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Reviews in Cardiovascular Medicine  2020, Vol. 21 Issue (1): 31-39     DOI: 10.31083/j.rcm.2020.01.24
Special Issue: Cardiovascular disorders in chronic kidney disease
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Management of heart failure in patients with end-stage kidney disease on maintenance dialysis: a practical guide
Megan S. Joseph1, Maryse Palardy1, Nicole M. Bhave1, *()
University of Michigan Medical School and Michigan Medicine, Department of Internal Medicine, Division of Cardiovascular Medicine, 1500 East Medical Center Drive, Ann Arbor, Michigan, 48109, USA.
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End-stage kidney disease (ESKD) and heart failure (HF) often coexist and must be managed simultaneously. Multidisciplinary collaboration between nephrology and cardiology is critical when treating patients with such complicated physiology. There is no "one-size-fits-all" approach to the evaluation of patients with new left ventricular systolic dysfunction, and diagnostic testing should be adapted to an individual's risk factors. Guideline-directed medical therapy (GDMT) for systolic heart failure should be employed in these patients. While limited randomized data exist, observational data and post hoc analyses suggest that GDMT, including renin angiotensin aldosterone system inhibitors, is associated with improved cardiovascular outcomes and can be safely initiated at low doses with close monitoring of kidney function in this population. Volume status is typically managed through ultrafiltration, so close communication between cardiology and nephrology is necessary to achieve a patient's optimal dry weight and mitigate intradialytic hypotension. Patient education and engagement regarding sodium and fluid restriction is crucial, and symptom burden should be reassessed following changes to the dialysis regimen.

Key words:  Heart failure      end-stage kidney disease      dialysis     
Submitted:  01 March 2020      Accepted:  05 March 2020      Published:  30 March 2020     
*Corresponding Author(s):  Nicole M. Bhave     E-mail:

Cite this article: 

Megan S. Joseph, Maryse Palardy, Nicole M. Bhave. Management of heart failure in patients with end-stage kidney disease on maintenance dialysis: a practical guide. Reviews in Cardiovascular Medicine, 2020, 21(1): 31-39.

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Table 1.  Heart failure medications in end-stage kidney disease.
Medication classMedicationsDialyzabilityMinimum Dose*
ACE inhibitorsCaptopril
Not dialyzable
Not dialyzable
1 mg TID (liquid)
2.5 mg daily
5 mg daily
2.5 mg daily
2.5 mg daily
1.25 mg BID
Angiotensin II receptor blockersCandesartan
Not dialyzable
Not dialyzable
Not dialyzable
4 mg daily
12.5 mg daily
20 mg BID
Angiotensin receptor-neprilysin inhibitorsSacubitril/valsartanUnknown24/26 mg twice daily
Metoprolol succinate
Not dialyzable
Not dialyzable
Not dialyzable
2.5 mg daily
3.125 mg BID
12.5 mg daily
2.5 mg daily
Cardiac glycosidesDigoxinNot dialyzable62.5 mcg every 48 hours
(recommended dosing in dialysis)
HCN blockersIvabradineUnknown2.5 mg BID
Mineralocorticoid receptor antagonistsEplerenone
Poorly dialyzed
Not dialyzable
12.5 mg daily
12.5 mg daily
Isosorbide dinitrate
Not dialyzable
Not dialyzable
10 mg BID or TID
10 mg TID
Figure 1.  Central illustration: Team approach to the management of Heart failure in End-Stage Kidney Disease

Box.  Clinical vignettes highlighting diagnostic and therapeutic challenges encountered when managing patients with HF, HTN, and ESKD.
Case 1Mr. X is a 39-year-old man with ESKD secondary to hypertension, on HD via arteriovenous (AV) fistula for 5 years. He was referred to cardiology clinic after a TTE, which was obtained as part of his evaluation for a kidney transplant, showed left ventricular (LV) dilation and LV ejection fraction (LVEF) 40-45%. TTE was also notable for prominent apical trabeculations. Because of his TTE findings and risk factors, the differential diagnosis for his cardiomyopathy included non-compaction cardiomyopathy, ischemic heart disease, and hypertensive cardiomyopathy. The first therapeutic intervention made was that his HD regimen was adjusted to target a lower dry weight. He subsequently underwent cardiovascular magnetic resonance (CMR), which revealed LVEF 61%, hypertrabeculation of the LV apex not meeting criteria for non-compaction cardiomyopathy, and no late gadolinium enhancement of the myocardium. His coronary angiogram was normal. Ultimately, he was felt to have a non-ischemic cardiomyopathy attributable to hypertension and ESKD, with recovered LVEF in the setting of improved loading conditions. He subsequently underwent kidney transplant without complications. Though his antihypertensive regimen was de-escalated post-transplant, he continued on carvedilol and low-dose lisinopril, given his history of LV dysfunction.

Commentary: The improvement in this patient’s LVEF was attributed to better volume management, highlighting the dynamic nature of LV dysfunction depending on volume status in ESKD. GDMT, including beta-blocker and angiotensin converting enzyme inhibitor, should be continued even after the LVEF has recovered. Finally, if his kidney function remains stable for at least 6-12 months after transplant, he may benefit from ligation of his AV fistula, as ligation has been associated with significant reduction in LV mass index by CMR and decrease in NT pro-B-type natriuretic peptide levels (Rao et al., 2019).
Case 2Mr. Y is a 48-year-old man patient with a history of a bicuspid aortic valve with associated ascending aortic aneurysm and ESKD secondary to an unknown autoimmune disease who underwent a kidney transplant but subsequently developed graft failure and adult-onset type I diabetes mellitus. He was referred to cardiology clinic for management of resistant hypertension while on HD. Given his ascending aortic aneurysm, blood pressure control was felt to be critically important. He was initially maintained on clonidine 0.1 mg/24 hour transdermally, metoprolol succinate 100 mg daily, and extended-release nifedipine 60 mg daily. In an effort to improve blood pressure control, his antihypertensive regimen was adjusted to include carvedilol 25 mg twice daily, hydralazine 100 mg three times daily, losartan 25 mg daily, amlodipine 5 mg daily, and clonidine 0.2 mg/24 hour transdermally. Despite these changes, his blood pressure remained elevated, often as high as 180/100 mmHg. The cardiologist contacted his nephrologist, who felt that the patient was volume overloaded and suggested increased ultrafiltration. However, ultrafiltration was limited by cramping during HD, so no significant progress was possible. The patient elected to switch to PD, as he had done well on PD prior to his first transplant. Several weeks after the transition, his dry weight was decreased by approximately 5 kg, and home blood pressures were averaging 120/80 mmHg. Finally, as part of his kidney transplant workup, an evaluation for myocardial ischemia was recommended, given his history of diabetes mellitus and relatively sedentary lifestyle. A vasodilator nuclear stress test was ordered rather than a dobutamine stress echocardiogram, given his history of ascending aortic aneurysm; no evidence of ischemia was present.

Commentary: If a patient’s optimal dry weight is not identified and achieved, venous hypertension can be extremely challenging, if not impossible, to control. Modality for myocardial ischemia evaluation must be chosen based on an individual’s risk factors and comorbidities.
Table 2.  Acute Dialysis Quality Initiative XI Workgroup’s proposed functional classification system of heart failure in patients with end-stage kidney disease (Chawla et al., 2014).
Heart Failure ClassSymptoms
1Asymptomatic, with echocardiographic evidence of heart disease
2RDyspnea on exertion that is relieved with RRT/UF to a NYHA Class I level
2NRDyspnea on exertion that cannot be relieved with RRT/UF to a NYHA Class I level
3RDyspnea with ADLs that is relieved by RRT/UF to a NYHA Class II level
3NRDyspnea with ADLs that cannot be relieved by RRT/UF to a NYHA Class II level
4RDyspnea at rest that is relieved by RRT/UF to a NYHA Class III level
4NRDyspnea at rest that cannot be relieved by RRT/UF to a NYHA Class III level
Table 3.  Strategies to mitigate intradialytic hypotension.
Lengthen hemodialysis runs
Increase frequency of hemodialysis from 3 times weekly to 4-6 times weekly (may schedule one or more ultrafiltration-only runs per week)
Lower dialysate temperature (patient tolerability may be limited)
Hold anti-hypertensives the morning before dialysis (GDMT drugs may be given post-dialysis if tolerated)
Discontinuation of anti-hypertensives that have not been shown to provide mortality benefit in patients with heart failure (e.g., clonidine, minoxidil, calcium-channel blockers)
Use of midodrine or fludrocortisone (note that midodrine is associated with worse outcomes following kidney transplantation)
Switch from hemodialysis to peritoneal dialysis
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