safety and tolerability. In this state-of-the-art review, we discuss the avail-
able evidence for each of the foundational HF therapies in ESKD, review current challenges
and barriers to managing patients with HF on dialysis, and outline future directions to opti-
mize the management of HF in these high-risk patients. (J Cardiac Fail 2023;29:87 107)
Key Words: Heart failure, dialysis, chronic kidney disease, end-stage kidney disease.
Approximately half of the patients with heart disease (ESKD) requiring dialysis have HF.3,4 The
failure (HF) have coexisting chronic kidney disease prognosis of patients with both conditions is sub-
(CKD).1,2 Likewise, up to 70% of the patients with stantially worse than those with either condition
CKD and 36% of the patients with end-stage kidney alone. Cardiovascular disease, including HF,
accounts for approximately 50% of the deaths in
patients undergoing dialysis.5 Beta-blockers, angio-
From the 1Division of Cardiology, Duke University School of
Medicine, Durham, NC, USA; 2Division of Medicine, Dow Univer- tensin receptor neprilysin inhibitors (ARNIs), renin-
sity of Health Sciences, Karachi, Pakistan; 3Duke Clinical Research angiotensin-aldosterone system (RAAS) inhibitors,
Institute, Durham, NC, USA; 4Department of Cardiology, Smidt mineralocorticoid receptor antagonists (MRAs) and
Heart Institute-Cedars Sinai Medical Center, Los Angeles, CA,
USA; 5Department of Medicine, University of Mississippi Medical sodium-glucose cotransporter-2 (SGLT2) inhibitors
Center, Jackson, Mississippi, USA; 6Baylor Scott and White reduce mortality rates in patients with HF with
Research Institute, Dallas, TX, USA; 7Department of Medicine, reduced ejection fraction (HFrEF). However,
University of Chicago Medicine, Chicago, IL and 8Ahmanson-
UCLA Cardiomyopathy Center, David Geffen School of Medicine, patients with HF and ESKD have been excluded
University of California Los Angeles, Los Angeles, CA, USA. from landmark trials of all these therapies. Guide-
Manuscript received July 10, 2022; revised manuscript received line-directed medical therapy (GDMT) in patients
August 28, 2022; revised manuscript accepted September 20,
2022. with HFrEF who are on dialysis is often withheld or
Reprint requests: Gregg C. Fonarow, MD. Ahmanson-UCLA not uptitrated to recommended target doses due
Cardiomyopathy Center, David Geffen School of Medicine, to safety and tolerability concerns and lack of avail-
University of California Los Angeles, Los Angeles, CA; Tel: 310
206-9112 E-mail: [email protected] able clinical trial data. Similarly, patients with HF
1071-9164/$ - see front matter and ESKD are not eligible for initiation of multiple
© 2022 The Author(s). Published by Elsevier Inc. This is an open GDMTs according to current practice guidelines.
access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/) Although some randomized clinical trials (RCTs)
https://doi.org/10.1016/j.cardfail.2022.09.013 have evaluated the efficacy of GDMT in patients
87
88 Journal of Cardiac Failure Vol. 29 No. 1 January 2023
with HF and CKD, data regarding the management Beta-Blockers

of HF in patients with ESKD who are undergoing
Multiple trials demonstrate that beta-blockers
dialysis remain very limited.6,7 The current evidence
reduce HF hospitalizations and cardiovascular mor-
is mostly observational, and guidelines reflect this
tality rates in patients with HFrEF.12,13 Although
dearth of evidence. The National Kidney Founda-
beta-blockers are the most commonly prescribed
tion's Kidney Disease Outcomes Quality Initiative
cardiovascular medications (64% of all prescriptions)
guidelines note that left ventricular (LV) systolic
for patients on dialysis, their efficacy and safety
dysfunction and LV hypertrophy are independent
remain uncertain in patients with HF and on dialy-
predictors of poor survival rates in patients under-
sis.14 There is only 1 RCT of 114 patients that evalu-
going dialysis and recommend consistent mainte-
ated the effect of beta-blockers in patients with HF
nance of euvolemia as a cornerstone of HF
and on dialysis (Table 1).15 Patients receiving carve-
treatment in patients undergoing dialysis, with a
dilol demonstrated significant improvements in left
likely need to alter dosage of therapeutic drugs in
ventricular ejection fraction (LVEF) and reduced left
accordance with hemodialysis (HD) schedules.8 The
ventricular end-systolic volume (LVESV) and left ven-
2021 European Society of Cardiology guidelines
tricular end-diastolic volume (LVEDV) compared
offer a class IIa recommendation for the usage of
with placebo at both 6-month and 12-month follow-
renal-replacement therapy in patients with ESKD
ups.15 Furthermore, patients receiving carvedilol
and refractory volume overload as a treatment
rather than placebo were less likely to have NYHA
option for HF.9 However, guidelines offer little
functional class III or IV.15
direction regarding other specific HF management
At 2-year follow-up, patients receiving carvedilol
in these patients.
had a 49% lower mortality rate than patients receiv-
Given the lack of evidence and guidelines, it is
ing placebo (HR = 0.51 [0.32 0.82]) (Table 1).16 In
not surprising that patients with HFrEF who are on
addition, patients receiving carvedilol had signifi-
dialysis are less likely to receive GDMT in observa-
cant reductions in cardiovascular mortality rates
tional registries. In a cohort of 3124 patients with
(HR, 0.32 [0.18 0.57]), hospitalization for worsening
HF and on dialysis from the Get With The Guide-
HF (HR, 0.19 [0.09 0.41]) and all-cause hospitaliza-
lines-Heart Failure (GWTG-HF) registry, Pandey
tions (HR, 0.44 [0.25 0.77]).16 However, the gener-
et al. showed that patients with HFrEF and on dialy-
alizability of the trial is questionable because it
sis received GDMT less commonly than patients
included a small sample, and 13.6% of the patients
with normal renal function and those with
were excluded during the run-in phase due to
impaired renal function but not on dialysis.10
hypotension, bronchospasm, worsening HF, or
Although there was a significant increase in the
bradycardia.16
adherence to GDMT and HF-specific process-of-care
In contrast to the relative scarcity of RCT data,
measures over time, improvement in clinical out-
multiple observational studies have evaluated the
comes remained significantly lower than that in
association between beta-blocker use and outcomes
patients with normal renal function.10 More recent
in patients with HF and on dialysis.17,18 In a nation-
data from GWTG-HF from 2014 to 2019 also dem-
wide retrospective cohort study in Taiwan, including
onstrated less adherence to GDMT at discharge
3400 patients with HF on long-term HD, beta-
with increasing severity of CKD.11 The differences
blocker therapy was associated with a 20% reduc-
observed in the use of GDMT for HF were most pro-
tion in all-cause mortality (HR, 0.80 [0.72 0.90])
nounced in patients with estimated glomerular fil-
(Table 1).17 Similarly, in another retrospective cohort
tration rates (eGFRs) < 30 mL/min/1.73m2 and
study of 3503 patients on HD or peritoneal dialysis
those on dialysis.11
(PD), carvedilol was associated with a 21% reduction
In this context, the goal of this state-of-the-art
in mortality rates at 6 and 12 months (HR, 0.79
review is to discuss the available evidence for each
[0.65 0.91] HR, 0.79 [0.65 0.94], respectively).18
of the foundational HF therapies in ESKD, to review
Moreover, in about 11,000 patients from the US
current challenges and barriers to managing
Renal Data System (USRDS) registry, beta-blockers
patients with HF on dialysis and to outline the future
were the only antihypertensive drugs independently
directions to optimize the management of HF in
associated with substantial survival benefit (HR 0.84
these high-risk patients.
[0.75 0.93]), though only 39% of patients in this
study had HF.19
Although not a dedicated HF study, a large meta-
Evidence for GDMT in Patients With HF and ESKD
analysis evaluated the effectiveness of beta-blockers
The evidence regarding the use of differing HF in more than 120,000 patients on dialysis, irrespec-
therapies for patients on dialysis is summarized in tive of HF status.20 The included RCTs (n = 3) showed
Fig. 1. that beta-blockers significantly reduced all-cause
Managing Heart Failure in Patients on Dialysis: State-of-the-Art KHAN et al 89
Fig. 1. Summary of current evidence regarding the use of various HF therapies for patients with HF and on dialysis. ACE,
angiotensin-converting enzyme; ARB, angiotensin receptor blockers; ARNI, angiotensin receptor neprilysin inhibitor; BNP,
brain natriuretic peptide; CABG, coronary artery bypass grafting; CRT, cardiac resynchronization therapy; CV, cardiovascu-
lar; eGFR, estimated glomerular filtration rate; HF, heart failure; ICD, implantable cardioverter defibrillator; IV, intrave-
nous; LVEDD, left ventricular end diastolic diameter; LVEDV, left ventricular end diastolic volume; LVEF, left ventricular
ejection fraction; LVESV, left ventricular end systolic volume; MI, myocardial infarction; MRA, mineralocorticoid receptor
antagonists; NYHA, New York Heart Association; RCT, randomized controlled trial; SGLT2, sodium-glucose cotransporter-2.
mortality (risk ratio [RR], 0.73 [0.54 0.97]) cardiovas- blockers in patients with HF and ESKD.22 25 Thus,
cular mortality (RR, 0.44 [0.29 0.68]), and hospital- the choice of evidence-based beta-blocker in
izations (RR, 0.61 [0.48 0.78]) in patients on dialysis, patients with HF and ESKD (bisoprolol, carvedilol or
and the included observational studies (n = 9) also sustained-release metoprolol) should be based on
demonstrated significant reductions in all-cause tolerability and availability rather than on clinical-
mortality (RR, 0.86 [0.80 0.92]).20 trial evidence.
Important factors to consider when prescribing
beta-blockers to patients with HF and on dialysis are
Angiotensin Receptor Neprilysin Inhibitors
their cardioselectivity and dialyzability.21 Cardiose-
lective beta-blockers include atenolol, bisoprolol In post hoc or observational analyses, sacubitril/
and metoprolol; noncardioselective beta-blockers valsartan is effective and well tolerated in patients
include propranolol, carvedilol, labetalol, pindolol, with eGFRs 30 60 mL/min/1.73 m2.26,27 A single-cen-
nadolol, and timolol.21 Highly dialyzable beta-block- ter observational study of 110 patients with HF on
ers are atenolol, bisoprolol, acebutolol, nadolol, and HD noted that patients taking sacubitril/valsartan
metoprolol, whereas poorly dialyzable beta-blockers had improved improved LVEF (baseline, 35.1%; 12
are carvedilol, labetolol and propranolol.21 There is months, 49.8%), left ventricular mass index (base-
no clear evidence of differential benefit of beta- line, 167.8 g/m; 12 months, 154.9 g/m), left
Table 1. Completed RCTs and Key Observational Studies Evaluating HF Therapies Among HF Patients on Dialysis
Sample Follow-up
Study Name Year Intervention Control Size Population Key Findings Safety Concerns (months)
RCTs Evaluating HF Patients on Dialysis

Cice et al. 2001 Carvedilol Placebo 114 Patients with uremia, Significant improve- No significant safety con- 12
HFrEF (LVEF <35%) and ments in LVEF, cerns; however, hypo-
dilated cardiomyopathy LVEDV, LVESV, and tension, bradycardia,
on periodic HD NYHA functional acute myocardial infarc-
treatment class tion, and second-degree
heart block were seen in
carvedilol arm, and
worsening HF, sudden
death, acute myocardial
infarction, and death
due to refractory hyper-
potassemia were seen in
placebo arm
Cice et al. 2003 Carvedilol Placebo 114 Patients with uremia, Significant reductions No significant safety con- 24
HFrEF (LVEF <35%) and in all-cause mortal- cerns; however, hypo-
dilated cardiomyopathy ity, CV mortality, tension, bradycardia,
on periodic HD hospitalization for acute myocardial infarc-
treatment worsening HF and tion, and second-degree
all-cause heart block were seen in
hospitalizations carvedilol arm; and
worsening HF, sudden
death, acute myocardial
infarction, and death
due to refractory hyper-
potassemiwere seen in
placebo arm.
Cice et al. 2010 Telmisartan Placebo 332 Patients with chronic Significant reductions Adverse events leading to 35.5
HFrEF (LVEF <40%) on in all-cause mortal- discontinuations were
HD; NYHA functional ity, CV mortality, and higher in telmisartan
class II III hospitalization for arm. Most common
chronic HF. Improve- safety concern was
ments were noted in hypotension; other con-
LVEF and NYHA cerns noted were
functional class. increase in plasma
potassium, diarrhea,
back pain, sore throat,
and dizziness.
Taheri et al. 2009 Spironolactone Placebo 16 Patients with HFrEF (LVEF Significant increase in No significant risk of 6
<45%) and NYHA func- LVEF and significant hyperkalemia (2
tional classes III IV on decrease in LV mass patients reported
chronic HD treatment (3 hyperkalemia in pla-
sessions/week) since at cebo arm only).
least 1 month before
the study
(continued on next page)
Table 1 (Continued)
Sample Follow-up
Taheri et al. 2012 Spironolactone Placebo 18 Patients with HFrEF Significant increase in No significant risk of 6
(LVEF45%) and NYHA LVEF hyperkalemia
class III or IV HF on
CAPD, having a serum
potassium 5.5 mEq/L
Selectd observational studies evaluating HF patients on dialysis
Tang et al. 2016 Beta-blockers, Nonusers of beta- 3400 Patients with HF on long- Significant reduction Not reported NA
namely carvedi- blockers term HD (26 HD ses- in the risk of all-

lol, bisoprolol sions within 3 months of cause mortality
and metoprolol commencing HD)
CR/XL
Zhou et al. 2021 Beta-blockers at No beta-blockers at 3503 Patients aged 18 years Significant reductions Not reported 6
transition transition with CKD and docu- in the risk of mortal-
mented HF (5 years ity at 6 months and
before dialysis initia- 12 months
tion) on HD or PD
Wang et al. 2021 ARNI NA 110 Patients aged >18 years Significant improve- Not reported 12
with HFrEF (LVEF 40%) ments in LVEF,
and NYHA functional LVEDD, LVESD, LAD,
classes II IV undergoing KCCQ scores, and
maintenance HD NYHA functional
class
Lee et al. 2020 sacubitril/valsartan NA 23 Patients aged >18 years Significant increase in Symptomatic hypotension 4.4
with HFrEF (LVEF 35%) LVEF and significant (4/23) and dizziness (1/
and anuric ESKD on HD reductions in high- 23) noted
or PD since more than 6 sensitive troponin
months T and soluble ST2;
only 2/23 patients
were hospitalized
for HF, and no CV
deaths were noted.
Hsiao et al. 2022 ARNI ACE inhibitors and 1039 (618 on Patients with HFrEF (LVEF Significant increase in Significant increase in the 12
ARBs dialysis) <40%) and advanced the risk of HF hospi- risk of hyperkalemia
CKD (2 consecutive talization and com- with ARNI usage in
records of eGFR 30 mL/ posite of patients with HFrEF and
min/1.73 m2 in the pre- hospitalization for advanced CKD (but not
vious year) in the Chang HF and all-cause on dialysis); safety con-
Gung Research Data- death; no significant cerns not reported spe-
base between 2016 to effect on composite cifically in dialysis
2018 outcome of all-cause patients
mortality and hospi-
talization for HF,
reverse cardiac
remodeling, and
progression to ESKD
in patients with
HFrEF and advanced
CKD
Table 1 (Continued)
Sample Follow-up
Tang et al. 2013 RAS blockers (ACE No RAAS blockers 4,771 Patients with HF on long- Significant reductions Not reported 36
inhibitors and term HD ( 26 HD ses- in the risk of all-
ARBs) sions cause and cardiovas-
within 3 months after cular mortality
initiating HD)
Berger et al. 2007 ACE inhibitors and NA 2,169 Patients with chronic HF No significant reduc- Not reported 12
ARBs and CKD with data tions in mortality at
available for weight and 30 days or 1 year
serum creatinine among dialysis
enabling to calculate patients with HF
serum GFR
Lee et al. 2019 MRA NA 3464 ESKD patients on HD hav- Significant increase in Not reported NA
ing HF at ESKD inci- the risk of mortality;
dence in the USRDS no significant effect
between 2006 2014 on time to first HF
admission or time to
first hyperkalemia
admission
Pun et al. 2015 ICD no ICD 303 Patients aged 65 years No significant reduc- Not reported 56.4 (ICD registry);
with HFrEF (LVEF 35%) tions in mortality at 34.8 (GWTG-HF
and documented car- 1 and 3 years registry)
diomyopathy receiving
chronic dialysis treat-
ment; patients with
NYHA class IV symp-
toms, CABG 90 days
before implant, new-
onset HF (<3 months)
and MI 40 days before
implant were excluded
Hiremath et al. 2010 ICD no ICD 100 ESKD patients with ICD Significant reduction Not reported NA
and ESKD patients with in the risk of all-
left ventricular dysfunc- cause mortality
tion (LVEF <35%) on
dialysis for > 3 months
Friedman et al. 2013 CRT Matched control 15 Patients with ESKD and Significant increase in Not reported 36
HFrEF (LVEF <35%), on the risk of all-cause
dialysis having NYHA mortality and all-
functional class III or IV cause hospitaliza-
and QRS duration of tions but no signifi-
>120 ms cant effect on HF
hospitalizations
ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blockers; ARNI, angiotensin receptor neprilysin inhibitor; CABG, coronary artery bypass grafting; CAPD, continuous
ambulatory peritoneal dialysis; CKD, chronic kidney disease; CRT, cardiac resynchronization therapy; eGFR, estimated glomerular filtration rate; ESKD, end-stage kidney disease; GWTG-HF,
Get with the Guidelines-Heart Failure; HD, hemodialysis; HF, heart failure; ICD, implantable cardioverter defibrillator; KCCQ, Kansas City Cardiomyopathy Questionnaire; LAD, left atrial
diameter; LVEDD, left ventricular end diastolic diameter; LVEDV, left ventricular end diastolic volume; LVEF, left ventricular ejection fraction; LVESV, left ventricular end systolic volume; MI,
myocardial infarction; MRA, mineralocorticoid receptor antagonists; NA, not applicable; NT-proBNP, N-terminal pro b-type natriuretic peptide; NYHA, New York Heart Association; PD, peri-
toneal dialysis; RAS, rennin angiotensin-system; RCT, randomized controlled trial.
ventricular end diastolic diameter (baseline, 52.2 Although not specific to patients with HF, RCTs
mm; 12 months, 51.5 mm), and LVESD (baseline, evaluating ACE inhibitors in patients receiving dialy-
35.9 mm; 12 months, 36.9 mm), as well as in Kansas sis have produced mixed findings. In the Fosinopril
City Cardiomyopathy Questionnaire (KCCQ) scores in Dialysis (FOSIDIAL) trial of 397 patients with left
and New York Heart Association (NYHA) functional ventricular hypertrophy (LVH) on HD, fosinopril
classes (Table 1).28 However, the safety and long- failed to reduce the risk of the primary endpoint of
term efficacy of sacubitril/valsartan in patients with composite of cardiovascular death, nonfatal myocar-
HF and ESKD and those on dialysis has not been dial infarction, unstable angina, stroke, revasculari-
evaluated in any RCT to date. zation, or hospitalization due to HF.33 Similar
In contrast to these analyses demonstrating a ben- findings were observed in the Hemodialysis (HEMO)
eficial effect of ARNIs in patients with HF and ESKD, trial.34 In fact, the use of ACE inhibitors increased
a subgroup analysis of a retrospective multicenter the risk of hospitalization for HF (HR, 1.41
study of 618 dialysis patients with HFrEF in Taiwan [1.11 1.80]) in the HEMO trial.34 The lack of benefit
demonstrated that ARNIs were associated with of ACE inhibitors and ARBs in patients with dialysis
increased risk of hospitalization for HF (HR, 1.97 was confirmed in a meta-analysis of 11 studies
[1.36 2.85]) and composite of hospitalization for HF including 1856 patients, though a subgroup analysis
and all-cause death (HR, 1.73 [1.23 2.44]) compared revealed that ARBs reduced the risk of HF events by
with ACE inhibitors/ARBs (Table 1).29 33% (RR, 0.67 [0.47 0.93]).35 However, it must be
The lack of reliable evidence regarding the effi- emphasized that these studies comprised patients
cacy and safety of ARNI treatment in patients with on dialysis, and HF was not required for study entry.
HF and ESKD requiring dialysis warrants future Observational studies including HF patients on
investigation and, fortunately, there are 3 ongoing dialysis have also yielded conflicting results. A
trials to assess the safety and efficacy of sacubitril/ nationwide survey and propensity analysis including
valsartan in patients with HF and on dialysis: 4771 Taiwanese patients with chronic HF and on
NCT05243199 (Sacubitril/Valsartan for Dialysis dialysis showed that ACE inhibitors and ARBs
Patients With CKD5 Stage Complicated With Heart reduced all-cause (HR, 0.80 [0.72 0.89]) and cardio-
Failure: A Prospective, Randomized, Controlled Mul- vascular mortality (HR, 0.76 [0.64 0.90]).36 Con-
ticenter Study); NCT04572724 (The Effect of Sacubi- versely, a retrospective analysis of 2169 patients
tril/Valsartan on Cardiovascular Events Outcome in from the Minnesota Heart Survey showed that ACE
Maintenance Dialysis Patients With Heart Failure inhibitors or ARBs did not confer any survival bene-
and Efficacy Prediction of Baseline LVEF Value: A fits at 30 days or 1 year in patients on dialysis and
Prospective Cohort Study); and NCT04458285 (Effi- hospitalized with HF (Table 1).37 Given that most
cacy and Safety of Sacubitril/Valsartan in Mainte- ACE inhibitors are dialyzable, surveyed physicians
nance Hemodialysis Patients With Heart Failure prefer ARBs.35 However, current evidence does not
[ESARHD-HF]) (Table 2). Importantly, 2 of these trials offer reliable guidance regarding the use of ACE
(NCT05243199 and NCT04572724) have important inhibitors and ARBs in patients with ESKD and HF.
clinical endpoints (cardiovascular death and hospi-
talization for HF) as primary outcomes.
MRAs
Prescription rates of MRAs range from 33% in
ACE Inhibitors and ARBs
patients with HFrEF in the ambulatory setting to
ACE inhibitors and ARBs reduce cardiovascular 45% in patients at discharge post-HF
mortality rates and hospitalizations due to HF in hospitalization.38,39 Even when prescribed, titration
patients with HFrEF according to several RCTs.30,31 is often limited by the associated risk of hyperkale-
However, their use in patients with HF and on dialy- mia.40 These concerns are heightened in patients
sis has stayed limited due to conflicting findings and with HF and on dialysis. Two small RCTs have been
the paucity of reliable evidence in this population conducted to assess the efficacy and safety of MRAs
(Table 1). There is 1 RCT of ARB use in 332 patients in patients with HFrEF on dialysis. In 16 patients with
with HFrEF and ESKD.32 In this 3-year multicenter HFrEF on HD, spironolactone (25 mg/day) signifi-
Italian trial, telmisartan significantly reduced all- cantly increased mean LVEF and decreased mean LV
cause mortality rates (HR, 0.51 [0.32 0.82]), cardio- mass without increasing the risk of hyperkalemia
vascular mortality (HR, 0.42 [0.38 0.61]), and hospi- (reported in only 2 patients in the placebo group)
talization for chronic HF (HR, 0.38 [0.19 0.51]).32 (Table 1).41 Similarly, in 18 patients with HFrEF and
However, telmisartan was not well tolerated and ESKD undergoing continuous ambulatory PD, spiro-
was more likely than placebo to be discontinued nolactone vs placebo resulted in significant improve-
(16.3% vs 10.7%), most often due to hypotension or ment in the mean LVEF with the use of
hyperkalemia.32 spironolactone without significantly raising the risk
of hyperkalemia (Table 1).42 These pilot results sup- is a lack of trial-level and observational evidence
port the use of MRAs in patients with HFrEF on dialy- regarding the ue and effectiveness of SGLT2 inhibi-
sis, but they are limited by small sample sizes, low tors in patients with HF and on dialysis. However,
event rates and lack of ascertainment of hard clinical recent RCTs have provided reassuring results that
endpoints. Other trials in patients on dialysis (not indicate the possible renoprotection benefits associ-
necessarily having HF at baseline) have similarly ated with SGLT2 inhibitors in patients with HF and
revealed that MRA use is effective and does not CKD.48 Evidence from the ongoing Safety of Dapa-
increase the risk of clinically significant gliflozin in Hemodialysis Patients with Heart Failure
hyperkalemia.43 (SDHF) trial (NCT05141552) in the future will enable
In contrast to these small RCTs of patients with HF appropriate assessment of the usage of SGLT2 inhib-
and ESKD, an observational study based on the itors in patients with HF and on HD (Table 2). In
USRDS (2006 2014) of 3464 patients with HF and addition, the ongoing DAPA-HD (NCT05179668) trial
ESKD and on HD noted that MRAs were associated will provide additional information regarding the
with significantly greater risk of mortality (HR, 1.35 effects of SGLT2 inhibition by dapagliflozin in dia-
[1.25 1.46]) (Table 1). However, the mechanism of betic and nondiabetic patients on HD. Although this
death was not clear; there was no difference in the trial is not focused exclusively on patients with HF
risk of time to first admission due to HF (HR, 1.03 and on dialysis, the subgroup analysis of patients
[0.93-1.15]) or time to first admission due to hyper- with HF in this trial may be informative.
kalemia (HR, 0.98 [0.86–1.12]). In contrast, a meta-
analysis of 15 studies in patients on HD with no HF
Implantable Cardioverter Defibrillators
requirement showed that spironolactone reduced
all-cause mortality (RR, 0.42 [0.28 0.62]).44 Implantable cardioverter defibrillators (ICDs) have
Although spironolactone was associated with higher been shown to reduce mortality rates and morbidity
serum potassium (mean difference, 0.22 in patients with HFrEF. However, their benefit in
[0.12 0.31]), there was no increased risk of signifi- dialysis-dependent patients with HF remains unclear
cant hyperkalemia (RR, 1.21, [0.83 1.77]).44 Simi- owing to exclusions of such patients from pivotal tri-
larly, in a another meta-analysis of 1128 patients on als. Evidence from RCTs for ICD usage in patients
dialysis, low-dose MRA use reduced cardiovascular with HF and on dialysis is lacking. However, some
mortality by 54% (RR, 0.46 [0.28 0.76]) and all- observational studies have evaluated the efficacy of
cause mortality by 52% (RR, 0.48 [0.33 0.72]) but ICDs in patients with HFrEF and on dialysis. In a
did not significantly increase the risk of moderate matched cohort study including 303 patients on dial-
(RR, 1.29, [0.87 1.91]) to severe (RR, 1.85, ysis, no significant survival benefits (HR, 0.87
[0.90 3.80]) hyperkalemia.45 [0.66 1.13]) were noted with ICD use among dialysis
The lack of significant hyperkalemia risk in patients with HFrEF at follow-ups of both 1 (ICD,
patients with HF and ESKD requiring dialysis is prom- 42.2%; no ICD, 38.1%) and 3 years (ICD, 68.6%; no
ising and may be related to MRA dosage. Concomi- ICD, 75.7%), and the results were consistent on pro-
tant usage of novel potassium binders, such as pensity-matching as well (HR, 0.94 [0.67 1.31])
patiromer and sodium zirconium silicate, may help (Table 1).49 In contrast, results from a multicenter
to alleviate the associated hyperkalemia risk if it is registry study by Hiremath et al. that included 100
unable to be managed with HD therapy alone, patients on dialysis and with LV dysfunction showed
although there is no current evidence to support that ICD use significantly reduced the incidence of
their use. all-cause mortality (HR, 0.40 [0.19 0.82]) compared
Two large ongoing RCTs, Aldosterone Blockade to patients not having ICDs (Table 1).50 In a sub-
for Health Improvement EValuation in End-stage group analysis specific to patients with LVEF < 35%
Renal Disease (ACHIEVE) (NCT03020303) and ALdo- (n = 91), ICD use significantly reduced the risk of all-
sterone Antagonist Chronic HEModialysis Interven- cause mortality (HR, 0.32 [0.15 0.71]) as well.50 No
tional Survival Trial (ALCHEMIST) (NCT01848639) are safety concerns were reported in either of these
being conducted to establish the effects of MRAs in studies.
patients undergoing chronic hemodialysis. However, The recent ICD2 trial aimed to evaluate the effect
these trials are not specific to patients with HF of prophylactic ICD use in patients on dialysis but
requiring dialysis. without significant LV dysfunction (LVEF > 35%).
Although relatively healthy patients on dialysis were
recruited in this trial so as to attain significant sur-
SGLT2 Inhibitors
vival benefit, the trial was terminated early due to
SGLT2 inhibitors reduce cardiovascular mortality futility. ICD usage did not reduce the incidence of
rates and hospitalizations due to HF in patients with sudden cardiac death (HR, 1.32 [0.53 3.29]) or all-
HFrEF accoding to several RCTs.46,47 Currently, there cause mortality (HR, 1.02 [0.69 1.52]).51 In fact,
Table 2. Ongoing Trials Evaluating the Effect of Various HF Therapies in Patients on Dialysis
Estimated
Current Sample Inclusion Secondary
Study Name NCT Number Phase Nature Status Intervention Control Size Criteria Primary Outcomes Outcomes Location
Sacubitril/Valsartan for NCT05243199 4 Randomized Recruiting Sacubitril/ Irbesartan 600 CKD stage 5 patients with Hospitalization Rate of blood pres- Shanghai,
Dialysis Patients With Valsartan HF initiating regular HD for worsening sure compliance, China
CKD5 Stage Compli- or PD for more than 1 HF, death due to improvement in
cated With Heart Fail- month, NT-proBNP CV or other residual renal
ure: a Prospective, 2000 pg/mL. causes (at 1 function (at 1
Randomized, Con- year) year)
trolled Multicenter

Study
The Effect of Sacubitril/ NCT04572724 4 Non- Recruiting Sacubitril/ RAS 120 Patients with stable HF CV death and HHF Composite of death Guangdong,
Valsartan on Cardiovas- randomized Valsartan inhibitor (NYHA class II, III or IV), (at least 18 from CV diseases China
cular Events Outcome in typical HF symptoms, months) or first unplanned
Maintenance Dialysis and structural and/or HHF (at least 18
Patients With Heart functional cardiac months), change
Failure and Efficacy Pre- abnormality under from baseline to
diction of Baseline LVEF maintenance HD or PD 12 months in the
Value:A Prospective for more than 1 year, NT-proBNP,
Cohort Study NT-proBNP 600 pg/ml change from base-
line to 1 month, 6
month, and 18
months in the CSS
on KCCQ
A Multi-center, Random- NCT04458285 NA Randomized Recruiting Sacubitril/ Valsartan 118 Patients with chronic Changes in LVEF Changes in NT- Guangdong,
ized, Open-label, Valsartan HFrEF (LVEF 50%, at 12 weeks proBNP, LVEDV, China
Active-controlled, 12- NYHA class II) and LAV, E/E', pulmo-
week Study to Evaluate ESKD (eGFR <15mL/ nary artery pres-
the Efficacy and Safety min/1.73m2) receiving sure, Concentra-
of Sacubitril/Valsartan HD 3 times/week for at tion of high-
in Maintenance Hemo- least 12 weeks before sensitivity serum
dialysis Patients With registration troponin T, NYHA
Heart Failure (ESARHD- functional classifi-
HF) cation, Minnesota
Heart Failure
Quality of Life
Questionnaire
(LiHFe), SBP, DBP,
concentration of
potassium, ECG,
eGFR, incidence of
angioedema, Con-
centration of ala-
nine aminotrans-
ferase or
aspartate amino-
transferase (at 12
weeks)

BNP, brain natriuretic peptide; CKD, chronic kidney disease; CSS, clinical summary score; CV, cardiovascular; DBP, diastolic blood pressure; ECG, electrocardiogram; eGFR, estimated glo-
merular filtration rate; ESKD, end-stage kidney disease; HD, hemodialysis; HF, heart failure; HFrEF, HF with reduced ejection fraction; KCCQ, Kansas City Cardiomyopathy Questionnaire;
LAV, left atrial volume; LVEDV, left ventricular end diastolic volume; LVEF, left ventricular ejection fraction; NA, not applicable; NCT, national clinical trial; NT-proBNP, N-terminal pro b-
more than 50% of the patients died during the fol-
Shanghai,
low-up period. Interestingly, the major cause of
Location
China
death was found to be infections (ICD, 15/97; con-
trol, 14/91) followed by sudden cardiac death.51
Although this trial was not specific to patients with
HF, it provides important insights regarding the risks
proBNP at 12
Hypoglycemia and Change in NT-
and benefits of ICD therapy in patients on dialysis.

Secondary
Primary Outcomes Outcomes
Subcutaneous ICD implantation has been found to

weeks
reduce the risk of infections associated with transve-

nous ICD implantation in patients on dialysis and is
likely to be a safer alternative.52 However, current
UTI at 12 weeks
literature has conflicting evidence regarding the

efficacy and safety of ICD therapy in patients with
type natriuretic peptide; NYHA, New York Heart Association; PD, peritoneal dialysis; RAS, rennin angiotensin-system; SBP, systolic blood pressure.
HF and on dialysis, and its usage should generally be
avoided until further evidence is available.
Patients with chronic HF
perfusion, hemofiltra-
>11500 pg/mL or BNP

nance blood purifica-
(including HD, hemo-

undergoing mainte-
tion) 2 or 3 times a
(NYHA class II IV)
week, NT-proBNP
tion 2 or 3 times
Cardiac Resynchronization Therapy

>500 pg/mL
The effectiveness of CRT in patients with HFrEF

Inclusion
and on dialysis remains questionable owing to the

Criteria
lack of pertinent RCTs and the exclusions of these

high-risk patients from landmark clinical trials. Few
Estimated
observational studies have evaluated the effective-

Sample
ness of CRT in patients with HF and on dialysis. A

Size
20
Table 2 (Continued)
case-control study evaluating the effectiveness and

therapy)
safety of CRT in 15 patients on dialysis and with HF

anti-HF
(stan-
Control
dard
demonstrated that CRT increased the risk of all-

None
cause mortality (CRT, 73%; control, 44%; P= 0.038)

and all-cause hospitalizations (CRT, 100%; control,
76%; P= 0.047), but it did not significantly affect
Recruiting Dapagliflozin
Intervention
hospitalizations due to HF (CRT, 31%; control, 45%;

P= 0.39) when compared with matched controls
(Table 1).53 In contrast, a large retrospective analysis
based on almost 11,000 patients with HFrEF and
advanced CKD (stages 3 5), including those on dial-
Current
Status
ysis, showed that the use of CRT with defibrillators

significantly reduced the risk of mortality (CRT-D,
2936/9525; ICD, 569/1421; HR, 0.84 [0.76 0.94]) and
Randomized
hospitalizations due to HF(CRT-D, 2722/9525; ICD,

Phase Nature
529/1421; HR, 0.81 [0.72 0.91]) when compared

with ICD.54 The clinical benefits yielded were sus-
tained across all classes of CKD. Overall complication
NA
rates (in-hospital: CRT-D, 6.0% vs ICD, 5.8%; 30-day:

CRT-D, 5.0% vs ICD, 4.7%; 90-day: CRT-D, 0.3% vs
ICD, 0.4%) and rates for individual complications
NCT05141552
NCT Number
such as hematoma (in-hospital: CRT-D, 2.5% vs ICD,

2.3%; 30-day: CRT-D, 3.2% vs ICD, 3.0%), pneumo-
thorax or hemothorax (in-hospital: CRT-D, 0.9% vs
ICD, 1.1%; 30-day: CRT-D, 1.1% vs ICD, 1.2%), car-
The Safety of Dapagliflo-
diac tamponade or pericardial effusion requiring

Patients With Heart
zin in Hemodialysis
pericardiocentesis (in-hospital: CRT-D, 0.6% vs ICD,

0.9%; 30-day: CRT-D, 0.9% vs ICD, 1.1%), and
Failure (SDHF)
device-related infections (90-day: CRT-D, 0.3% vs

Study Name
ICD, 0.4%) were also similar in the CRT-D and ICD

groups.54 However, patients with HF and on dialysis
were not evaluated separately in this study.
Given the paucity of evidence and the presence of dialysis are lacking. In a case report of a patient with
conflicting findings regarding the usefulness of CRT HF and on HD by Sato et al., transcatheter mitral
in patients on dialysis and with HF, no definitive con- valve replacement (TMVR) using MitraClip signifi-
clusions can be reached unless further evidence spe- cantly reduced mitral regurgitation and improved
cific to patients on dialysis and with HF is generated. NYHA functional class from II to I without any post-
operative complications.58 However, non-HF-specific
Left Ventricular Assist Devices observational studies evaluating patients on dialysis
have revealed potential futility regarding the use of
Dialysis-dependent patients with advanced CKD or
MitraClip in this high-risk patient cohort. In a large
ESKD are often not recommended for left ventricular
retrospective study (n = 13,563) using the Nation-
assist device (LVAD) implantation due to concerns
wide Readmissions Database (NRD), Raheja et al.
about poor patient prognosis and increased mortality
showed that patients with ESKD on dialysis (n = 476)
rates (> 60%) owing to LVAD implantation-related
undergoing TMVR had significantly higher rates of
complications. Moreover, dialysis centers have typi-
in-hospital mortality (7.2% vs 2.5% vs 2.0%; P<
cally avoided accepting high-risk patients with
0.001), greater incidence of bleeding (16.6% vs
LVADs. In a retrospective analysis by Kirklin et al. that
10.3% vs 10.0%; P= 0.003), blood transfusions
included 4917 patients from Interagency Registry for
(19.7% vs 8.1% vs 6.0; P< 0.001), and 30-day all-
Mechanically Assisted Circulatory Support (INTER-
cause readmission (22.7% vs 15.6% vs 13.7%; P<
MACS), continuous-flow LVAD implantation was
0.001) compared with patients with CKD or no CKD,
associated with a 22% mortality rate at a 3-month
respectively.59 Although this study was not specific
follow-up in patients with HF on dialysis and those
to patients with HF, a large proportion of patients
with eGFRs < 30 mL/min/1.73 m2.55 Similarly, an 11-
had HF at baseline in all the 3 groups (ESKD, 80.2%;
year-long observational study by Bansan et al.
CKD, 87.1%; no CKD, 74.5%), and chronic HF was
showed that most of the patients (81.9%) with ESKD
found to be the most common cause of hospital
died during follow-up after LVAD implantation, with
readmission post MitraClip placement.59 Similarly,
the median time to death being only 16 days for
Shah et al. showed that patients on dialysis (n = 154)
patients with ESKD compared with 2125 days for
were at an almost 5-fold increase in risk of primary
those without ESKD. However, this study was not
composite outcome of all-cause mortality, stroke
specific to patients with HF and on dialysis.56
and new requirement for dialysis (OR, 4.93
LVAD implantation complicates the management
[2.33 10.5]) compared to patients with a creatinine
of patients receiving maintenance dialysis; the risks
clearance > 60 mL/min.60 Upon multivariable adjust-
are more pronounced in patients on HD compared
ment, patients on dialysis were significantly associ-
with those on PD. Lack of a pulsatile blood pressure
ated with a higher risk of any bleeding event at 1
in patients with continuous-flow LVAD implants may
year (HR, 2.11 [1.31 3.41]) and all-cause mortality,
result in ventricular arrythmias due to low ventricular
both at 30-day (HR, 3.31 [1.79 6.13]) and 1-year
volumes and pressures caused by ultrafiltration dur-
(2.44 [1.66 3.57]) follow-ups when compared with
ing dialysis. The slower ultrafiltration rate among
patients with creatinine clearances > 60 mL/min.60
patients on PD confers greater stability in these
In contrast, a large national study (n = 2197) by
patients. In addition, patients on HD are less likely to
Doshi et al. showed that TMVR significantly reduced
preserve residual renal function and more likely to
in-hospital mortality rates (OR, 0.06 [0.01 0.56])
have bacteremia and other infections. A recent case
and stroke (OR, 0.05 [0.03—0.07]) in patients with
report by Ajuria et al. showed that transitioning to
ESKD (n = 1,628) when compared with surgical
PD from HD improved kidney function significantly
mitral valve replacement.61 However, few patients
for an obese woman with nonischemic HFrEF and
had HF at baseline in this study. In the future, clinical
hypertension.57 In addition, PD was found to be safer
trials and observational studies specific to patients
and more well tolerated compared with HD. Interest-
with HF and on dialysis need to be conducted to
ingly, studies have also displayed survival and clinical
evaluate the efficacy of transcatheter therapeutics
benefits associated with chronic intermittent HD.
in this population of high-risk patients.
Although current evidence indicates worsening of
patient prognosis and poor survival rates in patients
with HF and on dialysis receiving LVAD implantation, Heart and Kidney Transplantation
the use of PD or intermittent HD may be a safer alter-
Patients with concomitant advanced HF and ESKD
native for these high-risk patients.
on dialysis constitute an extremely high-risk popula-
tion and are more susceptible to complications after
Transcatheter Mitral Valve Repair
transplantation. The incidence of dialysis-dependent
Clinical trials and observational studies evaluating acute renal failure post heart transplantation
the usage of MitraClip in patients with HF and on remains an important clinical issue.62,63 A recent
analysis by Shoji et al. revealed a 5-fold greater risk Although observational studies of patients with
in the incidence of all-cause mortality (HR, 5.2 HF and ESKD seem to favor HD for clinical endpoints,
[4.7 5.7]) in patients receiving dialysis after heart there is some evidence of favorable surrogate end-
transplantation.63 Post-transplant dialysis makes points and functional status with PD. A systematic
these patients more susceptible to clinical complica- review and meta-analysis of 31 studies showed that
tions and also increases the cost of care.64,65 There- PD significantly increased LVEF (mean difference,
fore, simultaneous heart and kidney transplant 3.76% [2.24 5.27]) and NYHA functional class.76
(SHKT) is generally recommended in patients with Patients with HF on PD also had a reduced frequency
concomitant end-stage HF and ESKD on dialysis. of hospitalization or length of stay after PD was
In a retrospective analysis of the United Network introduced (mean difference, 26.9, [ 36.9 to
for Organ Sharing database, Schaffer et al. showed 16.83]).76
that patients with end-stage HF on dialysis receiving Given the limitations of observational analysis,
SHKT had better post-transplant survival rates than clear recommendations concerning the use of PD vs
propensity-matched heart transplant alone (HTA) HD in patients with HF cannot be offered. Factors
patients (1 year, 84% vs 69%; 5 years, 73% vs 51%; P impacting the decision include patient preferences
< 0.001).66 In addition, multiple non-HF-specific for lifestyle and for participating in the dialysis pro-
observational studies have shown that SHKT offers cess and the recommendations of the collaborating
greater survival rates and clinical benefits than HTA nephrologist.
in patients with ESKD.67 70 Prior studies (although
not HF-specific) have also shown that patients
Modifications in Dialysis Procedure
undergoing SHKT have a lower risk of acute rejec-
tion compared with patients receiving HTA.70 In a small study including ESKD patients with con-
Another study has demonstrated that the effective- comitant HF (n = 6), conversion to frequent noctur-
ness of SHKT over HTA is sustained across various nal HD significantly increased the LVEF (from
age groups ( 60 and < 60 years) and in both dialy- 28% 42%; P= 0.01), reduced the systolic (138
sis-dependent and nondialysis-dependent patients mmHg 120 mmHg; P= 0.04) and mean arterial BP
with renal insufficiency.71 In contrast, a recent obser- (99 mmHg to 86 mmHg; P= 0.01), and decreased the
vational analysis by Melvinsdottir et al. included 845 number of prescribed cardiovascular medications
patients with end-stage heart and kidney failure (from 2.2% 0.7%; P= 0.02) when compared with
and revealed a 4.7-fold increase in the risk of mortal- conventional HD at baseline.77 Cardiovascular bene-
ity (HR, 4.77 (2.41 9.44]) when compared with fits of intensive HD were also noted in the Frequent
patients who underwent kidney transplant after Hemodialysis Network Daily Trial (n = 245), where 6
heart transplant.72 However, not all patients times-weekly, in-center HD significantly reduced left
included in this study were on dialysis. Nonetheless, ventricular mass (mean change, 13.1 [ 21.3, 5.0];
this mode of subsequent transplantation needs to P= 0.002) and the risk of mortality (HR, 0.54
be assessed further in comparison with simultaneous [0.31 0.93]).78,79 However, this trial was not specific
dual-organ transplantation. to patients with HF.
Home HD is another potential alternative that has
Dialysis in HF multiple clinical benefits, including blood pressure
and extracellular volume control, reduction in LV
Dialysis Modality Preference
hypertrophy and improvements in LVEF.80 In a retro-
Multiple observational studies have compared HD spective cohort study (n = 144) by Trinh et al., LV
to PD in patients with HF. A retrospective propensity hypertrophy regression due to home HD was signifi-
score-matched study in 2019 included 65,899 cantly associated with a decrease in the risk of mor-
patients and showed that HD was associated with tality (HR 0.24 [0.08 0.77]).81 Home HD can possibly
higher incidence rates of HF (HR, 1.45 [1.23 1.70]) alleviate the hemodynamic shifts by reducing inter-
compared with PD.73 However, in patients with dialytic gaps and decreasing the intensity of ultrafil-
established HF, evidence is conflicting, although it is tration associated with thrice-weekly conventional
overall in favor of HD. An observational study of HD, but there is a dearth of evidence specific to
3468 patients on HD and 933 patients on HD showed patients with HF.82
that PD significantly increased the risk of overall and Although conventional HD is subject to increased
cardiovascular mortality compared with HD.74 In risks due to greater ultrafiltration rates and relative
contrast, a smaller retrospective cohort study of 69 lack of preservation of residual renal function, modi-
patients on PD and 195 patients on HD revealed no fications in HD have proven to be beneficial. For
difference in overall survival, although deaths due instance, cooled dialysate, extracorporeal ultrafiltra-
to cardiovascular cause were significantly increased tion, higher levels of dialysate sodium and calcium
with PD (PD, 64.4%; HD, 37.9%; P= 0.001).75 and use of midodrine have yielded significant
improvements in the efficacy and safety of the HD with AVF in patients with HF. The aggravating pro-
procedure.83 However, current literature lacks evi- gression of HF with AVF can possibly render PD as a
dence for the efficacy of these modifications in preferred modality over HD in patients with HF.
patients with HF and on dialysis.
Myocardial Stunning
Management of Arteriovenous Fistula Myocardial stunning is a well-established compli-
cation of HD and is more commonly observed in
The arteriovenous fistula (AVF) is the preferred
patients receiving thrice-weekly HD. HD-induced
vascular access for patients on chronic HD, compared
myocardial stunning has been found to be associ-
with arteriovenous graft (AVG) (which have shorter
ated with an increased risk of mortality at 12 months
secondary patency following successful cannulation)
and may even lead to the incidence of HF.88 In a
and tunneled central venous catheter (which are
small cross-sectional study including patients (n = 46)
susceptible to an increased risk of infections, throm-
with a mean LVEF 30% 40%, all patients receiving
bosis, hospitalizations, and mortality).84,85,86 How-
thrice-weekly conventional HD were found to have
ever, the widely acceptable “fistula-first” approach
myocardial stunning compared with 92% of patients
harbors important clinical complications in the set-
receiving more frequent HD, 5–6 times/week, 75%
ting of HF.84 Creation of an AVF leads to a large
of patients receiving frequent home HD, and 50%
amount of blood’s being shunted from the left-
of patients receiving home nocturnal HD.89 Patients
sided circulation to the right-sided circulation.86 The
on more frequent HD schedules had lower volumes
resulting extra demand on cardiac output due to
and rates of ultrafiltration, decreased markers of
AVF creation can worsen the progression of HF.
inflammation and less myocardial intracellular dam-
In a retrospective cohort study including 137
age; hence, they were less likely to develop dialysis-
patients on HD, AVF/AVG creation significantly
induced myocardial stunning compared with con-
increased the risk of RV dilation, RV dysfunction and
ventional thrice-weekly HD.89 Prolonged dialysis ses-
left atrial dilation.84 Worsening RV dilation was
sions (median 24 hours/week) have also been found
associated with a 4-fold increased risk of mortality
to be associated with improved cardiac systolic func-
(HR, 3.9 [1.7 9.2]).84 Patients developing incident
tion by reduction in LV mass index and improve-
HF had significantly greater increments in left atrial
ments in LVEF.90 Other strategies include
volume and worsening of both RV dilation and dys-
individualized-temperature HD, intradialytic exer-
function compared with patients who did not
cise, dialysate cooling, and maintaining dialysate cal-
develop incident HF.84 A subgroup analysis of 35
cium 2.5 mEq/L.83,91,92 However, these studies are
patients who underwent AVF ligation revealed
not specific to patients with HF on HD.
reductions in left ventricular end diastolic diameter
and LV mass index and stability or improvement in
Management of Hyperkalemia
RV function, but there were no significant changes
in LV systolic or diastolic function nor any significant Patients on dialysis have an increased risk of
reverse RV remodeling.84 hyperkalemia, which is often due to poor dietary
The development of high-output HF is an under- adherence or, less likely, to higher catabolism
appreciated complication of AVF, which poses an rates.93 All foundational HF therapies except
important clinical dilemma.86,87 The ideal approach SGLT2 inhibitors can potentially precipitate
may be the prevention of worsening HF while main- hyperkalemia.94,95 There are several ways to miti-
taining AVF access, but balancing them simulta- gate this concern. Given that the kidneys are the
neously is often not possible, and AVF may have to main source for K+ excretion mainly, limiting food
be ligated, causing loss of vascular access.87 Alterna- sources rich in potassium may reduce serum potas-
tively, AVF can be maintained by partial banding, in sium levels. The usage of novel potassium binders,
which the AVF can be constricted in 1 or more places such as patiromer or sodium zirconium silicate, may
to decrease the AVF blood flow.87 Other techniques offer an effective strategy to prevent hyperkalemia
include placement of hemoclips over the venous while allowing for optimization of foundational
supply, the inflow reduction procedure or the Miller therapies for HF.96
procedure.87 However, these are proposed The potassium binder patiromer was associated
approaches for the management of high-output HF, with a reduction in serum potassium and lesser dis-
and current literature lacks evidence of their efficacy continuations of RAAS inhibitors in the 4-week
and safety in patients with HF. Although the use of a PEARL-HF (Evaluation of Patiromer in Heart Failure
central venous catheter is the least desirable form of Patients) and 12-week OPAL-HK (A Two-Part, Single-
vascular access, the risk of infection, morbidity and Blind, Phase 3 Study Evaluating the Efficacy and
mortality should be weighed against the risk of Safety of Patiromer for the Treatment of Hyperkale-
increasing HF progression and should be compared mia) trials.97,98 In the DIAMOND (Patiromer for the
Management of Hyperkalemia in Subjects Receiving Whether this represents association vs causation is

RAAS inhibitor Medications for the Treatment of not clear.
Heart Failure) trial, patiromer was associated with a It is important to note that predialysis and post-
reduced the incidence of severe hyperkalemia (> 5.5 dialysis BP are subject to several limitations and can-
mEq/L) and enabled optimization of guideline- not be used as reliable metrics for diagnosing
directed medical doses of RAAS inhibitors in 85% of hypertension or assessing long-term cardiovascular
the included patients with HFrEF.99 Nonetheless, it risk in patients on dialysis.108,109,110 The white-coat
must be emphasized that there is no current evi- effect, masked hypertension, limited time for
dence to support the use of novel potassium binders patient relaxation before or after the dialysis proce-
in patients on dialysis; further investigation is dure, and variability in volume status during the
needed. intra- and interdialytic periods render this method
SGLT2 inhibitors reduce the risk of hyperkalemia imprecise for BP management in dialysis
while enabling optimization of GDMT in patients patients.108,109 A meta-analysis has shown that both
with HF. In a recent analysis of the EMPEROR-Pooled pre- and postdialysis BP measurements give inaccu-
(Empagliflozin Outcome Trial in Patients with rate estimates of the mean interdialytic BP mea-
Chronic Heart Failure–EMPEROR-Reduced and sured by ambulatory BP monitoring, with the
EMPEROR-Preserved combined) HF population, predialysis diastolic BP overestimating the ambu-
empagliflozin reduced the rates of hyperkalemia latory BP (ABP) and the postdialysis systolic and
compared with placebo (serum potassium > 5.5 diastolic BP underestimating the ABP.111 Ambula-
mmol/L: HR, 0.85 [0.74, 0.97]; serum potassium > 6.0 tory BP monitoring is considered the gold stan-
mmol/L: HR, 0.62 [0.48, 0.81]) without significantly dard for diagnosing hypertension in patients on
increasing the incidence of hypokalemia (investiga- dialysis and has been found to predict all-cause
tor-reported HR, 1.20 [0.91, 1.57]; serum potassium and cardiovascular mortality better than peridia-
< 3.0 mmol/L: HR, 1.35 [0.75, 2.45]).100 Although lytic BP.108 However, these studies are limited to
these findings are not directly applicable to patients patients on dialysis who did not necessarily have
with HF on dialysis, SGLT2 inhibitors can potentially HF at baseline.
enable the continuation and optimization of other Given that hypertension affects almost 70% 80%
HF therapies in patients with HF on dialysis as of patients on dialysis, appropriate management is
well.101 Another approach to managing hyperkale- key.104 The most common cause of hypertension in
mia in patients with HF on dialysis includes reduction patients on dialysis is failure to remove enough vol-
of the dialysate K+ concentration. Close monitoring ume effectively.102 Given that PD is a better way to
of electrolyte levels is required to allow for effective remove fluid than HD, it is likely that patients on PD
management of hyperkalemia in these high-risk have better BP control and, hence, do better, even
patients. in the setting of concomitant HF. Nonpharmacologi-
cal measures for reducing hypertension include con-
trol of dietary sodium intake, attainment of dry
Management of Blood Pressure
weight and reduction in dialysate sodium concentra-
Blood pressure (BP) control in patients on dialysis tion.104 In addition, higher frequency, prolonged
remains challenging. In fact, BP in patients on dialy- durations of dialysis and nocturnal HD are also effec-
sis is often measured incorrectly, and readings taken tive measures of BP control.104 Antihypertensive
at dialysis units hold less prognostic value.102,103 Evi- medications, however, remain the cornerstone
dence has suggested that BP taken the morning, treatment for hypertension in patients with HF and
after dialysis, is most accurate and reliable. Multiple on dialysis. It is imperative that in these instances,
observational studies have shown a U-shaped rela- antihypertensive medications, which are not life-
tionship between pre-HD systolic BP (SBP) and mor- prolonging, such as clonidine and nifedipine, be
tality in patients on dialysis.104,105,106 Postdialysis switched to foundational HF therapies that are
SBP > 180 mmHg and diastolic BP (DBP) > 90 mmHg effective in controlling blood pressure and poten-
are associated with an increased risk of cardiovascu- tially prolonging survival as well.
lar mortality. In patients with HFrEF and on dialysis, In the future, studies specific to patients with HF
in particular, predialysis BP values of < 120 mmHg, and on dialysis should be conducted to evaluate the
considered to be within the normal range, relationship of BP with important clinical outcomes
increased the risk of cardiovascular mortality and to ascertain the U-shaped paradoxical associa-
more than higher BP values.107 In fact, lower pre- tion between BP and mortality. Research focused on
dialysis SBP and mean arterial pressure were asso- determining the ideal BP range for patients with HF
ciated with increased mortality rates, whereas and on dialysis is also needed. Based on the current
higher postdialysis SBP and mean arterial pressure dearth of evidence, the BP control in patients with
were associated with increased mortality rates. HF on dialysis should be guided toward avoiding
symptomatic hypotension and hypotension limiting patients with HF on dialysis (Visual Take Home
effective dialysis, particularly for patients receiving Graphic).
HD. Future RCTs are needed to assess the effectiveness
of well-established HF therapies in patients with HF
and on dialysis. As compared with the initial cardio-
Challenges and Future Directions
vascular outcome trials that that have confirmed the
Fig. 2 summarizes the barriers to and possible sol- efficacy of therapies in nondialysis patients with HF,
utions for patients with HF and on dialysis. One of patients with HF and on dialysis are generally frailer,
the major reasons for the undertreatment of HF in older and have poorer prognoses.112 Thus, the
patients on dialysis is the lack of reliable evidence degree to which the safety and efficacy seen in the
from well-powered RCTs. Few to no RCTs specific to prior landmark trials of HF therapies generalize to
patients with HF and on dialysis have been con- patients with ESKD and on dialysis are generally
ducted; the majority of evidence to date is derived uncertain. It may be feasible to answer these
from observational studies, which are inherently research questions with pragmatic RCTs, leveraging
subject to confounding and biases. Moreover, exclu- the benefits of randomization to determine cause-
sions of these high-risk patients from landmark RCTs effect relationships while potentially maximizing
of drug and device interventions for HF make it application to the generally multimorbid ESKD pop-
even more difficult to ascertain the efficacy and ulation encountered in routine practice.
safety of these therapeutic agents in dialysis-depen-
dent patients with HF. Conflicting findings from
Conclusion
observational studies further complicate the assess-
ment, consequently, leaving the important drug In patients with HF who are receiving dialysis,
efficacy and safety questions unanswered for these despite being at substantially higher risk for morbid-
high-risk patients. In addition, perceived concerns ity and mortality, there is a critical lack of reliable
regarding the safety and tolerability of GDMT for evidence to guide management and inform best
HF in dialysis-dependent patients have led to discon- practice. Owing to perceived concerns about the
tinuations of therapies, thereby compromising the effectiveness and safety of conventional therapies
management of HF in these patients. Fig. 3 gives an for HF, clinicians have been reluctant to prescribe
overview of the proposed clinical approach in these medications. Trial-level evidence is warranted
Fig. 2. Current barriers and possible solutions for managing HF in patients on dialysis. CKD, chronic kidney disease; ESKD,
end-stage kidney disease; HF, heart failure; OS, observational studies; RCT, randomized controlled trial.
Fig. 3. (Visual Take-Home Graphic). Proposed clinical approach in patients with HF and on dialysis. ACE, angiotensin-con-
verting enzyme; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; CRT, cardiac resynchro-
nization therapy; CV, cardiovascular; GDMT, guideline-directed medical therapy; HF, heart failure; ICD, implantable cardiac
defibrillator; LVAD, left ventricular assist device; MRA, mineralocorticoid receptor antagonist; SGLT2, sodium-glucose
cotransporter 2.
in the future to endorse the efficacy and safety of but data regarding the management of HF in
therapeutic HF interventions in patients on dialysis. patients with ESKD and undergoing dialysis remain
Collaborations between the cardiologists and neph- very limited. Trial-level evidence is warranted in the
rologists are needed to devise an optimal treatment future to endorse the efficacy and safety of thera-
strategy for these patients. peutic interventions in patients with HF and on dial-
ysis. Collaborations between the cardiologists and
nephrologists are needed to devise an optimal treat-
Brief Lay Summary
ment strategy for these patients.
Heart failure (HF) and end-stage kidney disease
(ESKD) frequently coexist, with 1 comorbidity wors-
Tweet
ening the prognosis of the other. Some randomized
clinical trials have evaluated the efficacy of thera- There is a paucity of data regarding the manage-
pies in patients with HF and chronic kidney disease, ment of heart failure in patients on dialysis. Trial-
level evidence is warranted in the future to endorse 2005;45(Suppl 3):16–153. https://doi.org/10.1053/J.

the efficacy and safety of therapeutic interventions AJKD.2005.01.019.
for heart failure in patients on dialysis, and collabo- 9. McDonagh TA, Metra M, Adamo M, Gardner RS,
Baumbach A, Bo € hm M. 2021 ESC Guidelines for the
rations between the cardiologists and nephrologists diagnosis and treatment of acute and chronic heart
are needed. @ShahzebKhanMD; @gcfmd failure. Eur Heart J 2021;42:3599–726. https://doi.org/
10.1093/EURHEARTJ/EHAB368.
10. Pandey A, Golwala H, DeVore AD, Lu D, Madden G,
Bhatt DL, et al. Trends in the use of guideline-directed
therapies among dialysis patients hospitalized with sys-
tolic heart failure: findings from the American Heart
Association Get With The Guidelines-Heart Failure pro-
gram. JACC Hear Fail 2016;4:649–61. https://doi.org/
10.1016/J.JCHF.2016.03.002.
11. Patel RB, Fonarow G, Greene S, Zhang S, Alhanti B,
DeVore A, et al. Clinical profiles, medical therapies,
and outcomes among patients hospitalized for HF
Supplementary materials across the spectrum of kidney function: the GWTG-
HF registry. J Am Coll Cardiol 2021;77:559. https://
Supplementary material associated with this doi.org/10.1016/S0735-1097(21)01918-5.
article can be found in the online version at 12. Packer M, Coats AJS, Fowler MB, Katus HA, Krum H,
doi:10.1016/j.cardfail.2022.09.013. Mohacsi P, et al. Effect of carvedilol on survival in
severe chronic heart failure. N Engl J Med.
2001;344:1651 8. doi: 10.1056/NEJM200105313442201
References 13. Dargie HJ, Lechat P. The Cardiac Insufficiency Biso-
prolol Study II (CIBIS-II): a randomised trial. Lancet
1. McAlister FA, Ezekowitz J, Tarantini L. Renal dysfunc- 1999;353:9–13. https://doi.org/10.1016/S0140-6736
tion in patients with heart failure with preserved ver- (98)11181-9.
sus reduced ejection fraction impact of the new 14. Frankenfield DL, Weinhandl ED, Powers CA, Howell
chronic kidney disease-epidemiology collaboration BL, Herzog CA, St. Peter WL. Utilization and costs of
group formula. Circ Heart Fail 2012;5:309–14. https:// cardiovascular disease medications in dialysis patients
doi.org/10.1161/CIRCHEARTFAILURE.111.966242/-/ in Medicare Part D. Am J Kidney Dis 2012;59:670–81.
DC1. https://doi.org/10.1053/J.AJKD.2011.10.047.
2. House AA, Wanner C, Sarnak MJ, Pin ~ a IL, McIntyre 15. Cice G, Ferrara L, Di Benedetto A, Russo PE, Marinelli
CW, Komenda P, et al. Heart failure in chronic kidney G, Pavese F, et al. Dilated cardiomyopathy in dialysis
disease: conclusions from a Kidney Disease: Improv- patients: beneficial effects of carvedilol: a double-
ing Global Outcomes (KDIGO) Controversies Confer- blind, placebo-controlled trial. J Am Coll Cardiol
ence. Kidney Int 2019;95:1304–17. https://doi.org/ 2001;37:407–11. https://doi.org/10.1016/S0735-1097
10.1016/J.KINT.2019.02.022. (00)01158-X.
3. Waldum-Grevbo B. What physicians need to know 16. Cice G, Ferrara L, D’Andrea A, D’Isa S, Di Benedetto
about renal function in outpatients with heart A, Cittadini A, et al. Carvedilol increases two-year
failure. Cardiology 2015;131:130–8. https://doi.org/ survivalin dialysis patients with dilated cardiomyopa-
10.1159/000381012. thy: a prospective, placebo-controlled trial. J Am Coll
4. Bhatti NK, Karimi Galougahi K, Paz Y, Nazif T, Moses Cardiol 2003;41:1438–44. https://doi.org/10.1016/
JW, Leon MB, et al. Diagnosis and management of S0735-1097(03)00241-9.
cardiovascular disease in advanced and end-stage 17. Tang CH, Wang CC, Chen TH, Hong CY, Sue YM.
renal disease. J Am Hear Assoc Cardiovasc Cerebro- Prognostic benefits of carvedilol, bisoprolol, and
vasc Dis 2016;5:e003648. https://doi.org/10.1161/ metoprolol controlled release/extended release in
JAHA.116.003648. hemodialysis patients with heart failure: a 10-year
5. Tong J, Liu M, Li H, Luo Z, Zhong X, Huang J. et al. cohort. J Am Heart Assoc 2016;5:1–11. https://doi.
Mortality and associated risk factors in dialysis org/10.1161/JAHA.115.002584.
patients with cardiovascular disease. Kidney Blood 18. Zhou H, Sim JJ, Shi J, Shaw SF, Lee MS, Neyer JR, et al.
Press Res 2016;41:479–87. https://doi.org/10.1159/ b-blocker use and risk of mortality in heart failure
000443449. patients initiating maintenance dialysis. Am J Kidney
6. McMurray JJV, Wheeler DC, Stefa nsson BV, Jongs N, Dis 2021;77:704–12. https://doi.org/10.1053/J.
Postmus D, Correa-Rotter R, et al. Effects of dapagliflo- AJKD.2020.07.023.
zin in patients with kidney disease, with and without 19. Foley RN, Herzog CA, Collins AJ. Blood pressure and
heart failure. JACC Heart Fail 2021;9:807–20. https://doi. long-term mortality in United States hemodialysis
org/10.1016/J.JCHF.2021.06.017. patients: USRDS Waves 3 and 4 Study1. Kidney
7. Wali RK, Iyengar M, Beck GJ, Chartyan DM, Chonchol Int 2002;62:1784–90. https://doi.org/10.1046/J.1523-
M, Lukas MA, et al. Efficacy and safety of carvedilol 1755.2002.00636.X.
in treatment of heart failure with chronic kidney dis- 20. Jin J, Guo X, Yu Q. Effects of beta-blockers on cardio-
ease: a meta-analysis of randomized trials. Circ Heart vascular events and mortality in dialysis patients: a
Fail 2011;4:18–26. https://doi.org/10.1161/CIRCH- systematic review and meta-analysis. Blood Purif
EARTFAILURE.109.932558. 2019;48:51–9. https://doi.org/10.1159/000496083.
8. K/DOQI clinical practice guidelines for cardio- 21. Hundemer GL, Sood MM, Canney M. b-blockers in
vascular disease in dialysis patients. Am J Kidney Dis hemodialysis: simple questions, complicated answers.
Clin Kidney J 2021;14:731. https://doi.org/10.1093/ 34. Chang TI, Shilane D, Brunelli SM, Cheung AK, Cher-
CKJ/SFAA249. tow GM, Winkelmayer WC. Angiotensin-converting
22. Weir MA, Dixon SN, Fleet JL, Roberts MA, Hackam enzyme inhibitors and cardiovascular outcomes in
DG, Oliver MJ, et al. b-blocker dialyzability and mor- patients on maintenance hemodialysis. . https://doi.
tality in older patients receiving hemodialysis. J Am org/10.1016/j.ahj.2011.05.004 Published online.
Soc Nephrol 2015;26:987–96. https://doi.org/10.1681/ 35. Liu Y, Ma X, Zheng J, Jia J, Yan T. Effects of angioten-
ASN.2014040324. sin-converting enzyme inhibitors and angiotensin
23. Tieu A, Velenosi TJ, Kucey AS, Weir MA, Urquhart BL. receptor blockers on cardiovascular events and resid-
b-blocker dialyzability in maintenance hemodialysis ual renal function in dialysis patients: a meta-analysis
patients a randomized clinical trial. Clin J Am Soc of randomised controlled trials. BMC Nephrol
Nephrol 2018;13:604–11. https://doi.org/10.2215/ 2017;18:206. https://doi.org/10.1186/S12882-017-
CJN.07470717/-/DCSUPPLEMENTAL. 0605-7.
24. Wu PH, Lin YT, Kuo MC, Liu JS, Tsai YC, Chiu YW, 36. Tang CH, Chen TH, Wang CC, Hong CY, Huang KC,
et al. b-blocker dialyzability and the risk of mortality Sue YM. Renin-angiotensin system blockade in heart
and cardiovascular events in patients undergoing failure patients on long-term haemodialysis in Tai-
hemodialysis. Nephrol Dial Transplant 2020;35:1959– wan. Eur J Heart Fail 2013;15:1194–202. https://doi.
65. https://doi.org/10.1093/NDT/GFAA058. org/10.1093/EURJHF/HFT082.
25. Assimon MM, Brookhart MA, Fine JP, Heiss G, Layton 37. Berger AK, Duval S, Manske C, Vazquez G, Barber C,
JB, Flythe JE. A comparative study of carvedilol versus Miller L, et al. Angiotensin-converting enzyme inhibi-
metoprolol initiation and 1-year mortality among tors and angiotensin receptor blockers in patients
individuals receiving maintenance hemodialysis. Am with congestive heart failure and chronic kidney dis-
J Kidney Dis 2018;72:337. https://doi.org/10.1053/J. ease. Am Heart J 2007;153:1064–73. https://doi.org/
AJKD.2018.02.350. 10.1016/J.AHJ.2007.03.017.
26. Mcmurray JJ V, Packer M, Desai AS, Gong J, Lefko- 38. Greene SJ, Butler J, Albert NM, DeVore AD, Sharma
witz MP, Rizkala AR, et al. Angiotensin-neprilysin PP, Duffy CI, et al. Medical therapy for heart failure
inhibition versus enalapril in heart failure. N Engl J with reduced ejection fraction: The CHAMP-HF Regis-
Med 2014;11:993–1004. https://doi.org/10.1056/NEJ- try. J Am Coll Cardiol 2018;72:351–66. https://doi.org/
Moa1409077. 10.1016/J.JACC.2018.04.070.
27. Pontremoli R, Borghi C, Perrone Filardi P. Renal pro- 39. Greene SJ, Ezekowitz JA, Anstrom KJ, Demyanenko
tection in chronic heart failure: focus on sacubitril/val- V, Givertz MM, Pina IL, et al. Medical therapy during
sartan. Eur Hear J/Cardiovasc Pharmacother hospitalization for heart failure with reduced ejec-
2021;7:445. https://doi.org/10.1093/EHJCVP/PVAB030. tion fraction: the VICTORIA Registry. J Card Fail
28. Lihua W, Cheng L, Chen H, Wei F, Jiang A. Use of 2022;14::S1071–9164. https://doi.org/10.1016/J.CARD-
angiotensin receptor neprilysin inhibitor in patients FAIL.2022.02.011.
on maintenance hemodialysis with reduced cardiac 40. Lisi F, Parisi G, Gioia MI, Amato L, Bellino MC, Grande
ejection fraction, real-world experience from a single D, et al. Mineralcorticoid receptor antagonist with-
center. Iran J Kidney Dis 2021;15:288–99. drawal for hyperkalemia and mortality in patients
29. Hsiao FC, Lin CP, Yu CC, Tung YC, Chu PH. Angiotensin with heart failure. Cardiorenal Med 2020;10:145–53.
receptor-neprilysin inhibitors in patients with heart https://doi.org/10.1159/000505286.
failure with reduced ejection fraction and advanced 41. Taheri S, Mortazavi M, Shahidi S, Pourmoghadas A,
chronic kidney disease: a retrospective multi-institu- Garakyaraghi M, Seirafian S, et al. Spironolactone in
tional study. Front Cardiovasc Med 2022;9:794707. chronic hemodialysis patients improves cardiac func-
https://doi.org/10.3389/FCVM.2022.794707. tion. Saudi J Kidney Dis Transplant 2009;20:392–7.
30. Group* TCTS. Effects of enalapril on mortality in Accessed July 7, 2022 https://www.sjkdt.org/article.
severe congestive heart failure. N Engl J Med. asp?issn=1319-2442;year=2009;volume=20;issue=3;
2010;316:1429 35. https://doi.org/10.1056/ spage=392;epage=397;aulast=Taheri.
NEJM198706043162301 42. Taheri S, Mortazavi M, Pourmoghadas A, Seyrafian S,
31. Granger CB, McMurray JJV, Yusuf S, Held P, Michel- Alipour Z, Karimi S. A prospective double-blind ran-
son EL, Olofsson B, et al. Effects of candesartan in domized placebo-controlled clinical trial to evaluate
patients with chronic heart failure and reduced the safety and efficacy of spironolactone in patients
left-ventricular systolic function intolerant to with advanced congestive heart failure on continu-
angiotensin-converting-enzyme inhibitors: the ous ambulatory peritoneal dialysis. Saudi Journal of
CHARM-Alternative trial. Lancet 2003;362:772–6. Kidney Diseases and Transplantation (SJKDT): Table
https://doi.org/10.1016/S0140-6736(03)14284-5. of Contents. Accessed July 7, 2022. https://www.
32. Cice G, Di Benedetto A, D’Isa S, D’Andrea A, Marcelli D, sjkdt.org/showcaptcha.asp?RedirectUrl=arti-
Gatti E, et al. Effects of telmisartan added to angioten- cle&issn=1319-2442;year=2012;volume=23;issue=3;
sin-converting enzyme inhibitors on mortality and spage=507;epage=512;aulast=Taheri
morbidity in hemodialysis patients with chronic heart 43. Matsumoto Y, Mori Y, Kageyama S, Arihara K,
failure: a double-blind, placebo-controlled trial. J Am Sugiyama T, Ohmura H, et al. Spironolactone
Coll Cardiol 2010;56:1701–8. https://doi.org/10.1016/J. reduces cardiovascular and cerebrovascular morbid-
JACC.2010.03.105. ity and mortality in hemodialysis patients. J Am Coll
33. Zannad F, Kessler M, Lehert P, Gru € nfeld JP, Thuilliez Cardiol 2014;63:528–36. https://doi.org/10.1016/J.
C, Leizorovicz A, et al. Prevention of cardiovascular JACC.2013.09.056.
events in end-stage renal disease: results of a ran- 44. Liu J, Jia WY, Yu C. Safety and efficacy of spironolac-
domized trial of fosinopril and implications for tone in dialysis-dependent patients: meta-analysis of
future studies. Kidney Int 2006;70:1318–24. https:// randomized controlled trials. Front Med 2022;9:663.
doi.org/10.1038/SJ.KI.5001657. https://doi.org/10.3389/FMED.2022.828189/BIBTEX.
45. Zhu Y, Liu Y, Cai R, Zheng D, Liang X, Tao M, et al. The Intern Med 2018;178:204. https://doi.org/10.1001/
safety and efficacy of low-dose mineralocorticoid JAMAINTERNMED.2017.4831.
receptor antagonists in dialysis patients: A meta-analy- 57. Ajuria M, Franz DD, Morris JT, Abra G, Hussein WF.
sis. Medicine (Baltimore) 2021;100:e24882. https://doi. Peritoneal dialysis following left ventricular assist
org/10.1097/MD.0000000000024882. device placement and kidney recovery: a case report.
46. McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kidney Med 2021;3:438–41. https://doi.org/10.1016/J.
Kosiborod MN, Martinez FA, et al. Dapagliflozin in XKME.2020.12.009.
patients with heart failure and reduced ejection frac- 58. Sato H, Sakurada T, Kojima S, Okamoto T, Shibagaki
tion. N Engl J Med. 2019;381):1995 2008. doi: Y, Ishibashi Y, et al. Transcatheter mitral valve repair
10.1056/NEJMOA1911303 with a mitraclip for severe mitral regurgitation in a
47. Packer M, Anker SD, Butler J, Filippatos G, Pocock SJ, patient on hemodialysis. Saudi J Kidney Dis Trans-
Carson P, et al. Cardiovascular and renal outcomes plant 2021;32:1465. https://doi.org/10.4103/1319-
with empagliflozin in heart failure. N Engl J Med 2442.344769.
2020;383:1413–24. https://doi.org/10.1056/NEJ- 59. Raheja H, Ahuja KR, Nazir S, Saad AM, Gad MM,
MOA2022190/SUPPL_FILE/NEJMOA2022190_DATA- Chatterjee S, et al. Association of baseline kidney dis-
SHARING.PDF. ease with outcomes of transcatheter mitral valve
48. Zannad F, Ferreira JP, Pocock SJ, Zeller C, Anker SD, repair by MitraClip. Catheter Cardiovasc Interv
Butler J, et al. Cardiac and Kidney benefits of empa- 2021;97:E857–67. https://doi.org/10.1002/CCD.29129.
gliflozin in heart failure across the spectrum of kid- 60. Shah B, Villablanca PA, Vemulapalli S, Manandhar P,
ney function: insights from EMPEROR-Reduced. Amoroso NS, Saric M, et al. Outcomes after trans-
Circulation 2021;143:310–21. https://doi.org/10.1161/ catheter mitral valve repair in patients with renal dis-
CIRCULATIONAHA.120.051685. ease: insights from the Society of Thoracic Surgeons/
49. Pun PH, Hellkamp AS, Sanders GD, Middleton JP, American College of Cardiology national cardiovas-
Hammill SC, Al-Khalidi HR, et al. Primary prevention cular data registry, transcatheter valve therapy regis-
implantable cardioverter defibrillators in end-stage try. Circ Cardiovasc Interv 2019;12. https://doi.org/
kidney disease patients on dialysis: a matched cohort 10.1161/CIRCINTERVENTIONS.118.007552.
study. Nephrol Dial Transplant 2015;30:829. https:// 61. Doshi R, Shlofmitz E, Shah J, Meraj P. Comparison of
doi.org/10.1093/NDT/GFU274. transcatheter mitral valve repair versus surgical
50. Hiremath S, Punnam SR, Brar SS, Goyal SK, Gardiner mitral valve repair in patients with advanced kidney
JC, Shah AJ, et al. Implantable defibrillators improve disease (from the national inpatient sample). Am J
survival in end-stage renal disease: results from a Cardiol 2018;121:762–7. https://doi.org/10.1016/J.
multi-center registry. Am J Nephrol 2010;32:305–10. AMJCARD.2017.12.015.
https://doi.org/10.1159/000319461. 62. Thongprayoon C, Lertjitbanjong P, Hansrivijit P, Crisa-
51. Wouter Jukema J, Timal RJ, Rotmans JI, Hensen LCR, fio A, Mao MA, Watthanasuntorn K, et al. Acute kid-
Buiten MS, De Bie MK, et al. Prophylactic use of ney injury in patients undergoing cardiac
implantable cardioverter-defibrillators in the preven- transplantation: a meta-analysis. Medicines 2019;6:108.
tion of sudden cardiac death in dialysis patients: the https://doi.org/10.3390/MEDICINES6040108.
prospective, randomized, controlled ICD2 trial. Circu- 63. Shoji S, Kuno T, Kohsaka S, Amiya E, Asleh R, Alvarez
lation 2019;139:2628–38. https://doi.org/10.1161/CIR- P, et al. Incidence and long-term outcome of heart
CULATIONAHA.119.039818. transplantation patients who develop postoperative
52. Pun PH, Parzynski CS, Friedman DJ, Sanders G, Curtis renal failure requiring dialysis. J Heart Lung Trans-
JP, Al-Khatib SM. Trends in use and in-hospital out- plant 2022;41:356–64. https://doi.org/10.1016/J.HEA-
comes of subcutaneous implantable cardioverter LUN.2021.11.017.
defibrillators in patients undergoing long-term dialy- 64. Hornberger J, Best J, Geppert J, McClellan M. Risks
sis. Clin J Am Soc Nephrol 2020;15:1622–30. https:// and costs of end-stage renal disease after heart
doi.org/10.2215/CJN.07920520. transplantation. Transplantation 1998;66:1763–70.
53. Friedman DJ, Upadhyay GA, Singal G, Orencole M, https://doi.org/10.1097/00007890-199812270-00034.
Moore SA, Parks KA, et al. Usefulness and conse- 65. Cantarovich M, Hirsh A, Alam A, Giannetti N, Cecere
quences of cardiac resynchronization therapy in dial- R, Carroll P, et al. The clinical impact of an early
ysis-dependent patients with heart failure. Am J decline in kidney function in patients following heart
Cardiol 2013;112:1625–31. https://doi.org/10.1016/J. transplantation. Am J Transplant 2009;9:348–54.
AMJCARD.2013.07.018. https://doi.org/10.1111/J.1600-6143.2008.02490.X.
54. Friedman DJ, Singh JP, Curtis JP, Tang WHW, Bao H, 66. Schaffer JM, Chiu P, Singh SK, Oyer PE, Reitz BA,
Spatz ES, et al. Comparative effectiveness of CRT-D Mallidi HR. Heart and combined heart-kidney
versus defibrillator alone in HF patients with moder- transplantation in patients with concomitant renal
ate-to-severe chronic kidney disease. J Am Coll Car- insufficiency and end-stage heart failure. Am J
diol 2015;66:2618–29. https://doi.org/10.1016/J. Transplant 2014;14:384–96. https://doi.org/10.1111/
JACC.2015.09.097. AJT.12522.
55. Kirklin JK, Naftel DC, Kormos RL, Pagani FD, Myers 67. Bin Hsu R, CI Chang, Tsai MK, Lee PH, Chou NK, Chi
SL, Stevenson LW, et al. Quantifying the effect of car- NH, et al. Effect of simultaneous kidney transplanta-
diorenal syndrome on mortality after left ventricular tion on heart-transplantation outcome in recipients
assist device implant. J Heart Lung Transplant with preoperative renal dysfunction. Eur J Cardio-
2013;32:1205–13. https://doi.org/10.1016/j.hea- Thoracic Surg 2010;37:68–73. https://doi.org/10.1016/
lun.2013.09.001. J.EJCTS.2009.06.006.
56. Bansal N, Hailpern SM, Katz R, Hall YN, Tamura 68. Kilic A, Grimm JC, Whitman GJR, Shah AS, Mandal K,
MK, Kreuter W, et al. Outcomes associated with Conte JV, et al. The survival benefit of simultaneous
left ventricular assist devices among recipients heart-kidney transplantation extends beyond
with and without end-stage renal disease. JAMA dialysis-dependent patients. Ann Thorac Surg
2015;99:1321–7. https://doi.org/10.1016/J.ATHORAC- disease. Kidney 2020;1:993–1001. https://doi.org/

SUR.2014.09.026. 10.34067/KID.0003132020. 360.
69. Agarwal KA, Patel H, Agrawal N, Cardarelli F, Goyal 83. Roehm B, Gulati G, Weiner DE. Heart failure man-
N. Cardiac outcomes in isolated heart and simulta- agement in dialysis patients: many treatment
neous kidney and heart transplants in the United options with no clear evidence. Semin Dial
States. Kidney Int Rep 2021;6:2348–57. https://doi. 2020;33:198–208. https://doi.org/10.1111/SDI.12878.
org/10.1016/J.EKIR.2021.06.032. 84. Reddy YNV, Obokata M, Dean PG, Melenovsky V,
70. Gill J, Shah T, Hristea I, Chavalitdhamrong D, Anastasi Nath KA, Borlaug BA. Long-term cardiovascular
B, Takemoto SK, et al. Outcomes of simultaneous changes following creation of arteriovenous
heart-kidney transplant in the US: a retrospective fistula in patients with end stage renal disease. Eur
analysis using OPTN/UNOS data. Am J Transplant Heart J 2017;38:1913–23. https://doi.org/10.1093/
2009;9:844–52. https://doi.org/10.1111/J.1600- EURHEARTJ/EHX045.
6143.2009.02588.X. 85. Roca-Tey R. Permanent arteriovenous fistula or cathe-
71. Awad MA, Czer LSC, Emerson D, Jordan S, De Rob- ter dialysis for heart failure patients. J Vasc Access
ertis MA, Mirocha J. et al. Combined heart and kid- 2016;17(1):S23–9. https://doi.org/10.5301/JVA.5000511.
ney transplantation: clinical experience in 100 Suppl.
consecutive patients. J Am Heart Assoc 2019;8: 86. Hartley JL, Sharma A, Taha L, Hestletine T. High-out-
e010570. https://doi.org/10.1161/JAHA.118.010570. put cardiac failure secondary to high-output arterio-
72. Melvinsdottir I, Foley DP, Hess T, Gunnarsson SI, Koh- venous fistula: investigations, management and
moto T, Hermsen J, et al. Heart and kidney trans- definitive treatment. BMJ Case Rep 2020;13. https://
plant: should they be combined or subsequent? ESC doi.org/10.1136/BCR-2019-233669.
Hear Fail 2020;7:2734–43. https://doi.org/10.1002/ 87. Stern AB, Klemmer PJ. High-output heart failure
EHF2.12864. secondary to arteriovenous fistula. Hemodial Int
73. Sun CY, Sung JM, Der Wang J, Li CY, Kuo YT, Lee CC, 2011;15:104–7. https://doi.org/10.1111/J.1542-
et al. A comparison of the risk of congestive heart 4758.2010.00518.X.
failure-related hospitalizations in patients receiving 88. Burton JO, Jefferies HJ, Selby NM, McIntyre CW.
hemodialysis and peritoneal dialysis: a retrospective Hemodialysis-induced cardiac injury: determinants
propensity score-matched study. PLoS One 2019;14. and associated outcomes. Clin J Am Soc Nephrol
https://doi.org/10.1371/JOURNAL.PONE.0223336. 2009;4:914–20. https://doi.org/10.2215/CJN.03900808.
74. Sens F, Schott-Pethelaz AM, Labeeuw M, Colin C, Vil- 89. Jefferies HJ, Virk B, Schiller B, Moran J, Mcintyre CW.
lar E. Survival advantage of hemodialysis relative to Frequent hemodialysis schedules are associated with
peritoneal dialysis in patients with end-stage renal reduced levels of dialysis-induced cardiac injury
disease and congestive heart failure. Kidney Int (myocardial stunning). Clin J Am Soc Nephrol
2011;80:970–7. https://doi.org/10.1038/KI.2011.233. 2011;6:1326. https://doi.org/10.2215/CJN.05200610.
75. Kunin M, Klempfner R, Beckerman P, Rott D, Dinour 90. Loutradis C, Papadopoulos CE, Sarafidis P. Longer
D. Congestive heart failure treated with peritoneal dialysis sessions improve cardiac systolic function
dialysis or hemodialysis: typical patient profile and by reducing myocardial stunning. J Card Fail
outcomes in real-world setting. Int J Clin Pract 2020;26:1026–7. https://doi.org/10.1016/J.CARD-
2021;75:e13727. https://doi.org/10.1111/IJCP.13727. FAIL.2020.06.001.
76. Chionh CY, Clementi A, Poh CB, Finkelstein FO, Cruz 91. McGuire S, Horton EJ, Renshaw D, Chan K, Jimenez
DN. The use of peritoneal dialysis in heart failure: a A, Maddock H, et al. Cardiac stunning during haemo-
systematic review. Perit Dial Int 2020;40:527–39. dialysis: the therapeutic effect of intra-dialytic exer-
https://doi.org/10.1177/0896860819895198. cise. Clin Kidney J 2021;14:1335–44. https://doi.org/
77. Chan C, Floras JS, Miller JA, Pierratos A. Improvement 10.1093/CKJ/SFZ159.
in ejection fraction by nocturnal haemodialysis in 92. Jefferies HJ, Burton JO, McIntyre CW. Individualised
end-stage renal failure patients with coexisting heart dialysate temperature improves intradialytic haemo-
failure. Nephrol Dial Transplant 2002;17:1518–21. dynamics and abrogates haemodialysis-induced myo-
https://doi.org/10.1093/NDT/17.8.1518. cardial stunning, without compromising tolerability.
78. Chan CT, Greene T, Chertow GM, Kliger AS, Stokes Blood Purif 2011;32:63–8. https://doi.org/10.1159/
JB, Beck GJ, et al. Determinants of left ventricular 000324199.
mass in patients on hemodialysis: the Frequent 93. Bansal S, Pergola PE. Current management of
Hemodialysis Network (FHN) trials. Circ Cardiovasc hyperkalemia in patients on dialysis. Kidney Int
Imaging 2012;5:251. https://doi.org/10.1161/CIRCI- Reports 2020;5:779–89. https://doi.org/10.1016/J.
MAGING.111.969923. EKIR.2020.02.1028.
79. Chertow GM, Levin NW, Beck GJ, Daugirdas JT, Eggers 94. Sadjadi SA, McMillan JI, Jaipaul N, Blakely P, Hline SS.
PW, Kliger AS, et al. Long-term effects of frequent in- A comparative study of the prevalence of hyperkale-
center hemodialysis. J Am Soc Nephrol 2016;27:1830–6. mia with the use of angiotensin-converting enzyme
https://doi.org/10.1681/ASN.2015040426. inhibitors versus angiotensin receptor blockers. Ther
80. Ibrahim A, Chan CT. Managing kidney failure with Clin Risk Manag 2009;5:547. https://doi.org/10.2147/
home hemodialysis. Clin J Am Soc Nephrol TCRM.S5176.
2019;14:1268–73. https://doi.org/10.2215/CJN.13931118. 95. Cooper LB, Lippmann SJ, Greiner MA, Sharma A,
81. Trinh E, Chan CT. Intensive home hemodialysis results Kelly JP, Fonarow GC, et al. Use of mineralocorticoid
in regression of left ventricular hypertrophy and bet- receptor antagonists in patients with heart failure
ter clinical outcomes. Am J Nephrol 2016;44:300–7. and comorbid diabetes mellitus or chronic kidney dis-
https://doi.org/10.1159/000449452. ease. J Am Hear Assoc Cardiovasc Cerebrovasc Dis
82. Lockridge R, Weinhandl E, Kraus M, Schreiber M, 2017;6. https://doi.org/10.1161/JAHA.117.006540.
Spry L, Tailor P, et al. A systematic approach to pro- 96. Butler J, Khan MS, Anker SD. Novel potassium
moting home hemodialysis during end stage kidney binders as enabling therapy in heart failure. Eur J
Heart Fail 2019;21:550–2. https://doi.org/10.1002/ 2019;41:400–11. https://doi.org/10.1590/2175-8239-

EJHF.1474. JBN-2018-0155.
97. Pitt B, Anker SD, Bushinsky DA, Kitzman DW, Zannad 105. Carney EF. Dialysis: U-shaped associations between
F, Huang IZ. Evaluation of the efficacy and safety of changes in blood pressure during dialysis and patient
RLY5016, a polymeric potassium binder, in a survival. Nat Rev Nephrol 2013;9:431. https://doi.org/
double-blind, placebo-controlled study in patients 10.1038/NRNEPH.2013.112.
with chronic heart failure (the PEARL-HF) trial. Eur 106. Robinson BM, Tong L, Zhang J, Wolfe RA, Goodkin
Heart J 2011;32:820–8. https://doi.org/10.1093/ DA, Greenwood RN, et al. Blood pressure levels and
eurheartj/ehr058. mortality risk among hemodialysis patients in the
98. Pitt B, Bakris GL, Bushinsky DA, Garza D, Mayo MR, Dialysis Outcomes and Practice Patterns Study. Kid-
Stasiv Y, et al. Effect of patiromer on reducing serum ney Int 2012;82:570–80. https://doi.org/10.1038/
potassium and preventing recurrent hyperkalaemia KI.2012.136.
in patients with heart failure and chronic kidney dis- 107. Losito A, Del Vecchio L, Del Rosso G, Malandra R.
ease on RAAS inhibitors. Eur J Heart Fail Blood pressure and cardiovascular mortality in dialy-
2015;17:1057–65. https://doi.org/10.1002/EJHF.402. sis patients with left ventricular systolic dysfunction.
99. Butler J, Anker SD, Siddiqi TJ, Coats AJS, Dorigotti F, Am J Hypertens 2014;27:401–8. https://doi.org/
Filippatos G, et al. Patiromer for the management of 10.1093/AJH/HPT190.
hyperkalaemia in patients receiving renin-angioten- 108. Sarafidis PA, Persu A, Agarwal R, Burnier M, De
sin-aldosterone system inhibitors for heart failure: Leeuw P, Ferro CJ, et al. Hypertension in dialysis
design and rationale of the DIAMOND trial. Eur J patients: a consensus document by the European
Heart Fail 2022;24:230–8. https://doi.org/10.1002/ Renal and Cardiovascular Medicine (EURECA-m)
EJHF.2386. working group of the European Renal Association-
100. Ferreira JP, Zannad F, Butler J, Filipattos G, Ritter I, European Dialysis and Transplant Association (ERA-
Schu€ ler E, et al. Empagliflozin and serum potassium EDTA) and the Hypertension and the Kidney working
in heart failure: an analysis from EMPEROR-Pooled. group of the European Society of Hypertension
Eur Heart J. 2022. https://doi.org/10.1093/ (ESH). Nephrol Dial Transplant 2017;32:620–40.
EURHEARTJ/EHAC306. Published online June 10. https://doi.org/10.1093/ndt/gfw433.
101. Greene SJ, Khan MS. Quadruple medical therapy for 109. Georgianos PI, Agarwal R. Epidemiology, diagnosis
heart failure: medications working together to pro- and management of hypertension among patients
vide the best care. J Am Coll Cardiol 2021;77:1408– on chronic dialysis. Nat Rev Nephrol 2016;12:636–47.
11. https://doi.org/10.1016/J.JACC.2021.02.006. https://doi.org/10.1038/nrneph.2016.129.
102. Sarafidis PA, Persu A, Agarwal R, Burnier M, De Leeuw 110. Sarafidis PA, Mallamaci F, Loutradis C, Ekart R, Torino
P, Ferro CJ, et al. Hypertension in dialysis patients: a C, Karpetas A, et al. Prevalence and control of hyper-
consensus document by the European Renal and Car- tension by 48-h ambulatory blood pressure monitor-
diovascular Medicine (EURECA-m) working group of ing in haemodialysis patients: a study by the
the European Renal Association-European Dialysis European Cardiovascular and Renal Medicine
and Transplant Association (ERA-EDTA) and the (EURECA-m) working group of the ERA-EDTA. Neph-
Hypertension and the Kidney working group of the rol Dial Transplant 2019;34:1542–8. https://doi.org/
European Society of Hypertension (ESH). Nephrol Dial 10.1093/NDT/GFY147.
Transplant 2017;32:620–40. https://doi.org/10.1093/ 111. Agarwal R, Peixoto AJ, Santos SFF, Zoccali C. Pre- and
NDT/GFW433. postdialysis blood pressures are imprecise estimates
103. Alborzi P, Patel N, Agarwal R. Home blood pressures of interdialytic ambulatory blood pressure. Clin J Am
are of greater prognostic value than hemodialysis Soc Nephrol 2006;1:389–98. https://doi.org/10.2215/
unit recordings. Clin J Am Soc Nephrol 2007;2:1228– CJN.01891105.
34. https://doi.org/10.2215/CJN.02250507. 112. Nitta K, Hanafusa N, Tsuchiya K. Frailty and mor-
104. Bucharles SGE, Wallbach KKS. Moraes TP de, Pecoits- tality among dialysis patients. Ren Replace Ther
Filho R. Hypertension in patients on dialysis: diagno- 2017;3:1–6. https://doi.org/10.1186/S41100-017-
sis, mechanisms, and management. J Bras Nefrol 0122-Y/FIGURES/2.

Managing Heart Failure in Patients On Dialysis

Uploaded by

Copyright:

Available Formats

Managing Heart Failure in Patients On Dialysis

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Managing Heart Failure in Patients On Dialysis

Uploaded by

Copyright:

Available Formats

Journal of Cardiac Failure Vol. 29 No.

with HF and CKD, data regarding the management Beta-Blockers

RCTs Evaluating HF Patients on Dialysis

Managing Heart Failure in Patients on Dialysis: State-of-the-Art  KHAN et al 91

Managing Heart Failure in Patients on Dialysis: State-of-the-Art  KHAN et al 95

(continued on next page)

and beneﬁts of ICD therapy in patients on dialysis.

Subcutaneous ICD implantation has been found to

reduce the risk of infections associated with transve-

literature has conﬂicting evidence regarding the

>11500 pg/mL or BNP

(including HD, hemo-

Cardiac Resynchronization Therapy

The effectiveness of CRT in patients with HFrEF

and on dialysis remains questionable owing to the

lack of pertinent RCTs and the exclusions of these

observational studies have evaluated the effective-

ness of CRT in patients with HF and on dialysis. A

case-control study evaluating the effectiveness and

safety of CRT in 15 patients on dialysis and with HF

demonstrated that CRT increased the risk of all-

cause mortality (CRT, 73%; control, 44%; P= 0.038)

hospitalizations due to HF (CRT, 31%; control, 45%;

ysis, showed that the use of CRT with deﬁbrillators

hospitalizations due to HF(CRT-D, 2722/9525; ICD,

529/1421; HR, 0.81 [0.72 0.91]) when compared

rates (in-hospital: CRT-D, 6.0% vs ICD, 5.8%; 30-day:

such as hematoma (in-hospital: CRT-D, 2.5% vs ICD,

diac tamponade or pericardial effusion requiring

pericardiocentesis (in-hospital: CRT-D, 0.6% vs ICD,

device-related infections (90-day: CRT-D, 0.3% vs

ICD, 0.4%) were also similar in the CRT-D and ICD

Management of Hyperkalemia in Subjects Receiving Whether this represents association vs causation is

level evidence is warranted in the future to endorse 2005;45(Suppl 3):16–153. https://doi.org/10.1053/J.

2015;99:1321–7. https://doi.org/10.1016/J.ATHORAC- disease. Kidney 2020;1:993–1001. https://doi.org/

Heart Fail 2019;21:550–2. https://doi.org/10.1002/ 2019;41:400–11. https://doi.org/10.1590/2175-8239-

You might also like

Managing Heart Failure in Patients on Dialysis: State-of-the-Art KHAN et al 91

Managing Heart Failure in Patients on Dialysis: State-of-the-Art KHAN et al 95