Heart failure common in patients receiving dialysis

Heart failure common in patients receiving dialysis

Key point: A recent narrative review published in the American Journal of Kidney Disease highlighted the common occurrence of heart failure in patients on long-term dialysis, kidney disease–related risk factors for heart failure, and the importance of an accurate diagnosis in this patient population to ensure proper treatment.

Finer points: Angela Yee-Moon Wang, MD, PhD, FRCP, and John E. Sanderson, MD, FRCP, wrote an extensive review of current perspectives on diagnosis of heart failure in patients receiving long-term dialysis.

The authors first summarized literature showing that heart failure is extremely prevalent in this patient population, ranging from 31% to 40%; a diagnosis of heart failure increases the risk of both early and long-term mortality. Patients with kidney disease are particularly susceptible to heart failure because of traditional risk factors such as hypertension, diabetes, dyslipidemia, and smoking, in addition to specific kidney disease–related factors such as salt and volume overload, uremic toxins, anemia, hypoalbuminemia, and poor calcium–phosphorus control.

The most common consequences of these numerous risk factors, especially salt and volume overload, are increased left ventricular (LV) afterload and myocardial hypertrophy. The authors noted that cardiac hypertrophy has been reported to occur in at least 75% of patients at the start of hemodialysis and that the prevalence of systolic dysfunction has been between 13% and 36%. In addition, diastolic dysfunction, also referred to as heart failure with normal LV ejection fraction (EF), occurs in this patient population.

Within the review, the authors provided a clinical approach to assessing patients on dialysis presenting with possible heart failure. Steps included obtaining a through history and physical examination to identify cardiac disorders that may affect the progression of heart failure; assessing a patient’s ability to perform routine activities of daily living; assessing a patient’s body weight, height, and volume status; looking for any orthostatic blood pressure changes; and obtaining a 12-lead electrocardiogram, chest radiograph, and two-dimensional echocardiogram with Doppler to determine systolic and diastolic dysfunction, valve function, and various LV parameters.

The authors also reviewed the role of cardiac biomarkers such as brain natriuretic peptide and cardiac troponin T. These biomarkers may be especially useful when used in conjunction with other measures such as EF and LV mass index. The general consensus, however, was that additional research is needed to fully determine the use of these biomarkers in identifying patients who are at increased risk for heart failure.

What you need to know: The current review focused on the huge burden of heart failure on the dialysis population and the importance of an accurate diagnosis. The authors of the review did not suggest appropriate pharmacologic treatments in this patient population.

Unfortunately, limited studies have been conducted in patients receiving dialysis who have heart failure. Data have shown that carvedilol reduces the risk of death in patients receiving hemodialysis with dilated cardiomyopathy. Based on this finding, carvedilol is a treatment of choice for patients with severe dilated cardiomyopathy, defined as an LV fraction less than 35%. It must be started at a very low dose to minimize the risk of hemodynamic deterioration.

ACE inhibitors are often added on because of the positive data seen in patients with normal kidney function; however, no prospective studies have specifically examined the role of ACE inhibitors in patients with heart failure receiving dialysis. Additional research focusing on this patient population is clearly needed.

What your patients need to know: Inform patients receiving dialysis that heart failure is a common condition. Counsel them to monitor their weight daily and pay particular attention to sodium intake; any significant changes should be reported to their health care provider immediately.

Sources:

Wang AYM, Sanderson JE. Current perspectives on diagnosis of heart failure in long-term dialysis patients. Am J Kidney Dis. 2011;57:308–19.
Herzog CA et al. Therapy of heart failure in hemodialysis patients. Version 18.3. UpToDate. Last updated September 18, 2010.
Related resource on www.pharmacist.com:

ADIL, February 2011: More frequent hemodialysis associated with decreased CV mortality.
Posted by Alex Egervary (aegervary@aphanet.org)
April 29, 2011, 4:30 pm

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